Rojced 4 (3) 2015

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ROMANIAN JOURNAL OF CLINICAL AND EXPERIMENTAL DERMATOLOGY RoJCED este indexată în următoarele BDI

IBI Factor: 3,16

Vol. II / Nr. 3 / 2015 ISSN 2392 – 7461 ISSN-L 2392 – 7461

RoJCED sub egida

ROMANIAN SOCIETY FOR LASERS IN MEDICINE AND BIOLOGY

September 2015

R o m a n i a n

J o u r n a l

o f

C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY Volume I I/ Issue 3 / September 2015

EDITOR-IN-CHIEF & MANAGING EDITOR Victor Gabriel Clatici, MD, “Carol Davila”University of Medicine and Pharmacy, Bucharest, Romania

ROMANIAN SENIOR EDITORS George Sorin Tiplica, Professor, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Virgil Patrascu, Professor, MD, PhD, University of medicine and Pharmacy Craiova, Romania Simona Fica, Professor, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Radu Vladareanu, Professor, M.D. PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Oana Andreia Coman, Professor, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Alexandru Rafila, Professor, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Sabina - Andrada Zurac, Professor, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Caius Solovan, Professor, MD, PhD, University of Medicine and Pharmacy ,,Victor Babes,, Timisoara, Romania Luiza Spiru, Professor, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Mihai Nicolescu, Professor, MD, Vicepresident of ASAS - Academy for Agriculture and Forestry Sciences Gheorghe Ionescu-Șișești, Craiova, Romania Mihai-Lucian Pascu, Professor, National Institute for Lasers, Plasma and Radiation Physics, Magurele, Romania Stefana Jurcoane, Professor, PhD, University of Agronomics and Veterinary Medicine, Bucharest, Romania Carmen Maria Salavastru, MD, PhD, Associate Professor, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Dana Mihaela Jianu, MD, PhD, Associate Professor “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Ruxandra Diana Sinescu, Associate Professor, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Roxana Silvia Bumbacea, MD, PhD, Associate Professor, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Horatiu Moldovan, MD, PhD, Associate Professor, University of Medicine and Pharmacy, Tirgu-Mures, Romania Angela Staicu, National Institute for Lasers, Plasma and Radiation Physics, Magurele, Romania

INTERNATIONAL SENIOR EDITORS Cassian Sitaru, Professor, MD, PhD, University of Freiburg, Freiburg, Germany Claude Dalle, Professor, MD, Paris, France Daniel Racoceanu, Professor, PhD, Sorbonne Universités, Université Pierre et Marie Curie, Paris, France Razvan Cristescu, MD, PhD, Merck Research Laboratories, Boston MA, USA Carmen Cantemir-Stone, PhD, Research Scientist, The Ohio State University, Columbus OH, USA Mihaela Balu, Professor, Beckman Laser Institute, University of California, Irvine, CA, USA Leonardo Marini, Professor, Skin Doctors Center, Trieste, Italy Miroslav Blumenberg, MD, PhD, Langone Medical Center, New York, USA Björn Brücher, Professor, MD, PhD, FRCS, FACS, Bon Secours Cancer Institute, Eichmond, Virginia, USA Klaus Fritz, Assoc. Prof. “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Ijaz Jamall, PhD, American Board of Toxicology, Sacramento, USA Marco A. Pelosi III, MD, FACOG, FACS, FICS, FAACS, International Society of Cosmetogynecology Bayonne, New Jersey, USA Mehmet Ufuk Abacioglu, MD, Radiation Oncology Department, Neolife Medical Center, Istanbul, Turkey Uwe Gieler, Professor, MD, PhD, Department of Dermatology and Allergology, University Clinic Giessen (UGKM), Germany Lucia Tomas-Aragones, MD, Department of Psychology, University of Zaragoza, Spain

ROMANIAN EDITORIAL BOARD Alin Laurentiu Tatu , MD, PhD, University Dunarea de Jos, Faculty of Medicine and Pharmacy, Galati, Romania Cristian Radu Jecan, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Madalina Musat, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Valentin Calu, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Cosmin Balabuc, DDS, Victor Babeș University of Medicine and Pharmacy, Timișoara, Romania Claudia Dima, MD, PhD, National Institute of Public Health, Bucharest, Romania Ileana Turcu, Senior Researcher, “Ana Aslan” International Foundation, Bucharest, Romania Violeta Corina Cristea, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Aurel-Florentin Badiu, PhD, Academy for Agriculture and Forestry Sciences Gheorghe Ionescu-Șișești, Bucharest, Romania Loredana Manolescu, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Catalin Enachescu, MD, PhD, Research, Elias Hospital, Bucharest, Romania Alexandra Maria Hillebrand -Voiculescu, PhD, ,,Emil Racovita,, Institute of Speleology of the Romanian Academy, Bucharest, Romania Loredana Mitran, MD, PhD, Emergency Universitary Hospital Elias , Bucharest, Romania Mihai Mitran, MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Carmen Sorina Martin MD, PhD, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania

INTERNATIONAL EDITORIAL BOARD Serban P. Georgescu, MD, Romanian American Biomedical Association, Boston, Massachusetts, USA Ciprian Enachescu, MD, Societé Francaise De Radiothérapie Et Oncologie, LYON, FRANCE Daniel Nichita, Md, Ms, Senior Medical Editor, Borm Bruckmeier Publishing, California, USA Raffaele Rauso, MD, University of Foggia, Foggia, Italy Nikoleta Koini, Md, Greek Medical Association, Athens-Greece Marinela van den Heuvel-Olăroiu, MD, PhD, SOAZ / RACE (Research and Advice in Care of Elderly), Maastricht, The Netherlands Carmen Dolea, MD, MPH, MBA, World Health Organization, Geneva, Switzerland Patrick Treacy, LRCSI, MICGP, MBCAM, DRCOG, DCH, H Dip Dermatology, Dublin, Ireland Tara Nekoroski, Bachelor degree, Halozyme Therapeutics, San Diego, CA, USA Elena Campione, MD, PhD, University Hospital of Rome ,,Tor Vergata,,, Italy

EDITORIAL OFFICE TEAM Cristiana Voicu Ana Livia Dută Ana Maria Cristina Medeleanu Ioana-Madalina Maftei-Antoneag Ana Maria Veronica Draganita

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PRIMA ANIVERSARE! Victor Gabriel Clătici

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YEAR OF THE LIGHT!

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OPTICAL TECHNOLOGIES AS MODERN IMAGING TOOLS IN DERMATOLOGY

Dana Jianu

Mihaela Balu

REVIEW

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MULTIPHOTON MICROSCOPY FOR NON-INVASIVE OPTICAL BIOPSY OF HUMAN SKIN Mihaela Balu, Bruce J. Tromberg

CLINICAL STUDY

CUTANEOUS FINDINGS IN CHRONIC KIDNEY DISEASE AND HEMODIALYSIS Ignat Ana-Sonia, Gliga Mirela, Badea Iudita-Maria, Badea Mihail-Alexandru, Lefter Elena, Morariu Sliviu-Horia

ISSN 2392 – 7461 ISSN-L 2392 – 7461

NON INVASIVE EVALUATION OF PATIENT WITH ACNE AND ROSACEA. IMPLICATIONS IN CASE - MANAGEMENT Victor Gabriel Clătici, Diana Ursu, Simona Fica

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CASE PRESENTATION

190 196

RELAPSING POLYCHONDRITIS - CASE REPORT

CEO Alina NICOLEANU Sales Manager Ionuţ NICOLEANU Communication Manager Alexandra Mănăilă Administrative Manager Andreea BANEA Editorial & Events Assistant Valentin MIROIU

Virgil Pătrașcu, Raluca Ciurea, Andreea-Oana Enache

THE ADVANTAGES OF DIGITAL DERMOSCOPY Radu-Nicolae Grigore, Klaus Fritz, George Sorin Ţiplică, Carmen Maria Sălăvăstru

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UP TO DATE A BIOBANK SUPPORTING RARE DISEASE RESEARCH IN DERMATOPATHOLOGY. OUR EXPERIENCE IN ESTABLISHING A BIOBANK Manfred Beleut, Edward Seclaman, Michael Baudis, Ancuta Nicula,Caius Solovan

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ROSACEA AND TECHNOLOGY – DIAGNOSIS AND TREATMENT Cristiana Voicu, Victor Gabriel Clătici, Leonardo Marini

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SUBSCRIPTIONS Tel.: 031.100.01.88 E-mail: office@msc-ro.com

ONCOLOGY AND DERMATO-ONCOLOGY RADIATION THERAPY SKIN TOXICITY Ciprian Enachescu, Sena Yossi, Tristan Brahmi, Victor Gabriel Clatici, Alina Tita.

230 INTERNATIONAL EVENTS CALENDAR

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Editorial

Prima aniversare!

Dr. Victor Gabriel Clătici Editor-in-Chief & Managing Editor

A trecut un an de când primul număr al ROJCED a apărut! m 1 an în cifre și date! m 4 numere! m Peste 35 de articole! m Tematică extrem de variată a articolelor! m Peste 150 de autori!

Autori de variate specialități – dermatologie și ginecologie, endocrinologie și chirurgie plastică, ORL și medicină internă, radioterapie și stomatologie!

Prezența online se concretizează în : m peste 16.000 de afișări și m peste 5000 de vizitatori unici din România și SUA, China și Brazilia, Rusia și Marea Britanie, Germania și Japonia, Italia și Franța!

Un aspect foarte important este reprezentat de către indexarea ROJCED de către Bazele de Date Internaționale, un prim pas către aplicarea pentru IF – Impact Factor ISI! Această indexare sprijină autorii care publică în ROJCED atât în dezvoltarea profesională și de cercetare, cât și în realizarea tezelor de doctorat!

Boardul științific al ROJCED este reprezentat de prestigioase personalități academice, din variate domenii de activitate și cu realizări de excepție!

Principalele proiecte de viitor se referă la îndeplinirea criteriilor de indexare tip Impact Factor -ISI și de dezvoltarea unei platforme multidisciplinare pentru realizarea unor proiecte transfrontaliere de cercetare și dezvoltare - ,,Research and Development,, -R&D. Mulțumesc pe această cale TUTUROR celor care au făcut posibil acest proiect!

Cu respect, Victor Gabriel Clătici

Year of the light!

2015 is the year which has officially been proclaimed by UNESCO as the “Year of the Light and light based technologies” .

Light is essential for life. Many things are revealed by light. For example beautiful intense blue sky is an effect of light...Beauty of human features is an impression produced by light and shadows...

LASER, acronym to “Light amplification by stimulated emission of radiation “, is a special type of light.

LASERS are incorporated in many scienceslike: medicine, biology, phisics, in clinical and research activities.

Plastic-aesthetic surgery and medicine are among them. European Society for Laser Aesthetic Surgery (ESLAS)- www.eslas.com and European Laser Association (ELA) - www.european laser association.com) are two important European societies involved in the domain. Recently, in Athens, took place ELA convened Congress who acted as the 16th annual Congress of the European Society for Laser Aesthetic Surgery and the Annual congress of the Dutch Aesthetic Laser Association- DALA. Here, worldwide delegates from different fields of laser, aesthetic surgery , dermatology and other specialties gave plenary and keynote lectures. The scientific program attracted young doctors and scientists in training as well as established physicians of different specialties and researchers. A wide range of subjects has been covered aiming in giving overviews and updates on recent research and clinical applications.

State of the art Master classes were organized; they covered many aspects of high importance in the field of lasers and aesthetics. Workshops were running parallel to the scientific sessions during the three days of the Congress to offer updated information on clinical applications of energy , light and laser based technology.

During the congress a trade exhibition took place, where the main companies working in the field of aesthetics, laser and energy based devices surgery were present. In June 2016 another exciting of ELA and ESLAS event that will take place in Berlin.

We wait for you there to share ….the light….of science.

Editorial

Dana Jianu MD, PhD., Associate Professor UMF "Carol Davila" Bucharest ESLAS President RASS President

Editorial

Optical technologies as modern imaging tools in dermatology Mihaela Balu Laser Microbeam and Medical Program, Beckman Laser Institute, University of California, Irvine, CA, USA, The current gold standard methods for diagnosis of skin diseases or other skin-related investigations such as assessment of cosmetic treatment effects are based on biopsy and histopathological examination. In an era that witnesses technological progress and innovation at an unprecedented rate in many fields, including medicine, it seems rather surprising that the main investigation tool for easily accessible human organs, such as skin, remains the traditional, unsophisticated invasive procedure.

Recent advances in optical imaging technologies hold the potential to provide breakthrough solutions to non-invasive clinical investigation of human skin. Among these technologies, the ones most advanced in clinical research studies for dermatology applications are Reflectance Confocal Microscopy (RCM) and Multiphoton Microscopy (MPM). Both are based on laser-scanning microscopy, a technique that utilizes a focused laser beam that is raster-scanned across the sample to create high-resolution images. A 3D-view of the skin can be reconstructed by scanning at multiple depths. Importantly, the high-resolution imaging capability is combined with a label-free contrast mechanism for both of these techniques. Thus, RCM detects variation in the refractive index of cellular and extracellular structures. As both detected and incident light have the same wavelength, this method provides gray scale images. Generally, gray scale images are sufficient for the overall assessment of tissue morphology. However, this approach limits the technique’s applicability to qualitative image evaluation by clinical readers. Therefore, inter-observer variability, a problem in the current gold standard diagnosis method, is not being addressed.

Also, gray scale images are very distinct from hematoxylin and eosin-stained images pathologists are trained to read. This may represent a limitation in terms of the need for new training to achieve accurate image interpretation. MPM contrast in skin is derived from second harmonic generation of collagen and two-photon excited fluorescence of tissue components such as the co-factors NADH and FAD+, elastin, keratin, and melanin. Due to its contrast mechanism, MPM provides dual-color images that distinguish cellular features from the extra-cellular matrix and closely resembles the histological sections. This feature facilitates image interpretation and also allows for quantitative approaches that involve parameters related to the MPM molecular contrast as recently shown by our group. A quantitative algorithm is important as such imaging instruments are mainly intended as an aid for dermatologists to improve their clinical diagnosis of early stage skin diseases. Most dermatologists do not have dermatopathology fellowship training and are not familiar with the microscopic hallmarks of diseases.

Both of these techniques have been implemented in commercial devices (RCM-based Vivascope from Caliber I.D., Rochester, New York, USA and MPM-based DermaInspect and MPTflex from JenLab, Jena, Germany) that are CE-marked and/or FDA-approved for clinical use. These devices have been employed in a broad range of clinical applications that span from skin disease detection and diagnosis, including skin cancer, to skin aging and cosmetic treatments. Most results are promising and show the capability of these techniques to investigate skin at microscopic scale and their potential to immediately assess disease status and improve diagnostic accuracy. RCM has the benefit of involving a low cost technology, while MPM provides selectivity due to its molecular contrast mechanism.

Nevertheless, both of these techniques have limitations that need to be addressed in order to increase their efficacy in clinical settings. Limited field of view and penetration depth are the main challenges. Size of interrogated area is usually increased by implementing the “stitching� feature (scanning adjacent field of views). This procedure requires longer acquisition times and if not compensated by rapid scanning of the area and by higher sensitivity detection, it becomes impractical. These are technical challenges that can be addressed. Recently, optical coherence tomography (OCT), an imaging technology that has had the largest clinical impact in ophthalmology, broadened its range of applications to include dermatology. This technique can generate three-dimensional images of tissue microstructures by measuring backscattered and backreflected light, in a way that is analogous to ultrasound imaging except light rather than sound is used as a source. OCT images larger field of views and provides increased penetration depth, but spatial resolution is lower compared to microscopy techniques and this a key feature in particular applications, such as melanoma diagnosis, likely the most important among all.

Multi-modality approaches that use a lower resolution technique such as OCT for large area investigation and a microscopy technique to assess particular regions of interest have been explored and appear to be worth pursuing.

The clinical studies results obtained with all these technologies in the recent years have been undoubtedly remarkable, enthusing the dermatologists and dermatopathologists alike and setting the stage for novel non-invasive means of assessing and diagnosing skin conditions. Their success will certainly depend on the ability of matching the demands of the medical community with the solutions provided by the engineering community in industry and academia.

September 2015

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Multiphoton microscopy for non-invasive optical biopsy of human skin

MULTIPHOTON MICROSCOPY FOR NON-INVASIVE OPTICAL BIOPSY OF HUMAN SKIN MULTIPHOTON MICROSCOPY – INSTRUMENT OPTIC NON-INVAZIV DE EVALUARE A PIELII Mihaela Balu (1), Bruce J. Tromberg (1) (1)

Laser Microbeam and Medical Program, Beckman Laser Institute, University of California, Irvine, 1002 Health Sciences Rd., Irvine, CA 92612, USA Corresponding author: Mihaela Balu, Laser Microbeam and Medical Program, Beckman Laser Institute, University of California, Irvine, 1002 Health Sciences Rd., Irvine, CA 92612, USA, Email: mbalu@uci.edu

Open Access Article

Abstract Multiphoton microscopy (MPM) is a laser scanning microscopy technique that can provide high resolution, label-free images of living tissues in their native environment that closely resembles the histological sections. In skin, several endogenous components can be visualized, including reduced nicotinamide adenine dinucleotide (NADH), flavin adenine dinucleotide (FAD), keratin, melanin, collagen and elastin fibers. The recent development of MPM-based clinical tomographs advanced its practical utility, accelerated its applications and generated increased interest, particularly in the dermatology field. This review summarizes the most recent applications of in vivo MPM imaging in dermatology.

We also discuss the challenges of implementing this technology into clinical practice.

Keywords: multiphoton microscopy dermatology, noninvasive imaging skin cancer, non invasive optical biopsy, melanoma, basal cell carcinoma

Rezumat Cuvinte-cheie:

Cite this article: Mihaela Balu, Bruce J. Tromberg.

Multiphoton microscopy for non-invasive optical biopsy of human skin.

RoJCED 2015; 2(3):160-166

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microscopie multifoton, dermatologie, diagnosticare noninvazivă cancer de piele, biopsie optică noninvazivă, melanom, carcinom bazocelular

Microscopia multifoton reprezintă o metodă de imagistică bazată pe scanare laser care produce imagini de înaltă rezoluție ale țesuturilor vii, în mediul lor natural, imagini asemănătoare secțiunilor histologice. Metoda nu necesită substanță de contrast și imaginile sunt obținute prin detectarea semnalului produs de diferite componente ale pielii (reduced nicotinamide adenine dinucleotide - NADH, flavin adenine dinucleotide - FAD, keratina, melanina, colagen, elastina) în urma excitării laser. Dezvoltarea recentă a tehnologiei de tip tomografie bazată pe microscopia multifoton a dus la îmbunătățirea metodei și la lărgirea spectrului de aplicații, generând interes în special în domeniul dermatologiei. Lucrarea de față include o sintetizare a celor mai recente aplicații în dermatologie ale microscopiei multifoton in vivo. Sunt de asemenea, discutate principalele provocări legate de implementarea acestei tehnologii în clinică.

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Mihaela Balu, Bruce J. Tromberg

Introduction Microscopic evaluation of skin is required in many areas of dermatology such as diagnosing skin diseases, assessing the effects of cosmetic treatments or understanding the skin tissue functionality. Skin is thick and it scatters light strongly.

Also, unstained tissue has very little contrast. The only way to image it with conventional optical microscopy is to slice it upon fixation, mount the slices on microscope slides, stain the slices on each slide and analyze them by using the standard optical microscope. This technique has two main limitations: 1. It is time consuming and it involves many steps in the process that can be prone to errors.

2. The tissue needs to be removed from its natural environment; while the overall tissue morphology is preserved during the slicing and staining process, the main features related to tissue functionality such as metabolism, are lost.

In recent years, optical technologies based on in vivo laser scanning microscopy have been developed to address these limitations. This method utilizes focused illumination of a laser beam to provide access to the sub-micron scale and raster-scanning across the sample to create highresolution images. Each image plane (about 2Îźm thick) forms an optical section and can be used in reconstructing a 3D-view of the skin by scanning at multiple depths.

How laser scanning microscopy (LSM) can overcome high scattering and low contrast of unstained tissue is an area of current research. The scattering limitation has been solved only partially. Using a laser beam as a light source allows for wavelength selection that affects the scattering process. Therefore, longer wavelengths are scattered less than shorter wavelengths by a turbid medium such as skin. Infrared wavelengths are particularly used

by LSM techniques for this reason. Nevertheless, limited depth penetration in skin due to light scattering remains a major limitation of these methods techniques and a permanent challenge that is being addressed as the technology advances.

Image contrast of unstained skin tissue, on the other hand, has been improved substantially and is based on different mechanisms corresponding to particular LSM techniques. Among these, reflectance confocal microscopy (RCM) and multiphoton microscopy (MPM) have been the most widely used in research studies related to applications in dermatology. RCM contrast is based on variations in tissue refractive index, which provide gray scale images with sub-micron resolution. MPM contrast in skin is derived from second harmonic generation (SHG) of collagen and two-photon excited fluorescence (TPEF) of tissue components such as the co-factors NADH and FAD, elastin, keratin, and melanin.

Due to its dual contrast mechanism, MPM provides dual-color images that distinguish cellular features from the extra-cellular matrix. MPM imaging is unique among other optical imaging technologies in that it provides 3D, near real-time

Figure 1.

MPM-based clinical tomograph MPTflex

sub-micron resolved label-free images of living tissues in their native environment with contrast that closely resembles the histological sections dermatopathologists use for diagnosis. MPM technology has been translated into clinical settings through the development of the MPM-based clinical tomographs, DermaInspect (1) and MPTflex by JenLab GmbH (Jena, Germany). This review summarizes the results of the most recent clinical studies in the dermatology field, performed by employing either the DermaInspect or the MPTflex tomographs.

MPM technology and translation into the clinic The first experiments using SHG and TPEF laser scanning microscopy have been performed in 1986 (2) and 1990 (3), respectively. The first experiments on in vivo TPEF imaging of human skin were performed at MIT in the late 1990s (4-6). TPEF and SHG imaging techniques were combined in a single MPM-based tomograph (DermaInspect) for in vivo skin imaging, at the University of Jena in 2003 (1). This system has been later developed by JenLab, GmbH (Jena, Germany) and CE-marked for clinical use along with its most advanced version MPTflex (Figure 1), a compact, portable device that features an articulated arm to allow imaging almost any region of the body. The system consists of a compact, Ti: Sapphire femtosecond laser, an articulated arm with near-infrared optics, and beam scanning module. The system has two photomultiplier tube detectors for parallel acquisition of twophoton excited fluorescence (TPEF) and secondharmonic generation (SHG) signals. A customized metallic ring taped on the subject’s skin attaches magnetically to the objective holder in the articulated arm, minimizing motion artifacts. The images September 2015

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Figure 2.

In vivo MPM imaging of normal skin (volar forearm). (Left) MPM horizontal sections (XY scans) at different depths showing images of the stratum corneum (z=0μm), keratinocytes normally distributed in the stratum spinosum (z=40μm), the basal cells (green) surrounding dermal papilla (blue) (z=85μm), collagen (blue) and elastin (green) in the dermis (z=115μm). (Right) Cross-sectional view (XZ scan) corresponding to a vertical plane through the horizontal sections on the left. The image shows the well-delineated layers of the stratum corneum, epidermis, dermalepidermal junction (DEJ) and the superficial dermis. Arrows point to blood vessels.

The dark circular shape inside each keratinocyte corresponds to the nucleus of the cell

acquired by MPTflex and DermaInspect have a lateral spatial resolution of ~0.5 μm and an axial resolution < 2 μm. The imaging depth in skin is about 200 μm, depending on the skin or lesion types imaged. The area imaged (field of view) is 250x250 μm2. The field of view can be increased to a few mm2 by implementing a mosaic “tiling” feature (acquisition of adjacent fields of view).

In the last years, both MPTflex and its former version DermaInspect have been employed in a broad range of clinical applications spanning from skin cancer detection and diagnosis (7-9), to cosmetic treatments (10), skin aging (11-14) and characterizing and understanding keratinocyte metabolism (15).

Applications of MPM-based clinical tomographs in dermatology In vivo MPM imaging of normal skin Commonly, MPM imaging is used in en-face (horizontal sections) mode, but cross-sectional (vertical) sections can also be acquired in realtime. Figure 2 shows a representative example of MPM images corresponding to normal skin and acquired with an MPTflex system. The en-face images were acquired as a z-stack of horizontal images every 5μm. En-face images corresponding to different skin layers were selected and shown in Fig. 1. The stratum corneum is visualized through the TPEF fluorescence from keratin. It appears as

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a thin bright layer on the top surface of the skin in the cross-sectional image and as an acellular bright fluorescent layer in the corresponding en-face image. The epidermis shows normally distributed keratinocytes imaged by the TPEF fluorescence from NADH/FAD, keratin and melanin (in the case of pigmented skin). The dermal-epidermal junction (DEJ) is clearly delineated in the cross-sectional view as it separates the basal cell layer from the dermis. Pigmented keratinocytes in the basal layer appear as bright fluorescent cells along the DEJ due to their melanin content. In the en-face images of the DEJ the basal cells are imaged as surrounding the tips of the dermal papillae. Dermal papillae and the dermis are visualized through the SHG signal from collagen and TPEF signal from elastin fibers. Occasionally, blood vessels and capillaries are imaged in the dermis as shown in Fig. 2.

In vivo MPM imaging of melanoma Melanoma is the most severe form of skin cancer.

It arises from melanocytes, the cells responsible for producing pigment. There are several subtypes of melanoma. Their features have differences and similarities, but generally the following are suggestive of malignancy: presence of melanocytes within the upper portion of the epidermis singly or in groups (Pagetoid spread); irregular junctional activity (atypical melanocytes, archi-

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Mihaela Balu, Bruce J. Tromberg

Figure 3.

MPM images of a micro-invasive melanoma lesion on a patient’s forehead (a) Clinical image (DermLite FOTO, Dermlite Inc.). The markers represent the locations where the images shown in (b1-b3), (c1-c3) and (d1-d3) were acquired. (b1-b3) MPM images corresponding to normal skin adjacent to lesion (red square in a) showing normal distribution of keratinocytes (b1), the basal cells (green) surrounding dermal papilla (blue) at 50 μm depth (b2) and collagen (blue) and elastin (green) fibers surrounding a hair follicle (arrow) in the dermis at a depth of 115 μm (b3). (c1-c2) MPM images of the epidermal layers corresponding to different depths of the lesion area indicated by the blue square in (a). The images show ascending melanocytes (white arrows) (c1-c2) and no obvious features of malignancy in the papillary dermis (c3). (d1-d3) MPM images of the lesion area indicated by the yellow square in (a). The images show ascending melanocytes (white arrows) in upper epidermal layers (d1), proliferation of melanocytes (white arrows) at DEJ (d2) and of pigmented cells with different shapes and enlarged nuclei (cellular atypia) in the dermis at a depth of 125 μm. Scale bar is 40 μm

tectural disorder); and invasion of tumor cells into the dermis (7, 16, 17). These features have been identified in melanoma lesions in a study published in 2009, where a DermaInspect MPM tomograph was used to establish sensitivity and specificity criteria

for melanoma diagnosis (9). The assessment by different observers of these features led to overall sensitivity and specificity values for melanoma diagnosis of 75% and 80%, respectively. In that study as well as in most of the RCM studies on in September 2015

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Figure 4.

MPM images of a superficial BCC lesion on the shoulder of a patient (a) Clinical image (DermLite FOTO, Dermlite Inc.). Scale bar is 2 mm. (b1-b5) MPM en-face images (XY scans) of the stratum corneum at z=0μm (b1), keratinocytes in the stratum spinosum at z=15μm (b2), a nest of basaloid cells (green) surrounded by collagen (blue) and elastin fibers (green) imaged at different depths: z=30μm, 45μm, 60μm (b3-b5). (c) Cross-sectional view (XZ scan) corresponding to a vertical plane through the same interrogating volume shown on the left. (d) H&E stained histologic section of the lesion. Both the MPM and the histologic images show a mucinous stroma adjacent to the tumor mass (arrows). Reproduced with permission from Ref. (8)

vivo imaging of melanoma, particular features of atypical/dysplastic nevi are hardly discussed. In a more recent pilot study, our group employed an MPM-based MPTflex tomograph to identify characteristic features of 15 melanocytic nevi at three different stages: common nevi without dysplastic changes, dysplastic nevi with structural and architectural atypia, and melanoma (5 in each group) (7). We proposed and developed a quantitative approach by translating the qualitative features used by dermatopathologists in histopathology into quantitative parameters that can be uniquely extracted from 3D in vivo MPM images. We defined a numerical “multiphoton melanoma index (MMI)” based on 3D in vivo image analysis that scores signals derived from TPEF, SHG, and melanocyte morphology features on a continuous 9-point scale.

Indices corresponding to common nevi (0–1), dysplastic nevi (1-4) and melanoma (5-8) were significantly different (p<0.05), suggesting the potential of the method to distinguish between melanocytic nevi in vivo(7). Nevertheless, a more comprehensive study of a larger number of patients is necessary in order to validate the proposed scoring algorithm and evaluate how well MPM technology can distinguish dysplastic nevi from common nevi and melanoma. Figure 3 illustrates representative

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MPM images of a micro-invasive melanoma lesion along with the MPM images corresponding to normal skin adjacent to lesion. The lesion was imaged prior to biopsy. The intra-epidermal proliferation of melanocytes and the upward intraepithelial spread shown in the MPM images of Figure 3 were confirmed by histopathology.

In vivo MPM imaging of basal cell carcinoma (BCC) BCC is a form of skin cancer that originates from the basal cells of the epidermis and associated follicular structures. Non-melanoma skin lesions, such as BCC have been imaged in vivo by MPM only recently in two pilot research clinical studies (8, 18) . In a first pilot study evaluating the in vivo MPM imaging of BCC lesions, the identified features were compared to the ones provided by RCM imaging (18). Besides the two main features: elongated, polarized nuclei and tumor nests showing peripheral palisading identified by both techniques, MPM had the ability to evaluate changes in the nucleus/cytoplasm ratio and in cell density across the epidermal layers of BCC lesions. In a more recent study, the MPTflex tomograph was used in order to evaluate if histopathologic criteria can be identified in MPM images (8). In this study, the use of MPTflex allowed imaging lesions on different parts

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Mihaela Balu, Bruce J. Tromberg

of the body rather than being limited to lesions on the extremities, as in the previous work, in which the DermaInspect was employed for MPM imaging (18) . This work demonstrated the ability of MPM to identify the main histopathologic criterion for BCC diagnosis in all the lesions imaged: tumor nests of basaloid cells at the DEJ and/or in the dermis that often showed palisading. The MPM ability to resolve the cellular structure inside the tumor nests is critical in distinguishing BCC from other types of neoplasms that involve presence of nests in the dermis. Figure 4 depicts representative MPM images of a BCC lesion imaged by MPM. Other applications of MPM in dermatology Aside from melanoma and non-melanoma skin cancers, MPM clinical tomographs have also been employed to imaging other skin conditions such as actinic keratosis (19, 20), atopic dermatitis (21) and pemphigus vulgaris(20). The morphological features identified in actinic keratosis lesions were associated with wide inter-cellular spaces between keratinocytes, an increase in the ratio of nuclear to cellular size of keratinocytes and an increase in epidermal thickness compared to adjacent normal skin (19). In atopic dermatitis lesions, changes in the cellular metabolism of the lesions have been assessed in vivo through protein-bound and free NADH fluorescence lifetime measurements (21).

Monitoring the effects of skin treatments, a key area of focus in cosmetic industry, is another field of interest for MPM imaging. In a study published in 2010, Bazin et. al used a DermaInspect MPM tomograph to evaluate the effects of a cosmetic product (topical cream) on the collagen and elastin fibers of the forearms of 24 subjects (10). The ratios between the signals from collagen and elastin were measured at different depths in the dermis for each subject. After 12 weeks of treatment, an increase in the collagen/elastin ratio was measured for the cosmetic product containing active components (soy and jasmine) known to increase collagen synthesis. The treatment with a placebo topical cream (no active ingredients) resulted in no significant variation in the collagen/elastin ratio over the same treatment period of time.

In order to evaluate cosmetic treatments targeting skin anti-aging, approaches to quantify skin aging non-invasively have been investigated by using MPM imaging. Lin et al. proposed a dermis index that estimates the skin age by the ratio of the SHG signal from collagen and the TPEF signal from elastin (22). The correlation of this index with age was demonstrated by in vivo MPM measurements of sites on subjects’ forearms and faces using a DermaInspect tomograph (11, 13). Kaatz performed depth-resolved measurements of the proposed dermis index and its correlation with age (12). MPM imaging has also been used by Koehler et al. to evaluate in vivo and non-invasively dermal elastosis, a characteristic of skin photoaging (14).

In addition to skin conditions diagnosis and treatments, in vivo MPM imaging has also been applied to monitoring of the supply of oxygen to

the mitochondria within epidermal cells (15). In this study, the ischemia-induced oxygen deprivation was associated with a strong increase in NADH fluorescence of keratinocytes in layers close to the stratum basale, whereas keratinocytes from epidermal layers closer to the skin surface were not affected. This outcome supports the hypothesis that the vascular contribution to the basal layer oxygen supply is significant and these cells engage in oxidative metabolism. Keratinocytes in the more superficial epidermal layers are either supplied by atmospheric oxygen or are functionally anaerobic (15) . Real-time, in vivo noninvasive monitoring of keratinocytes metabolism is important for clinical purposes and for understanding of cellular physiology and cytology.

Discussion The recent introduction of MPM for clinical studies in dermatology opened a new way to investigate human skin by imaging the epidermis and superficial dermis in vivo and non-invasively. Recent clinical studies have shown that MPM can be a potential tool for non-invasive imaging of different skin conditions including skin cancer, for monitoring cellular metabolism and the effects of skin treatments. While these are promising results indicating that real-time non-invasive “optical biopsies” can be performed at the bedside, translation of this technology into clinical practice seems to advance rather slowly due to several technical and practical challenges, which we discuss below.

In this early stage of MPM technology clinical translation, limited field of view (about 250x250 μm2) and penetration depth (about 200-300 μm) are the main technical challenges. The field of view can be increased by implementing a mosaic “tiling” feature (acquisition of adjacent fields of view) or by re-design of the optical components. This technical limitation is being addressed and implementation of tiling has been initiated in a newly developed MPTflex model. Penetration depth can be improved by employing dispersion compensation to decrease the laser pulse duration, but the gain would be limited. Generally, this technology is intended as an aid for dermatologists to improve their clinical diagnosis of early stage skin diseases when the uncertainty of their decision is likely to be higher than in the case of advanced disease.

Practical challenges are related to the need of establishing a correlation between the MPM and the histological images. Most importantly, the MPM provides high-resolution images that represent horizontal optical sections within a tissue. In histopathology, histological cross-sections of the biopsied tissue are used for diagnosis. Secondly, while the MPM provides images of the cellular structure and the extra-cellular matrix of the real tissue, the images of the histological sections contain artifacts due to tissue processing and staining. A relevant example is the different appearance of melanocytes, in the MPM images as dendritic cells, and in the hematoxylin and eosin (H&E) stained histoSeptember 2015

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logical sections, as highly pigmented cells sitting in a lacuna due to a marked fixation retraction artifact (23). Thirdly, the different color of the MPM and histology images might also be a barrier toward clinical acceptance of MPM. In MPM, images are usually color-coded using the primary colors: red, green or blue to represent the TPEF and the SHG signals. Histology is based on stains and images that have real color. For instance, the H&E histology is based on two stains (hematoxylin for nuclei, eosin for cellular cytoplasm and extra-cellular matrix of dermis) and the images appear purple and pink. This potential barrier can be addressed by “digitally staining” the MPM images to mimic the

histology appearance (24). Generally, overcoming these practical challenges related to translation of MPM to clinical practice requires training on both sides, the microscopy specialists and the dermatopathologists, in order to generate a common language that eases communication.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

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Clinical Study

Non invasive evaluation of patient with acne and rosacea. Implications in case - management.

NON INVASIVE EVALUATION OF PATIENT WITH ACNE AND ROSACEA. IMPLICATIONS IN CASE - MANAGEMENT EVALUAREA NON-INVAZIVĂ A PACIENTULUI CU ACNEE ȘI ROZACEE. IMPLICAȚII ÎN MANAGEMENTUL DE CAZ (1)

Victor Gabriel Clătici(1), Diana Ursu(1), Simona Fica(2,3) MD, Dermatology Department, ELIAS Emergency Universitary Hospital, Bucharest, Romania; (2) Professor, University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania; (3) Endocrinology Department, ELIAS Emergency Universitary Hospital, Bucharest, Romania Corresponding author: Victor Gabriel Clatici, 17 Bd Marasti Street, Sector 1, Bucharest, Phone 021 / 3161600 – 190 / 224, fax 021 / 3173052, E-mail victor.clatici@rojced.com

Open Access Article

Abstract Keywords: adult acne, rosacea, Propionibacterium acnes, antibiotic resistance

Acne and rosacea are chronic inflammatory skin diseases, with unpredictable evolution and associated with a major negative impact on quality of life.

Acne and rosacea therapeutic approach is holistic and individualized, based on complex evaluation of the patient prior to treatment and constant monitoring thereafter.

In this paper, we present non-invasive assessment of Propionibacterium acnes load on the face, both at baseline and after 3-4 weeks time using a washing gel based on piroctone olamine and white ichtiol. Also, we present an initial non invasive evaluation of parameters in patients with adult acne and rosacea, offering the possibility to an individualised treatment and better case management. Individualized approach (including digital evaluation) and holistic (diet, proper skin care, photoprotection, local and general treatment, laser intervention etc.) in adult acne and rosacea patients, and ongoing monitoring are critical elements in improving the quality of life and reducing adverse effects associated with these diseases.

Cite this article: Victor Gabriel Clătici, Diana Ursu, Simona Fica. Non invasive evaluation of patient with acne and rosacea.

Implications in case management.

RoJCED 2015; 2(3):168-179

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Victor Gabriel Clătici, Diana Ursu, Simona Fica

Rezumat Cuvinte-cheie: acnee forma tardivă a femeii adulte, rozacee, Propionibacterium acnes, rezistența la antibiotice

Acneea și rozaceea reprezintă afecțiuni inflamatorii cronice, cu evoluție ondulantă și adesea impredictibilă, asociate cu un impact negativ major asupra calității vieții pacienților.

Abordarea terapeutică în acnee și rozacee este de tip holistic și individualizat și are la bază evaluarea complexă a pacientului anterior instituirii tratamentului și monitorizarea permanentă a acestuia. În acest articol prezentăm evaluarea non-invazivă a încărcăturii cu propinibacterium acnes la nivelul feței, atât la momentul initial, cât și după utilizarea timp de 3-4 săptămâni a unui gel de spălare pe bază de piroctone olamine și ihtiol alb. De asemenea, prezentăm și evaluarea inițială noninvazivă a parametrilor feței la pacientele cu acnee – forma tardivă a femeii adulte și rozacee în vederea individualizării tratamentului și a managementului de caz.

Abordarea individualizată (inclusiv prin evaluare digitală) și holistică (dietă, îngrijirea pielii corectă, fotoprotecție, tratament local și general, intervenții laser etc.) a pacienților cu acnee și rozacee, precum și monitorizarea permanentă sunt elemente decisive în vederea îmbunătățirii calității vieții și reducerea efectelor negative asociate acestor boli.

1. Introduction 1.1 Acne, a chronic inflammatory disease, with a peak of incidence in adolescence (1,2), represents, in terms of practical activities, the most common diagnosis made by dermatologists (1,3).

More, acne vulgaris is considered now ,,epidemic,, in Western countries and affects 40-54% of population older than 25 years (4,5), especially women (1,6-8).

Acne - late form of adult women (form of acne after the age of 25 years) (9) is different from ,,classic acne,, respectively acne in adolescence through clinical aspects and therapeutic approach (7,10).

Acne in adult women is characterized by significant inflammatory lesions associated with a reduced number of comedones, and location of lesions (comedones, papules, nodules, cysts) is especially in the lower third of the face, neck and mandibular line(11-13).

The management of acne has to be holistic (14), characterized by “acute intervention” to induce clinical remission and “long-term intervention” for maintenance(1). Unfortunately, in general population there are a lot of misconceptions about the causes of acne especially about implications of stress, diet, skin hygiene and cosmetics, infection, exercise, and sunlight (9).

Acne pathogenesis is multifactorial and complex(4), including genetic factors, and is connected with excess sebum production by the sebaceous glands, follicular occlusion, hyper proliferation of Propionibacterium acnes (P. acnes) bacteria, and inflammation(14,15).

The public health issue in acne is represented by the frequency of disease, cost for medical care and

health systems, negative impact on quality of life, antibiotic resistance of P. acnes, and associated morbidity (9).

1.2 Rosacea is a chronic inflammatory(16,17) cutaneous skin disease, characterized by a fluctuant evolution, with clinical manifestations (flushing, persistant facial erythema, papules, pustules and telangiectasias), localized especially in the convex areas of the face. (18).

Elementary lesions are represented by flushing, telangiectasia, papules and pustules(16,19), with or without sebaceous gland hyperplasia, and secondary lesions include facial tenderness (burning, xerotic aspect), edema, plaques, phymas and ocular manifestations(19).

The ethyopathogenesis of rosacea remains a matter of controversies, being incompletely elucidated(20), and many factors are involved, sometimes difficult to identify. The disease occurs in genetically predisposed individuals, particularly those with 1-2 Fitzpatrick phototype, which are subject to certain environmental factors (16).

However, now it is considered that in the pathophysiology of rosacea two major factors are involved: the vascular factor and the inflammatory factor. Over the years, other etiopathogenic factors have been cited: genetic predisposition (16), gastrointestinal disorders (chronic gastritis, intestinal microbial flora imbalance, jejunal mucosal atrophy), hypertension, infection with Demodex folliculorum or Helicobacter pylori (21), vitamin B12 deficiency, endocrine disorders and neuro-psychological factors(20).

1.3 Propionibacterium acnes, which was classified as Corynebacterium parvum, has been implicated in acne for more than 100 years, respectively September 2015

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Figure 1.

Non invasive evaluation of patient with acne and rosacea. Implications in case - management.

Overview of a patient with rosacea - Personal archive of Victor Gabriel Clatici

from 1896 (22) when P acnes was found in acne lesions and this idea was supported by other authors (23).

P. acnes is a Gram positive, anaerobic bacteria and opportunistic pathogen which is found on skin, oral cavity, gastrointestinal and genitourinary tracts (24), and represents approximately half of the total skin microbiome (25) and predominates (more than 40% of total bacteria) in facial skin (26).

P. acnes is involved in many diseases, like acne vulgaris(27), medical device(28), dental(29) and ophthalmic(30) infections, as well as synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome (31) , sarcoidosis (32,33) and prostate cancer (34).

An update about P acnes implication in acne was published recently (35) and below will summarize the main elements. P acnes is involved both in the progression of inflammation in acne vulgaris (36,37) and tissue damage by releasing various virulence factors (38). P acnes activates adaptative (39) and innate immune system, and acts as a trigger of inflammation trough proinflammatory enzymes, cytokines and chemokines (40).

P acnes releases lipases, proteases, and hyaluronidases that contribute to tissue injury and induces the production of TNF-a, IL-1a, and IL-8 (41,42) . The toll-like receptor 2 (TLR2) is important in the pathogenesis of acne, and by activation of TLR-2, P acnes may trigger inflammatory cytokine responses in acne (42) and can activated by the same way , via TLR-2, keratinocytes and sebocytes of the pilosebaceous unit (43). Also, P acnes may be involved in the formation of the microcomedones (44,45).

An important problem in acne therapy is bacterial resistance to antibiotic, because in the last decades P acnes developed resistance to many

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antibiotics (46,47). In 1976, according to Leyden (48) there was no evidence of antibiotic-resistant propionibacteria on the skin of over 1000 patients with acne, but in 1979 Crawford (49) published about first resistance of P acnes to topical therapy ( erythromycin and clindamycin).

The importance of antibiotic resistance of P acnes is showed by the possibility to transfer the resistant genes from P acnes to staphylococci or streptococci (49,50).

The probability to develop resistance of P acnes is strongly connected with the patient’s age, duration of acne, and duration of treatment with topical or systemic antibiotics(51).

1.4 Impact of rosacea on Quality of life (QOL) Rosacea has been described as “the curse of the Celts”, emphasizing the major handicap of facial erythema on social relationships, mainly because of its association (not very true in all cases!) with alcohol consumption(52,53) and the high prevalence of rosacea among individuals with I-II Fitzpatrick phototype(54).

Historically, facial erythema was a major cause for social stigmatization (55-57), and facial blemishes interact in negative way with the psychological, social and occupational aspects on patients’ lives(52).

Rosacea is located in extremely visible places and may have a profound impact on patients’ lives (58) , who might suffer from anxiety, depression or social phobia QOL (53).

Rosacea patients can experience embarrassment (70%), low self-esteem (75%), frustration associated with their disease, impaired social functioning(59), all of these leading eventually to social and professional isolation (17). Similar to

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Victor Gabriel Clătici, Diana Ursu, Simona Fica

Figure 2.

Patient 15: level of porphirins before and after use of cleansing gel - Personal archive of Victor Gabriel Clatici

Figure 3.

Patient 7: level of porphirins before and after use of cleansing gel - Personal archive of Victor Gabriel Clatici

other dermatological conditions affecting visible sites, rosacea patients suffer from mental stress (60,61) and social stigmatization, sometimes leading to psychiatric comorbidities.

Consequently, patients with rosacea may associate psychological comorbidities, such as anxiety disorders, social phobia (62,63), or even depression (17,64,65).

1.5 Impact of acne on QOL The lesions of acne located on the face are very visible (and cannot be covered by clothes); therefore, it is understandable that Sulzberger et al came to the conclusion that: ‘There is no single disease which causes more psychic trauma, more maladjustment between parents and children, more general insecurity and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris.’ (9,66). Acne is not an insignificant problem (4,67) and is not a self- limiting disorder or a “cosmetic” problem (68).

Moderate to severe acne localized on the face has negative impact, including social, psychological, emotional and economic impact, and patients have great difficulties in finding a job (68) or present low self-esteem and depression (69,70). The appearance of the skin causes changes in body image,

with negative consequences as anger, fear, embarrassment, anxiety, depression or stigma (71,72).

Impact on quality of life of acne is similar with impact of epilepsy, asthma, diabetes or arthritis(73) and at least 40 % of patients with acne in adulthood present a psychiatric comorbidity (74), including suicidal thoughts (75).

The presence of acne in adult women increases the risk of anxiety, depression, and suicidal ideation (9) and has a negative effect on work or educational performance.

It is more than likely that the media’s portrayal of flawless skin as an ideal is the leading cause of psychological morbidity in females (76) and unemployment rates is significantly higher among adults with acne compared with matched – controls (68).

2. Digital analysis of the face (VISIA evaluation) Canfield VISIA Complexion Analysis System (Fairfield, NJ) is a multispectral digital analysis system that performs an in depth analysis of the skin (18,77-79) and allows taking digital photographs and analysis of the characteristics of the facial skin in a non-invasive manner. The technology uses polarized light system called RBX® Technology, for asSeptember 2015

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Table 1. Evaluation of PA load (percentile / score) before and after intervention Left view PT1 / ST1

Left view PT2 / ST2

Left view ΔP/ ΔS

Frontal view PT1 / ST1

Frontal view PT2 / ST2

Frontal view ΔP/ ΔS

Right view PT1 / ST1

Right view PT2 / ST2

Right view ΔP/ ΔS

1/ 32

11 / 3,461

14 / 2,754

27,27 / 20,42

5 / 4,794

8 / 3,635

60 / -24,17

11 / 3,407

13 / 2,990

18,18 / 12,23

7 / 24

13 / 2,992

96 / 0,074

638,48 / 97,52

9 / 3,143

94 / 0,103

944 / -96,98

13 / 2,987

96 / 0,065

638 / -97,82

10 / 31

42 / 1,039

94 / 0,099

123,80 / -90,47

49 / 0,836

96 / 0,080

95,91 / -92

40 / 1,110

96 / 0,080

140 / -92,79

12 / 44

14 / 2,672

32 / 1,332

128,57 / -50,14

8 / 3,685

13 / 2,819

62,5 / -23,5

22 / 1,828

26 / 1,658

18,18 / -9,2

15 / 23

3 / 8,627

27 / 1,587

800 / 81,60

3 / 6,666

38 / 1,123

1166 / -83,16

3 / 8,149

21 / 1,982

600 / -75,67

18 / 27

13 / 3,044

36 / 1,260

176,92 / -58,60

9 / 3,498

24 / 1,627

166,66 / -49,25

11 / 3,350

27 / 1,622

145 / -51,58

Patient / Age

Legend: PT1 = percentile T1, PT2 = percentile T2, ST1 = score T1, ST2 = score T2

sessing changes in epidermal and dermal level, and a lamp emitting in the ultraviolet spectrum (UV light lamp), and analysis of the photos is done by the integrated software (18, 80-82).

The VISIA technology (VISIA - Canfield Imaging Systems, Fairfield, NJ) was used for computerized analysis of facial wrinkles in terms of density and depth (79) or for general assessment for skin tone and number of wrinkles (83), while other authors (84) describe VISIA system applicability in evaluating treatments for wrinkles type fractional photothermolysis .

The quantification of parameters, conducted by the integrated software, is percentile (85) (compared with people of the same age / sex / phototype), feature counts (no size or intensity parameter) and absolute score - evaluated the impact parameter (total size and intensity parameter).

SPOT - standard shooting - are red / brown lesions, which include freckles, acne scarring, hyperpigmentation lesions and vascular lesions.

PORES - standard shooting - are circular openings in surface of sweat glands. WRINKLES - standard shooting - are cutaneous skin changes that are favored by sun exposure, and are associated with decreased skin elasticity. TEXTURE - standard shooting - is a primary analysis element of the skin and its fineness. UV SPOT - ultraviolet shooting is induced by exposure to UV radiation and occur when the skin melanin aggregates below the surface as a result of the negative effects associated with exposure to sunlight. UV spot are invisible to normal exam and selective absorption by melanin UV helps detect these spots using VISIA. By evaluating these changes caused by UV radiation and

172

sun exposure can estimate the lifetime risk of developing skin cancer. PORPHYRINS - shooting ultraviolet - are substances produced by the bacteria involved in the occurrence of acne and remain in the pores. Porphyrins are an accurate indicator of the load with Propionibacterium acnes, the bacterium involved in the development process of acne.

RED AREAS - shooting RBX - allow the identification of areas of red, representing blood or hemoglobin. The vascular changes are pointed towards some type of vascular structures (spider veins or broken capillaries), rosacea or acne. BROWN SPOT - shooting RBX- are the result of concentration of melanin in the skin or subcutaneous level, and represent various forms of hyperpigmentation resulting from exposure to sunlight or melasma.

Using VISIA computer analysis for rosacea was presented in (18), also the use of VISIA for assessment and monitoring to individualization of treatment in patients with acne was mentioned in other papers (14,86,87).

3. Evaluation of Propionibacterium acnes bacterial load with digital technology before and after using a cleansing agent (pirocton olamine and white ihtiol) Material and methods: we use for evaluation of Propionibacterium acnes load VISIA technology, by assessment the porphyrins (which is normally produced by P acnes and can be visualized by using Wood lamp or UV flash). We include 20 women, mean age 29,1 years, minimum = 23 years and maximum = 44 years. The evaluation was made at T1 (before intervention) and T2 (after 3-4 weeks) and using for cleansing an agent with piroctone

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Victor Gabriel Clătici, Diana Ursu, Simona Fica

Figure 4.

Patient 17 (rosacea, 43 years). Comparation spot and red areas - Personal archive of Victor Gabriel Clatici

Figure 5.

Patient 4 (acne, 23 years). Comparation spot and porphyrins - Personal archive of Victor Gabriel Clatici

olamine and white ihtiol (morning and evening, and allowing 3-5 minutes for action on the face).

We use 2 parameters, percentiles (the higher, the better) and scores (the lower, the better).

The patients was instructed to use sunscreen products, in diet (4,9) was forbidden milk and dairy, food with high glycemic index, and the patients don’t received any kind of treatment which can reduce the P acnes level (topical and / or systemic antibiotics or laser treatment).

The efficiency was evaluated trough the evolution of percentiles and scores: Δ P = Δ percentile = (PT2-PT1/ PT1) X 100 and Δ S = Δ score = (ST2-ST1/ST1) X100. The better evolution was defined as Δ P positive (the bigger, the better) and Δ S negative (the lower, the better). Patients did not present any notable adverse events.

The results for 6 patients are showed in Table 1.

Left view (LV) – for left cheek: Mean percentile T1 = 17 / Mean score T1 = 3,8721 / Minimum T1 (percentile / score) = 3(15) / 1,039(10) / Maximum T1 (percentile / score) = 42 (10) / 8,627 (15).

Mean percentile T2 = 50,32 / Mean score T2 = 1,1927 / Minimum T2 (percentile / score) =14(1) / 0,074(7) / Maximum T2 (percentile / score)= 96 (7) / 2,754 (1) Δ percentile (mean) = 196 / Minimum = 27,27 (1) / Maximum = 800 (15) Δ score (mean) = - 69,19 / Minimum = -20,42(1)/ Maximum = -97,52(7).

Frontal view (FV) – include the forehead: Mean percentile T1 = 12,87 / Mean score T1 = 3,963 / Minimum T1 (percentile / score) =3 (15)/ 0,836 (10) / Maximum T1 (percentile / score)=49 (10) / 6,6666 (15) Mean percentile T2 = 46,9 / Mean score T2 = 1,4731 / Minimum T2 (percentile / score) = 8 (1) / 0,080 (10) / Maximum T2 (percentile / score) = 96 (10) / 3,635(1) Δ percentile (mean) = 264,41 / Minimum = 60(1)/ Maximum = 1166(15) Δ score (mean) = -61,67 / Minimum = -24,17 (1) / Maximum = -96,98 (7).

Right view (RV) – for right cheek: Mean percentile T1 = 15,8 / Mean score T1 = 3,5832 / Minimum T1 (percentile / score) = 3(15) September 2015

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Table 2. ROSACEA (percentile)

Patient/ age

Left view

Frontal view

Right view

Spot

UV spot

Red areas

Prf.

Spot

UV spot

Red areas

Prf.

Spot

UV spot

Red areas

Prf.

1 / 36

49

42

42

17

51

43

45

11

70

45

29

20

4 / 36

62

45

69

73

63

45

69

81

63

45

47

83

9 / 37

29

24

32

70

26

38

51

56

34

27

26

67

10 / 38

34

64

70

34

45

69

87

20

21

62

67

24

12 /26

33

58

56

51

29

67

69

42

33

58

56

51

14 /36

46

63

51

18

42

56

57

11

64

58

51

17

16/32

76

47

30

11

62

47

49

9

81

52

40

8

17 / 43

11

71

88

20

13

69

87

5

13

64

91

13

18 / 31

32

43

56

46

45

51

60

39

43

46

54

66

20 / 33

33

46

52

68

42

48

45

68

43

49

42

70

Mean 35,2

41,2

50,9

56,3

40,9

42,1

52,9

62,5

35,2

45,5

51,5

50,9

42,3

Min. 26

11 (17)

24(9)

27(9)

26(9)

8(16)

Max.43

76 (16) 71 (17)

64 (17)

91(17)

83(4)

30(16)

11 (16) 13 (17)

38(9)

88 (17)

73 (4)

69(17) 87(17) 81(4)

63(4)

45(20) 5 (17) 13 (17) 81 (16)

Table 3. ROSACEA (scores) Patient/ age

174

Left view

Frontal view

Right view

Spot

UV spot

Red areas

Prf.

Spot

UV spot

Red areas

Prf.

Spot

UV spot

Red areas

Prf.

1 / 36

2,907

15,093

4,451

2,383

2,948

14,077

4,794

3,110

2,019

14,614

5,714

2,021

4 / 36

2,327

14,772

2,584

0,440

2,420

13,692

2,895

0,297

2,289

14,819

4,118

0,277

9 / 37

3,856

19,375

5,518

0,475

4,168

15,274

4,348

0,661

3,559

18,302

6,224

0,522

10 / 38

3,593

11,491

2,606

1,293

3,291

9,826

1,597

1,887

4,398

11,756

2,774

1,782

12 /26

3,168

9,827

2,975

0,824

3,601

7,689

2,487

0,969

3,168

9,827

2,795

0,824

14 /36

2,993

11,352

3,924

2,160

3,334

11,985

3,873

2,953

2,308

12,377

3,844

2,442

16/32

1,695

13,317

5,356

3,169

2,387

12,606

4,324

3,456

1,545

12,451

4,487

3,957

17 / 43

5,733

10,474

1,311

2,107

5,609

10,128

1,638

5,907

5,427

11,895

1,083

2,878

18 / 31

3,474

13,796

3,314

0,950

3,004

11,579

3,426

1,054

2,961

13,327

3,466

0,542

20 / 33

3,572

14,023

3,410

0,673

2,791

12,071

3,841

0,403

2,872

12,497

3,823

0,541

Mean 35,2

3,3871 13,473 3,5781 1,4571 3,4673

11,9123 3,3451

2,0984

3,0673

13,2783 3,7903 1,6103

Min. 26

1,695 (16)

9,827 (12)

1,311 (17)

0,440 (4)

2,387 (16)

7,689 (12)

1,638 (17)

0,297 (4)

1,545 (16)

9,827 (12)

1,083 (17)

0,277 (4)

Max. 43

5,733 (17)

19,375 (9)

5,518 (9)

3,169 (16)

5,609 (17)

15,274 (9)

4,794 (1)

5,907 (17)

5,427 (17)

18,302 (9)

6,224 (9)

3,957 (16)

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Victor Gabriel Clătici, Diana Ursu, Simona Fica

Table 4. ACNE (percentile) Patient/ age

Left view

Frontal view

Right view

Spot

UV spot

Red areas

Prf.

Spot

UV spot

Red areas

Prf.

Spot

UV spot

Red areas

Prf.

1/40

26

62

62

36

30

62

66

30

45

69

47

24

4/23

5

33

32

5

5

34

45

8

3

42

38

7

7/18

20

32

30

11

26

36

39

14

24

40

36

15

9/18

5

32

39

67

9

34

56

54

7

34

36

51

10/44

39

70

87

97

42

81

94

96

38

73

78

97

13/29

5

43

33

21

13

43

39

14

7

54

38

29

15/19

11

24

47

2

11

27

60

11

14

29

46

2

18/31

5

42

34

42

11

56

49

49

8

43

36

40

20/29

66

56

66

20

49

51

67

7

54

58

70

27

21/24

32

54

49

29

18

56

54

24

34

56

45

27

24/23

32

69

29

32

42

62

58

29

18

60

39

26

25 /23

27

51

40

17

40

54

56

20

26

45

36

14

28/27

39

42

39

27

45

57

47

20

39

42

39

27

29/36

27

49

40

8

26

47

45

5

29

39

45

9

30 / 32

45

51

54

7

66

66

63

13

40

52

58

7

Mean 26,82

25,2

47,8

46,2

27,5

27,9

50,5

54,9

26,7

25,2

49,61

44,9

26,9

Min18

5 (13)

2 (15)

5 (4)

27 (27)

39 (13)

5 (29)

3 (4)

29 (15) 36 (18)

Max 44

66 (20) 70 (10) 87 (10) 97 (10) 66 (30) 81 (10)

94 (10)

96 (10)

54 (20)

24 (15) 29 (21)

/ 1,110 (10)/ Maximum T1 (percentile / score)= 40(10) / 8,149 (15) Mean percentile T2 = 44,3 / Mean score T2 = 1,4821 / Minimum T2 (percentile / score) =13 (1) / 0,065 (7) / Maximum T2 (percentile / score)= 96 (7,10) / 2,990 (1) Δ percentile (mean) = 180,37 / Minimum = 18,18 (1) / Maximum = 638 (7) Δ score (mean) = -58,63 / Minimum = -9,2 (12) / Maximum = -97,82 (7).

4. Initial digital evaluation of patients with acne and rosacea in order to improve the case management Material and methods: we use for initial evaluation of patients with acne and rosacea VISIA technology, by assessment the spot (standard

2 (15)

73 (10) 78 (10) 97 (10)

shooting), UV spot (UV shooting), red areas (RBX shooting) and porphyrins (UV shooting).

We include 20 women with rosacea, mean age 35,2 years, minimum = 26 years and maximum = 43 years, and 30 women with acne, mean age = 26,8 years, minimum = 18 years and maximum = 44 years. We use 2 parameters, percentiles and scores. The results for 10 patients with rosacea are patients are showed in Table 2 and 3, and the results for 15 patients with acne are showed in Table 4 and 5.

5. Discussion 5.1. Propionibacterium acnes is a germ with multiple connections in medicine, including dermatology. P acnes represent an important target of September 2015

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Non invasive evaluation of patient with acne and rosacea. Implications in case - management.

Table 5. ACNE (score) Patient/ age

Left view

Frontal view

Spot

UV spot

Red areas

Prf.

Spot

UV spot

Red areas

Prf.

Spot

UV spot

Red areas

Prf.

1/40

4,085

12,490

3,275

1,230

4,102

11,841

3,394

1,342

3,185

10,921

4,324

1,776

4/23

5,920

13,716

4,683

5,944

6,806

12,648

4,024

3,943

7,069

12,292

4,109

4,535

7/18

3,587

12,601

4,472

3,372

3,431

11,439

4,185

2,559

3,383

11,233

3,969

2,654

9/18

5,431

12,268

3,587

0,536

4,834

11,058

2,888

0,735

5,002

11,827

3,960

0,825

10/44

3,574

11,432

1,606

0,049

3,661

8,401

0,872

0,067

3,651

10,807

2,273

0,032

13/29

6,148

13,153

4,795

1,971

4,931

12,287

4,847

2,470

5,565

11,132

4,488

1,539

15/19

5,136

9,263

3,447

2,006

5,180

7,820

3,114

1,307

4,756

7,917

3,523

2,192

18/31

6,559

13,762

4,853

1,039

5,473

10,704

4,250

0,836

5,609

13,660

4,729

1,110

20/29

2,029

10,839

2,542

2,158

2,803

11,250

2,721

4,324

2,420

10,472

2,236

1,602

21/24

3,184

10,184

3,280

1,507

4,194

9,188

3,463

1,662

3,041

9,612

3,631

1,626

24/23

3,077

7,366

4,889

1,391

2,870

8,056

3,049

1,449

3,927

8,886

3,963

1,709

25 /23

3,345

10,239

3,869

2,346

2,910

9,337

3,153

1,883

3,424

11,515

4,311

2,660

28/27

2,919

12,838

4,197

1,604

2,894

9,582

4,044

1,935

2,919

12,838

4,197

1,604

4,218

3,754

3,135

4,547

29/36

3,905

11,906

4,646

4,034

4,218

13,383

4,885

5,356

3,823

15,699

30 / 32

2,907

12,543

3,484

4,390

2,169

9,075

3,134

2,655

3,079

12,175

Mean 26,82

4,1903 11,6702 3,8214 2,2415 4,1283 10,7241 3,4823 2,1891 4,0615 11,3825 3,8241 2,1612

Min18

2,029 (10)

9,263 (15)

1,606 (10)

0,049 (10)

2,169 (30)

7,820 (27)

0,872 (10)

0,067 (10)

2,420 (20)

7,917 (15)

2,236 (20)

0,032 (10)

Max 44

6,559 (13)

13,762 (18)

4,889 (21)

4,390 (30)

6,806 (4)

13,383 (29)

4,885 (29)

5,356 (29)

7,069 (4)

15,699 (29)

4,729 (18)

4,547 (30)

treatment in acne and in the last decades a lot of concerns exist about the P acnes resistance to antibiotics and the possibility to transfer the resistance to other species.

The level of P acnes depends on many factors, including sebum, diet, skin care (with emphasis on cleansing agents), local treatment and systemic treatment, and laser treatment.

A lot of literature underlined the link between the efficacy of treatment in acne and the reduction of P Acnes levels in the skin, but the treatment must not induce antibiotic resistance.

The use of cleansing agent against P acnes (like piroctone olamine combined with white ihtiol) is good in acne management but must be associated with other therapies (topical retinoid, BPO, topical and/or systemic antibiotic) in order to reduce the bacterial load, improve the acne and don’t allow the selection of P acnes clones resistant to antibiotic.

About the results, globally the lower response was in patient1 (32 years) with next results : for left view Δ percentile 27,27 and Δ score - 20,42, frontal view Δ percentile 60 and Δ score -24,17, and for right view Δ percentile 18,18 and Δ score -12,23.

A dramatically response was note on patient 15 (23 years) – figure 2: left view Δ percentile = 800 , frontal view Δ percentile = 1166 , and for right view

176

Right view

Δ percentile = 600, and for patient 7 (24 years) – figure 3: left view Δ score = -97,52 , frontal view Δ score = -96,98 , and for right view Δ score = -97,82.

Possible explanations for these results are the age of the patients, the modalities of product use and/or other unknown factors. We must underline that the P acnes is not the only target of treatment in acne patients, but the best treatment strategy is based on combination (retinoid and/or antibiotic and/or BPO and/or azelaic acid etc.) and must permanently adapt the treatment to evolution and specific condition of the patient.

Antibiotic as mono-therapy (topic and /or systemic) should be discouraged because is a huge risk to select P acnes resistant to antibiotic and the duration of antibiotic therapy must be reduced at minimum possible.

Evaluation of P acnes load with non invasive technology allow as to have a quick and reproductible image of the face, and allow both personalized treatment (including skin care) and monitoring the evolution.

5.2 Rosacea and acne represent 2 of most important chronic conditions of the skin, with a big impact on patient’s quality of life. One of the most important things is to individualize the treatment according to the specific needs of the patients. In order to do this, we proposed a digital evaluation

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Victor Gabriel ClÄ&#x192;tici, Diana Ursu, Simona Fica

Figure 6.

Comparation of spot and porphirines in a patient with rosacea ( frontal view) - Personal archive of Victor Gabriel Clatici

Figure 7.

Digital evaluation for monitoring a patient with acne - Personal archive of Victor Gabriel Clatici

of the patient face with acne and rosacea, and focus on four features: spot, UV spot, red areas and porphyrins.

Regarding rosacea patients, we found an unexpected high values of porphyrins, especially in the FV (frontal view). A possible explanation could be that, even if the forehead does not present many lesions in rosacea, it does have many pilosebaceous units, therefore it contains a high load of P Acnes â&#x20AC;&#x201C; photo 6. Also, we found a high scores of UV spot which reflect the invisible damages on the skin due to ultraviolet exposure (and UV spot

reflect life time exposure to UV). Regarding the correlations between different features we found a positive correlation UV spot / Red areas, and an inverse correlation Spot / Porphyrins and Red areas / Porphyrins.

About acne patients, we found a good correlations Spot / Porphyrins and an inverse correlation Red areas / Porphyrins. Also, we found high scores of UV spot and Red areas, and an unexpected mean scores of Red areas higher than mean scores of Porphyrins (the meaning of this feature is, at the moment, unknown).

September 2015

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Figure 8.

Digital evaluation for monitoring a patient with rosacea - Personal archive of Victor Gabriel Clatici

6. Conclusions The digital evaluation of the patient with rosacea and acne is an important noninvasive tool both to first evaluation of the patient and for the monitoring of the treatment (photo 7, 8).

For the future, must set up new studies with a big number of patients to correlate age / skin parameters (spot, UV spot, red areas, porphyrins) / other factors (smoking, sun exposure, associated diseases etc.).

7. Aknowledgement This paper is supported by the Sectorial Operational Programme Human Resources

Development (SOP HRD), financed from the European Social Fund and by Romanian Government under the contract number POSDRU/159/1.5/S/137390.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

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52. C Voicu, VG Clatici. ROSACEA – IMPACT ON QUALITY OF LIFE. THE NEED OF EDUCATIONAL PROGRAMS FOR PATIENTS. ROZACEEA – IMPACT ASUPRA CALITĂȚII VIEȚII. NECESITATEA PROGRAMELOR EDUCAȚIONALE PENTRU PACIENȚI. Romanian Journal of Clinical and Experimental Dermatology - RoJCED 2015; 2 (2): 134-137, Print : ISSN 2392 – 7461, ISSN –L 2392-7461, Online ISSN 2392-8697 53. The psychological impact of rosacea and the influence of current management optionsFarah Moustafa, BS, Robin S. Lewallen, MD, Steven R. Feldman, MD, PhD, Journal of the American Academy of Dermatology , Publication stage: In Press Corrected Proof, Accepted:

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86. VG Clatici, EFICIENȚA ASOCIERII IHTIOL ALB – PIROCTON OLAMINĂ IN REDUCEREA INFECTIEI CU PROPIONIBACTERIUM ACNES LA NIVELUL FEȚEI, Al 11 lea Congres national de Dermatologie cu Participare Internationala, Cluj-Napoca, 24-27 octombrie 2012 87. VG Clatici, O Clatici, ER Kasimati, AM Draganita, ACNEE VULGARĂ – EVALUARE COMPUTERIZATĂ VISIA, ABORDARE COMPLEXĂ ȘI TRATAMENT LASER 4th International Conference on Lasers in Medicine, Sibiu, 22-24 Septembrie, 2011

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MODIFICAREA MICROBIOMULUI CUTANAT: O NOUĂ ABORDARE ÎN MANAGEMENTUL DERMATITEI ATOPICE Prof. Thomas Bieber, MD, PhD, MDRA Departamentul de Dermatologie și Alergologie, Universitatea din Bonn, Germania

Cunoștințele acumulate în înțelegerea cât mai profundă a afecțiunilor cronice și inflamatorii ale pielii au fost posibile datorită progresului în domeniile epidemiologiei, geneticii și imunologiei. În acest context, rolul organismelor microbiene a fost întotdeauna luat în considerare din punctul de vedere al caracteristicilor patogene. În ultima vreme, datorită analizelor metagenomice moderne s-a dovedit că, la fel ca și în cazul altor organe, pielea fără leziuni este colonizată de o comunitate bogată de microorganisme comensale , iar diversitatea acestora este un factor cheie pentru o piele sănătoasă. Pe de altă parte, multe afecțiuni sunt caracterizate de o colonizare microbiană anormală (așa numita «disbioză»), al cărei rol patologico-fiziologic rămâne un subiect de dezbatere. În aceast caz, o modificare directă a microbiomului cutanat, ce are ca scop diversificarea acestuia, reprezintă o abordare terapeutică interesantă pentru multe afecțiuni.

O astfel de strategie a fost explorată pentru tratarea dermatitei atopice înca de acum câțiva ani. Având la bază observațiile realizate în Centrul Termal Terapeutic din orășelul francez La Roche-Posay, s-a presupus că un emolient îmbogățit cu o biomasă de Vitreoscilla Filiformis (VF) crescută în apă termală, ar putea avea un efect clinic asupra acestei afecțiuni. Într-adevăr, într-un articol publicat în 2008 în British Journal of Dermatology, Gueniche et al. au raportat o îmbunătățire semnificativă la pacienții cu dermatită atopică, folosind această strategie.

Aceste rezultate încurajatoare i-au determinat pe cercetători să analizeze în detaliu mecanismele implicate. Într-o lucrare mai recentă publicată în Clinical, Cosmetic and Investigational Dermatology, Mahe et al. au arătat că un lizat Aqua Posae Filiformis (APF), obținut din VF crescută în APĂ TERMALĂ LA ROCHE-POSAY, a fost capabil să activeze celule prin intermediul receptorilor Toll-like 2 și să exercite un impact asupra expresiei superoxid dismutazei 2 și expresiei peptidelor anti-microbiene, cât și asupra proteinei S100A7. Aceste experimente sugerează că un extract de VF este capabil să stimuleze componente importante ale sistemului imunitar cutanat.

Prin urmare, sunt martorii unei noi și fascinante ere în domeniul dermatologiei, în care rolul «musafirilor microbieni permanenți» din organismul nostru, abia începe să fie înțeleasă.

Extras din Editorial Prof. T. Bieber. Rezumat publicații, EADV 2014.

Clinical Study

Cutaneous findings in chronic kidney disease and hemodialysis

CUTANEOUS FINDINGS IN CHRONIC KIDNEY DISEASE AND HEMODIALYSIS MANIFESTĂRI CUTANATE LA PACIENŢII CU INSUFICIENŢĂ RENALĂ CRONICĂ HEMODIALIZAŢI Ignat Ana-Sonia1), Gliga Mirela2), 5), Badea Iudita-Maria3), Badea Mihail-Alexandru1), Lefter Elena4), 5), Morariu Sliviu-Horia1) 1) Dermatology and Venerology Clinic, Mureş County Hospital, Tîrgu-Mureș, Romania 2) Nephrology Clinic, Mureş County Hospital, Tîrgu Mureș, Romania 3) Anesthesiology Clinic, Emergency County Hospital, Tîrgu -Mureș, Romania 4) Galenus Medical Center Tîrgu-Mureș, Romania 5) Hiparion Dialysis Center Tîrgu-Mureș, Romania Corresponding author: Ignat Ana-Sonia, Resident physician, Dermatology Clinic, Mureş County Hospital, Tîrgu-Mureș, Romania; Phone: 0740262279; E-mail: comsa.sonia@gmail.com

Open Access Article

Abstract Keywords: chronic kidney disease, hemodialysis, cutaneous lesions

Cite this article: Ignat Ana-Sonia, Gliga Mirela, Badea Iudita-Maria, Badea Mihail-Alexandru, Lefter Elena, Morariu Sliviu-Horia.

Cutaneous findings in Chronic Kidney Disease and hemodialysis.

RoJCED 2015; 2(3)182-189

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Introduction: Chronic Kidney Disease together with hemodialysis play a role in the cutaneous findings of those affected. The aim of our paper was to evaluate the incidence and the characteristics of the cutaneous findings among patients with chronic kidney disease, undergoing hemodialysis.

Materials and methods: We analyzed 35 patients, from a hemodialysis center, in Tirgu-Mures, filling in observation sheets with all information including the onset of the chronic kidney disease, hemodialysis, laboratory results, and dermatologic exam.

Results: Each analyzed patient had at least one cutaneous finding, varying from xerosis (12 patients), pruritus (12 patients), cutaneous pallor (23 patients), pigmentation (all of them), petechiae (13 patients), nail changes (4 patients), oral changes (12 patients), cutaneous viral infections (21 patients), to cutaneous tumors (1 patient), psoriasis (1 patient), seborrheic dermatitis (1 patient), erythema nodosum (1 patient).

Discussion: Poor hydration of the stratum corneum, protein malnutrition, increased levels of parathyroid hormone, immunosuppression caused by chronic renal insufficiency, are favoring causes of the cutaneous findings.

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Ignat Ana-Sonia, Gliga Mirela, Badea Iudita-Maria, Badea Mihail-Alexandru, Lefter Elena, Morariu Sliviu-Horia-

Rezumat Cuvinte-cheie: insuficiență renală cronică, hemodializă, leziuni cutanate

Introducere: Insuficiența renală cronică și hemodializa influențează manifestările cutanate ale celor afectați.

Scopul lucrării este evaluarea incidenței și caracteristicilor manifestărilor cutanate în rândul bolnavilor cu boală renală cronică, hemodializați.

Materiale și metodă: Am analizat 35 de pacienti, din cadrul unui centru de dializă din Târgu-Mureş. S-au întocmit fișe de consultații, incluzând istoricul afecțiunii de fond, debutul hemodializei, rezultate de laborator și examenul dermatologic.

Rezultate: Toți cei examinați au prezentat cel puțin o manifestare cutanată, variind de la xeroză (12 pacienți), prurit (12 pacienți), paloare tegumentară (23 pacienți), hiperpigmentare (toți pacienții), peteșii (13 pacienți), modificări unghiale (4 pacienți), orale (12 pacienți), infecții cutanate virale (21 pacienți), la tumori cutanate (1 pacient), forme rebele de psoriazis (1 pacient), dermatită seboreică (1 pacient), eritem nodos (1 pacient).

Discuții: Hidratarea redusă a stratului cornos, malnutriția proteică, nivelul crescut al parathormonului, imunodepresia determinată de insuficiența renală cronică, sunt cauze favorizante ale leziunilor cutanate întâlnite.

Introduction Chronic kidney disease (CKD) summarizes all functional and renal changes and their consequences, due to progressive and irreversible reduction in kidney function by decreasing the number of functional nephrons (1, 3).

Thereby, after a study led by Kidney Disease: Improving Global Outcomes (KDIGO) and a conference on this subject, chronic kidney disease is defined as a glomerular filtration rate (GFR) <60 mL / min / 1.73m for 3 months or even more, whatever the cause.

GFR can be estimated by using special formulas and its value is used for the classification of renal disease into 5 stages (2).

The aims of the conventional treatment in chronic renal failure are: the delay of hemodialysis through a rigorous control of the progressive factors of chronic renal insufficiency; prevent potential risks (e.g. vaccination); prevent complications of chronic renal insufficiency (hyperthyroidism, anemia); avoidance of nephrotoxic drugs and preservation of vessels for a good vascular approach in the case of hemodialysis (HD); preparation of the patient for hemodialysis (HD). A favorable prognosis may be suggested by: diuresis over 1000ml/24h and the absence of high blood pressure. The worsening of acid-base disorders without any possibility of correction can only be treated with hemodialysis (4).

Hemodialysis represents an extra-renal therapy by which the uremic toxins are removed from the blood, the patient re-achieving an acid-base and electrolytic balance (4).

Patients with end-stage chronic kidney disease turned out to have at least one cutaneous change, in the proportion of 50-100% (12) .

These cutaneous changes are diverse and polymorphous, with the possibility of onset before or after the initiation of hemodialysis. Thus, it is possible to classify them into two categories: specific, conditioned by chronic renal failure, and non-specific, influenced by chronic kidney disease and hemodialysis.

The aim of our research is to evaluate the incidence of cutaneous manifestations and their features in patients with chronic renal failure undergoing hemodialysis.

Materials and methods We analyzed 35 patients from a dialysis center in Tîrgu-Mureș.

Medical sheets for each patients were filled in with the main medical background (chronic renal failure), the onset of the hemodialysis, daily treatment, laboratory results of the last check-up and the dermatological examination, including medical history of the cutaneous lesions and all treatments followed until that moment.

Name, sex, age, primary and secondary diagnoses, current health status of these patients were filled in tables. The medical history includes the date of onset of CKD and HD for each patient.

A full clinical check-up of all patients included in the study was performed, also taking photos of skin lesion and cutaneous changes of interest.

Surgical excisions / excisional biopsies, with histopathological examination, or other further investigations were carried out where needed.

Results 35 patients were examined, belonging both to urban and rural areas, among which 14 womSeptember 2015

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Clinical Study

Figure 1.

Figure 3.

Cutaneous findings in chronic kidney disease and hemodialysis

Half–and- half’ nails

Favre-Racouchot Cysts and Comedones Elastosis

en (21.60%) and 21 men (14.40%). The youngest patient is 23 years old, and the oldest is 78 years, both males. The mean age is 54.51 years (Fig.1, Fig.2, Fig.3).

The distribution frequency on the basis of age is shown in Graphic 3.

All of the patients were diagnosed with stage V chronic renal failure, undergoing hemodialysis, the nephrological diagnosis varying from case to case.

Regarding secondary diagnoses an increased frequency of cardiovascular diseases was observed, 25 of the patients being diagnosed with hypertension secondary to renal disease, as many patients associating at least another cardiovascular disease diagnosis.

16 patients had one or more gastrointestinal diseases, including chronic B and C hepatitis.

Regarding the approach of the hemodialysis, 31 patients had an arterial-venous fistula (AVF), 8 patients a central venous catheter (CVC), 7 patients had both devices.

Among endocrine disorders, most diagnosed were renal bone diseases, osteoporosis, secondary and tertiary hyperparathyroidism, thyroid disease, impaired glucose tolerance or even diabetes.

The remaining diagnoses were associated with neurological, rheumatologic, orthopedic, urologic,

184

Figure 2.

Keratoacanthoma

gynecologic, lung or otorhinolaryngology and occurred with a medium frequency.

Regarding laboratory results, in the moment of assessment, 30 of 35 patients were diagnosed with anemia secondary to the renal disease, most of them treated with erythropoietin (EPO), also having low hemoglobin values and in some cases even decreased hematocrit and red blood cell count. Several cases of increased blood glucose values, increases in total cholesterol or triglycerides, changes of ionogram with hyponatremia and hyperkalemia, elevated parathyroid hormone values, were noted. All patients presented elevated levels of urea (of which 12 presented elevated levels of creatinine, too), with their decrease after hemodialysis.

All the cutaneous changes encountered in our study were reported in a table. (Table 1) Xerosis Cutis This cutaneous change was observed in 12 patients, mostly on the chest, back and extensor aspects of the limbs, varying from fine scales, to eczema ‘craquelle’, being really bothersome to patients. None of these patients, diagnosed with xerosis cutis, had elevated blood sugar levels or diabetes.

Pruritus One of the most disturbing encountered symptom was pruritus: 14 of the examined patients showed generalized pruritus, sometimes accompanied by scratching marks. 3 of the patients claimed a worsening of the pruritus in the evening and at night, another patient observed an improvement in pruritus after initiating HD. In 5 cases pruritus was associated with xerosis cutis.

There was one case of a severe form of pruritus (nodular prurigo) with a high resistance to the usual treatment (antihistamine treatment) and a relative response to systemic corticosteroids.

A correlation between pruritus and high levels of parathyroid hormone were observed in 5 cases, a 6th showed severe pruritus, refractory to usual treatment (antihistamine + emollient) with onset about one year ago, correlating with insulin requiring, poorly controlled, diabetes.

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Ignat Ana-Sonia, Gliga Mirela, Badea Iudita-Maria, Badea Mihail-Alexandru, Lefter Elena, Morariu Sliviu-Horia-

Graphic 1.

Frequency by environment

Graphic 2.

Frequency by sex

Graphic 3.

The frequency according to age Cutaneous Pallor 24 examined patients presented cutaneous pallor, frequently found in patients with chronic renal failure and hemodialysis. All of these also associated anemia, secondary to renal disease, treated with erythropoietin, the hemoglobin values varying between 6,9- 13,5 g/dl.

Hyperpigmentation This is a frequent sign found in patients with chronic renal failure, undergoing hemodialysis: almost all the examined patients presented diffuse hyperpigmentation of the photo-exposed areas.

Capillary fragility/ petechiae 13 of the 35 examined patients presented such lesions, mostly on the limbs.

Nail changes Of the 35 examined patients, 3 presented discrete nail colour changes, without the possibility of integrating them in the color changes typically seen in these patients: ‘Lindsey nails’, or ‘half-andhalf nails’, and ‘Terry nails’.

We encountered the ‘half-and-half’ nails in just one female patient. (Img. 1) Oral changes The most frequent oral change encountered was saburral tongue: 12 patients presented this change, one of them also associating furrowed tongue.

Cutaneous infections Fungal infections were encountered most commonly among the patients: onychomycosis,

in 7 out of 35 patients, tinea corporis in 2 out of 35 patients. Regarding viral infections, the results of assessment showed 1 female patient with herpes zoster, at T8 dermatome. She claimed having the lesions every year, repetitively, the first episode in 2010, without a severe post-herpetic pain.

We would also like to mention the presence of a similar case, among the examined patients, with a history of herpes zoster, at left frontal region, with severe symptomatology and post-herpetic pain, claiming to have a recurrence, few months after the initial episode.

There were also another 2 patients known with a medical history of herpes zoster, with severe evolution and post-herpetic pain.

Other frequently encountered viral lesions were warts: 6 examined patients had at least one of these lesions, 2 others presented multiple lesions of cervical and facial viral papilloma.

Among bacterial infections we noted cutaneous staphylococcal infections; the medical history of an examined patient highlighted repetitive flares of cutaneous staphylococcal infections, on the chest and on the back, with improvement of the symptoms after antibiotics and complete remission after parathyroidectomy.

Juvenile acne was also encountered, 2 of the examined patients presenting a mild form of disease, in one case, and papulopustular form in the other (with extension to chest and medical history of grain furuncles).

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Table 1. Report of all the cutaneous changes encountered in our study Cutaneous changes

Number of affected patients

Pre-/Skin cancer lesions (name and number)

1 patient- 1 keratoacanthoma

Xerosis cutis

12

Pruritus

14

Nodular prurigo

1

Cutaneous pallor

24

Hyperpigmentation

33

Petechiae/ capillary fragility

13

Nail changes

3

‘Half-and-half nails’

1

Oral changes- Saburral Tongue

12

-Furrowed Tongue Onychomycosis

7

Tinea corporis

2

Active Herpes zoster

1

A history of Herpes Zoster-with severe evolution and severe postherpetic pain

3

Warts

6

Viral papilloma

2

Polymorphous Acne

2

Melanocytic lesions

1

Seborrheic keratosis

3

Skin changes due to chronic venous insufficiency and chronic arterial insufficiency of the lower extremities

4

Cutaneous Poikilodermia

1

Favre-Racouchot Cysts and Comedones Elastosis

1

Bullous Pemphigoid

1

Psoriasis

1

Erythema Nodosum

1

Seborrheic Dermatitis

1

Fixed Drug Eruption

1

Melanocytic lesions One of the examined patients presented multiple melanocytic naevi, clinically without atypia, all of them being under dermatoscopic surveillance.

Another 3 patients presented multiple seborrheic keratosis, on the chest and back.

Skin changes due to chronic venous insufficiency and chronic arterial insufficiency of the lower extremities 4 of the examined patients presented such changes, materialized in the lack of pilosity on the ankles, stasis dermatitis, or dermatitis pigmentosa.

Cutaneous oncologic pathology When assessing, in June 2014, we noted a papular lesion, with central hyperkeratosis, localized on the forearm of a patient, clinical and dermatoscopic examination being highly suggestive for a keratoacanthoma (img.2). For patient’s personal reasons, the lesion hadn’t been excised until

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September 2014, to this date having doubled its dimension.

Histopathology describes the presence of a keratinized squamous cell carcinoma, well-differentiated, infiltrating the reticular dermis, surgically excised in safe limits.

Bullous dermatoses Of the examined patients, one presented lesions highly suggestive for pseudo-porphyria cutanea tarda, with poikiloderma on the back of the hands, and Favre-Racouchot Cysts and Comedones Elastosis (img.3). There were no symptoms other than aesthetic discomfort.

Bullous pemphigoid: 1 male patient Other encountered dermatosis: Psoriasis vulgaris: With appearance shortly after the onset of chronic renal failure (1 patient); positively influenced by hemodialysis

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Ignat Ana-Sonia, Gliga Mirela, Badea Iudita-Maria, Badea Mihail-Alexandru, Lefter Elena, Morariu Sliviu-Horia-

Table 2. The distribution frequency on the basis of age Age Mean

54.51428571

Standard Error

2.395854764

Median

59

Mode

62

Standard Deviation

14.17406793

Sample Variance

200.9042017

Kurtosis

-0.584201088

Skewness

-0.460040078

Range

55

Minimum

23

Maximum

78

Sum

1908

Count

35

Confidence Level (95,0%)

4.868962688

cv (variation coefficient)

26.00064872

More

Bin

Frequency

23

1

34

2

45

7

56

7

67

12 5

Erythema nodosum: 1 female patient Seborrheic dermatitis: With onset 3 months after the initiation of hemodialysis (1 male patient) Fixed drug eruption: 1 male patient

Discussion Our research is the proof of the polymorphism of cutaneous lesions in this kind of patients.

The skin of these patients is usually dry, covered with ichthyosiform scales. This may be due to a change in vitamin A metabolism, on one hand, common in chronic renal failure, and on the other hand, to the volume exchanges from dialysis process (5).

Literature claims the presence of xerosis in this category of patients at a rate of 40-90%. There are studies showing a higher frequency of xerosis among hemodialysed patients in comparison

with those following conservative treatment. This may be due to a lower hydration of the horny layer, seen in hemodialysed patients (8, 9).

Certain characteristics of the skin belonging to patients following chronic hemodialysis suggest an aging process. In a study conducted in Liege, Belgium, researchers assessed, by a non-invasive technique (using a SM 474 Cutometer) the biomechanical properties of the skin, in 72 hemodialysed patients. Thus, chronic hemodialysed patients present some changes in the binding properties of the skin, while changes in the elasticity of the skin were minimal (6).

The pathogenesis of xerosis in these patients is not fully understood; it may be caused by dermal atrophy, decreased number of blood vessels, sebaceous and sweat glands, an increased alkalinity of the skin or even protein malnutrion, due to several restrictions (7, 14).

Pruritus is frequently reported by patients with chronic renal failure, undergoing hemodialysis.

Its incidence among these patients is about 5090%. Although the etiology of pruritus is not fully understood, several mechanisms seem to be responsible: increased histamine and parathyroid hormone levels, mast cell hyperplasia, peripheral polyneuropathy or xerosis cutis(5, 9, 14, 18, 19, 20) From what we have observed, antihistamines and emollients often are insufficient in treating this symptom, parathyroidectomy having a positive influence over it.

Its severe form, nodular prurigo, is frequently associated to metabolic imbalances (20).

Cutaneous pallor, typical of these patients, seems to be due to iron, folic acid, and vitamin D deficiencies (caused by dietary restrictions), together with the specific treatment- dialysis (6, 7).

Diffused hyperpigmentation of photo-exposed areas could be attributed to melanin, present in high amounts in the basal layer and superficial dermis, because the kidneys are unable to excrete beta-melanocyte stimulating hormone (7, 14).

Abnormal function of platelets or the use of heparin during hemodialysis are leading causes of abnormal bleeding in these patients, and also are the causes of petechial lesions encountered among them (14).

Similar studies show the presence of such lesions, in patients with chronic renal failure, following conservative treatments, at a 20% rate. (14) Also specific for patients with chronic renal failure are nail color changes. Thus, ‘Lindsey nails’, or ‘half-and-half nails’, normally colored in their distal half, and white in their proximal half, are well known. The name of ‘Terry nails’ has been associated to 20% normally colored nails in their distal part. Their prevalence in patients with chronic renal failure varies between 16-50,6% in comparison to 1,4% in healthy individuals. It is known to be an early sign in chronic renal failure (5, 7, 17).

The pathogenesis of the distal pigmented band still remains unclear, this being absent in patients with acute renal failure. Leukonychia was also noted September 2015

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in patients with hypoalbuminemia, due to nephrotic syndrome (9).

Several studies cite oral changes such as macroglossia, xerostomia, ulcerative stomatitis, angular cheilitis, uremic fetor, in 90% of cases, this type of changes being influenced by dehydration or serum urea levels higher than 150mg/100ml (12,14).

Among the encountered viral infections, herpes zoster presented the most severe symptomatology. A study conducted in Taiwan, the country with the highest incidence of chronic kidney disease worldwide, emphasizes a higher incidence of herpes zoster in these patients (73.34 / 1000 inhabitants / year) compared to general population (31.03 / 1000 inhabitants / year) (21).

Although limited to a single episode, more studies nowadays claim the possibility of a recurrence, in herpes zoster, especially in patients with a poor immune status. Recurrence was also associated with the symptomatology of the first episode, or post- herpetic pain persistence (over 30 days being a predictor of recurrence) (21).

Porphyria Cutanea Tarda was also described among patients undergoing hemodialysis. Although the pathogenesis is not clear, it seems that inadequate clearance of the plasma porphyrin precursors, through renal excretion or hemodialysis, results in the deposition of porphyrin in the skin, clinically manifested by extreme photosensitivity and subepidermal blisters. Among associated skin changes, hypertrichosis of the malar areas, capillary fragility and discoloration of the photo-exposed areas, changes in the elastic fibers, with different clinical variants (cutis rhomboidalis, Favre-Racouchot Cysts and Comedones Elastosis) were cited (5, 8, 11, 16).

The disease may also have an internal echo, affecting the liver and stomach (8, 10).

Erythema nodosum is remarkable in this case by its unusual coloration (violet-red), its appearance both on the extensor part of the legs and forearms, and evolution (prolonged, painful, in comparison to a healthy individual).

The relationship between bullous pemphigoid, histologically diagnosed, and chronic renal failure, is not fully understood. It is believed that the immune changes in to renal disease may be responsible for the appearance of the bullous pemphigoid (15, 16).

We also encountered in our study, other cutaneous changes, which we attributed to the immuno-

suppression caused by chronic kidney disease and hemodialysis.

The immunosuppression caused by chronic renal failure and hemodialysis manifests through an increase in neutrophil number, lymphopenia, decreased B lymphocytes and impaired antibody synthesis. The effects of hemodialysis on the immune system lead to changes in the pattern of T cells and damage of the key molecules (CD 54).

This broad spectrum of changes seems to be responsible for the high morbidity and mortality in advanced chronic renal failure (13).

We didn’t meet in our research dermatoses conditioned directly by chronic renal failure and hemodialysis (calciphylaxys, nephrogenic fibrosing dermopathy), given the small number of patients examined and the short follow-up period.

Conclusions We observed a significant incidence of cutaneous changes among patients with chronic renal failure, undergoing hemodialysis. One cannot blame only chronic renal failure and hemodialysis for their appearance, though these have an influence over the cutaneous changes that were found.

Immune status, comorbidities, the promptitude and specificity of the established treatment, as well as the materials used (dialyzers membranes), seem to be contributing factors.

Acknowledgements The authors would like to thank to all those who made this research possible: management and all staff of the dialysis center, particularly to chief nurse of the center, Ioana Bathori; we would also like to thank to the person who helped us with the informatics job.

The research was conducted according to the principles expressed in the Declaration of Helsinki.

Informed consent, signed by the patients examined and photographed, was obtained.

The authors contributed equally to the study and drafting the article.

Conflict of Interest None This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

Bibliography 1. Fauci A. S., Braunwald E., Kasper D., Harrison’s Principles of Internal Medicine. Mc Graw -Hill Medical, 2008, 17th Edition 2. Levey AS, Eckardt KU, Tsukamoto Y, Levin A, Coresh J, Rossert J, De Zeeuw D, Hostetter TH, Lameire N, Eknoyan G, Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO), Kidney Int. 2005 Jun;67(6):2089-100 3. Cozlea L., Rediş R., Negovan A., Semiologie Medicală, Tg. Mureș: University Press, 2006, Ed. I

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4. Ciocâlteu A., Nefrologie clinică pentru examenul de rezidenţiat, București:Infomedica, 2000 5. Freedberg I.M., Eisen A.Z., Wolff K., Fitzpatrick’s Dermatology In General Medicine (Two Vol. Set), 6th Edition, McGraw-Hill Professional, 2003 6. Deleixhe-Mauhin F., Piérard-Franchimont C., Rorive G., Piérard G. E., Influence of chronic hemodialysis on the mechanical properties of skin.

Clinical and Experimental Dermatology, Mar,1994: 130–133

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Ignat Ana-Sonia, Gliga Mirela, Badea Iudita-Maria, Badea Mihail-Alexandru, Lefter Elena, Morariu Sliviu-Horia7. Supriya P. D., Yugal K. S., Kedarnath D., Nitin C. C., Kirti S. D., Clinicoepidemiological study of skin manifestations in patients of chronic renal failure on hemodialysis, Indian Dermatol Online J. 2013 Jan-Mar; 4(1): 18–21 8. Saurat J.H., Laugier P., Grosshans E., Lachapelle J.M., Dermatologie et Vénéréologie. Paris: Masson,1990, 2ème edition revue at augumentée 9. Falodun O, Ogunbiyi A, Salako B, George AK, Skin changes in patients with chronic renal failure, Saudi J Kidney Dis Transpl 2011;22:268-72 10. Gh. Bucur, Dana A. Opris, Boli Dermatovenerologice, enciclopedie, București: Ed. Medicala Nationala, 2002, Editia a II-a 11. Swartz RD, Crofford LJ, Phan SH, Ike RW, Su LD, Nephrogenic fibrosing dermopathy: a novel cutaneous fibrosing disorder in patients with renal failure, Am J Med. 2003 May;114(7):563-72 12. Masmoudi A., Darouiche M.H., Salah H.B., Hmida B.M., Turki H., Cutaneous abnormalities in patients with end stage renal failure on chronic hemodialysis. A study of 458 patients, J Dermatol Case Rep. 2014 Dec 31; 8(4): 86–94 13. Vaziri N.D., Pahl M.V., Crum A., Norris K., Effect of Uremia on Structure and Function of Immune System, J Ren Nutr. 2012 January; 22(1): 149–156

14. Udayakumar P, Balasubramanian S, Ramalingam K S, Lakshmi C, Srinivas C R, Mathew AC. Cutaneous manifestations in patients with chronic renal failure on hemodialysis, Indian J Dermatol Venereol Leprol 2006;72:119-25 15. Hajheydari Z., Makhlough A., Cutaneous and Mucosal Manifestations in Patients on Maintenance Hemodialysis, A Study of 101 Patients in Sari, Iran, IJKD 2008;2:86-90 16.Bergler-Czop B., Brzezińska-Wcisło L., Pseudoporphyria induced by hemodialysis, Postepy Dermatol Alergol. Feb 2014; 31(1): 53–55 17. Sahoo JP, Half and half nail, Saudi J Kidney Dis Transpl 2014;25:168-9 18. Œnit M., Gawlik R., Łącka-GaŸdzik B., KuŸniewicz R., Dwornicki M., Owczarek A., Walaszczyk M., Grabiec P., Grzeszczak W., Substance P and intensity of pruritus in hemodialysis and peritoneal dialysis patients, Med Sci Monit. 2013 19. Razeghi E, Tavakolizadeh S, Ahmadi F. Inflammation and Pruritus in Hemodialysis Patients, Saudi J Kidney Dis Transpl 2008;19:62-6 20. Berger T.G., Steinhoff M., Pruritus and Renal Failure, Semin Cutan Med Surg. Jun 2011; 30(2): 99–100.

21. Kuo CC1, Lee CT, Lee IM, Ho SC, Yang CY, Risk of herpes zoster in patients treated with long-term hemodialysis: a matched cohort study, Am J Kidney Dis. 2012 Mar;59(3):428-33.

Franco Rongioletti, Irina Margaritescu, Bruce R Smoller Publisher: Springer Language: English ISBN: 9781493920228 Edition: 1/e Publish Year: 2015 Pages: 347 Price: 160,49 € The book “Rare Malignant Skin Tumors” edited by Franco Rongioletti, Irina Margaritescu and Bruce R Smoller addresses all physicians involved in the diagnosis and treatment of skin tumors: dermatopathologists, general pathologists, general dermatologists, cutaneous oncologists, and surgeons. The book presents clinical findings and essential pathological features of rarely encountered malignant cutaneous neoplasms. The newest immunohistochemical and molecular data are included. Main differential diagnosis, prognosis data and therapeutic options are also covered.

All the 70 cutaneous tumor entities presented are grouped in 12 sections according to the cell(s) of origin: tumours of the epidermis, tumours of hair follicle and sebaceous gland, tumours of apocrine gland, tumours of eccrine gland, tumours of fibrous and myofibroblastic tissue, tumours of vessels, tumours of fat, tumours of muscle, tumours of bone, melanocytic tumors, neuroendocrine, neuroectodermal and nervous tumours, and hematopoietic tumors. Cutaneous metastases of internal malignancies are presented in the last section of the book. The book is written by experts in the field, each chapter being presented in a clear and concise way and is highly illustrated with representative clinical pictures and excellent photomicrographs. Without doubt, “Rare Malignant Skin

Books Review

Rare Malignant Skin Tumors

Tumors” represents a valuable book and should be read both by residents and practicing physicians that care for patients with cutaneous neoplasms.

The third part, Anatomical Structures of the Oral Cavity, presents in two chapters the relationship of the teeth to landmarks of the skull, temporomandibular joints, and the muscles, nerves, vessels, associated with the oral cavity, as well as the visible structures on a panoramic radiography; and also the intra- and extra-oral examination of normal oral structures. This dental anatomy book links anatomy to clinical practice enabling a practical understanding of tooth structure and function, the dental morphology and terminology and hence the application of the professional knowledge to patient evaluation, treatment and education. The book was republished, revised and updated and has clear explanations, colored illustrations and hands-on exercises.To facilitate the study and application of dental anatomy, the book also offers special chapters on practical aspects, such as: learning objectives, new terms, review questions and answers, learning exercises and an appendix.

The book is also useful to dental anatomy courses instructor, as a teaching manual during lectures, discussion periods, and laboratory sessions, as well as during early clinical experiences. It is also useful as a reference in the dental office.

September 2015

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Case Presentation

Relapsing polychondritis - case report

RELAPSING POLYCHONDRITIS - CASE REPORT POLICONDRITA RECIDIVANTĂ – CAZ CLINIC 1)

Virgil Pătrașcu1), Raluca Ciurea2), Andreea-Oana Enache1) University of Medicine and Pharmacy of Craiova, Dermatology Department, Romania 2) University of Medicine And Pharmacy of Craiova, Pathology Department, Romania Corresponding author: Virgil Pătrașcu, MD, PhD, University of Medicine and Pharmacy Craiova, Petru Rareș Street, No2-4, 200345, Craiova, Romania, Phone: 004-0724273676, e-mail: vm.patrascu@gmail.com.

E-mail addresses of the others authors: Andreea-Oana Enache – oana.popescu86@yahoo.com Raluca Ciurea - raluca1ciurea@gmail.com

Open Access Article

Abstract Keywords: Relapsing polychondritis, auricular, autoimmune diseases

Relapsing polychondritis is a rare autoimmune disorder defined by recurrent episodes of inflammation of cartilaginous structures (especially the ears, nose and tracheobronchial tree). We present a case of polychondritis with an onset during the seventh decade of life, wich simultaneously involved both auricular pavilions.

A 65-year-old woman referred to our department for intensely painful, erythematous infiltrated plaques, with symmetrical disposition at the cartilaginous part of the ear, sparing the lobule and the presence of erosion at the right antihelix level. The disease onset was 3 months ago. Physical examination and laboratory investigations revealed the coexistence of aortic insufficiency, dorsal spondylosis and bilateral coxarthrosis; the histopathological examination pleaded for the diagnosis of polychondritis. The patient was started on systemic corticosteroids. Given the frequent association of relapsing polychondritis with other autoimmune diseases, the patient will be closely monitored to early detect other pathological conditions that can worsen the vital prognosis.

Rezumat Cuvinte-cheie: policondrita recidivantă, auricular, boli autoimune

Cite this article: Virgil Pătrașcu, Raluca Ciurea, Andreea-Oana Enache Relapsing polychondritis - case report.

RoJCED 2015; 2(3):190-193

190

Policondrita recidivantă este o afecțiune autoimună rară, definită prin episoade recurente de inflamaţie a structurilor cartilaginoase (în special urechilor, nasului și arborelui traheobronșic). Prezentăm un caz la care policondrita a debutat în decada a VII-a de viață, cu interesarea ambelor pavilioane auriculare. Pacientă în vârstă de 65 de ani, mediul urban, solicită consult dermatologic pentru apariția de plăci eritematoase, infiltrate, intens dureroase, cu dispoziție simetrică la nivelul pavilioanelor auriculare, fără să afecteze lobul auricular, cu prezenţa unei eroziuni în regiunea antehelixului drept. Boala a debutat în urmă cu 3 luni. Examenul clinic și investigațiile paraclinice au evidențiat coexistența insuficienței aortice, spondilozei dorsale și coxartrozei bilaterale, iar rezultatul ex HP a pledat pentru diagnosticul de Policondrită. Am inițiat corticoterapia sistemică. Având în vedere asocierea frecventă cu alte boli autoimune, considerăm necesară supravegherea trimestrială a bolnavei pentru a depista din timp alte condiții patologice care pot întuneca prognosticul vital al acesteia.

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Virgil Pătrașcu, Raluca Ciurea, Andreea-Oana Enache

Figure 1, 2.

Erythematous and infiltrated plaques, intensely painful, with symmetrical disposition at the cartilaginous part of the ear, sparing the lobule; at the right antihelix level an erosion with a diameter of 0.5 cm, well defined, covered by an adherent hematic crust

Introduction Relapsing polychondritis (RP), also known as chronic atrophic polychondritis is a rare autoimmune disorder defined by recurrent episodes of inflammation of cartilaginous structures (especially the ears, nose and tracheobronchial tree) (1).

Clinical case A 65-year-old woman, urban area, was referred to the Dermatology Clinic of Craiova, in 2014, for 2 intensely painful, erythematous infiltrated plaques, with symmetrical disposition at the cartilaginous part of the ear, sparing the lobule, which had been present for approximately 3 months. About two months before the presentation to the hospital she affirms the appearance of an erosion located at the right antihelix, 0.5 cm in diameter, well defined, covered by an adherent hematic crust (Figure 1,2).

Personal medical history: Nodular goiter (2008), stage 2 primary hypertension (2004), osteoporosis (with a 4-month history), total hysterectomy with bilateral anexectomy for uterine fibromas (2005).

The patient was under chronic treatment with: Euthyrox 50 µg/day, Lacidipine 2 mg /day, Nebivolol 5 mg/day, Preductal 40 mg/day, ALPHA D3 0.25 µg /day.

Clinical examination revealed: good general status, afebrile, bilateral hip pain (mechanical nature), normal pulmonary stethacoustic parameters, liver was palpable 1,5 cm below the right costal margin.

The patient had tinnitus without response to specific therapy and also hardness in leg flexion with marked difficulty in getting up from a chair.

Abdominal ultrasonography was normal.

Thyroid ultrasound - isthmus 5.8 mm, right lobe 15/18/43 mm, diffuse inhomogeneity, macronodular appearance. Left lobe 16/19/41mm presents

the same inhomogeneous and macronodular structure, with hyperechoic formations 4.5 mm in diameter.

Chest radiography: no active lung pathology, no pleural effusion; prominent aortic arch; moderate thoracic spondylosis.

Radiography of the pelvis: osteophytosis of the greater trochanter on infero-external contour and slight osteophytosis in the rim of the acetabulum.

Cardiac ultrasound - Left ventricular hypertrophy, diastolic heart failure by impaired relaxation, mild aortic regurgitation, secondary pulmonary hypertension, left atrial enlargement.

Routine laboratory investigations were normal, except for raised erythrocyte sedimentation rate (18mm/h). Serum protein electrophoresis, antinuclear antibodies, rheumatoid factor (14UI/mL), circulant immune complexes (2RU/mL), PPD and VDRL test were normal.

The histopathological exam (right ear antihelix) showed: ulcerated epidermis with areas of acanthosis, papillomatosis, underlying chronic inflammatory cell infiltrate, predominantly lymphoplasmacytic and diffuse interstitial infiltrate (Figure 3).

Based on the clinical and paraclinical data, we established the following diagnoses: relapsing polychondritis; stage 2 primary hypertension; aortic insufficiency; nodular goiter; dorsal spondylosis; bilateral coxarthrosis.

Recommendations at hospital discharge: • Low dietary sodium and fat intake; • Treatment with Prednisone 30mg/day as a single dose in the morning, Omeprazole 20 mg/day, Aspacardin 1tb/ day, Piascledine 300 mg / day; • Continue the monitoring program and the treatment for cardiovascular and endocrine diseases.

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Case Presentation

Figure 3.

Relapsing polychondritis - case report

Right ear antihelix fragment: ulcerated epidermis with areas of acanthosis, underlying chronic inflammatory cell infiltrate, predominantly lymphoplasmacytic and diffuse interstitial infiltrate, HE stain X 40

Discussions Relapsing polychondritis was first described in 1923 by the Austrian internist Rudolf von JakschWartenhorst under the term of “polychondropathia” and in 1960, Pearson and his colleagues called it “relapsing polychondritis” (2).

It is more common in Caucasians, in the fifth decade of life (3).

There is a slight predilection for females (sex ratio F / B: 3.1 / 1) (4).

It is a rare disorder with an incidence of 3.5 per million people affected annually (5).

The etiopathogenesis is complex and poorly understood.

There are arguments that support the involvement of autoimmune mechanisms (6): Antibodies to types II, IX, and XI collagen in the serum of patients (30%-70%); Immunoglobulin and complement deposits are detected at sites of inflammation; A significantly higher frequency of HLA-DR4 than in healthy individuals; Macrophage migration inhibitory factor (MIF) levels were significantly higher than in controls; Elevated levels of anti-matrilin-1 antibodies (cartilage-specific matrix protein highly expressed in tracheal, nasal, auricular and costal cartilages).

There have been described rare cases of relapsing polychondritis after administration of hormones (human chorionic gonadotropin injections) or after auricular cartilage trauma (ear piercings) (7,8).

The higher prevalence of the disease among patients with connective tissue diseases raises the question of common pathophysiological mechanisms.

McAdam et al have reported that 25% -35% of patients with relapsing polychondritis have an associated autoimmune disease (9). The autoimmune conditions reported in patients with Relapsing

192

Polychondritis include: wegener’s granulomatosis, polyarteritis nodosa, Churg-Strauss syndrome, microscopic polyangiitis, systemic lupus erythematosus, Sjogren’s syndrome, Raynaud’s syndrome, systemic sclerosis, Bechet’s disease (MAGIC syndrome), rheumatoid arthritis, endocrinopathies, ulcerative colitis disease Crohn’s disease, type I diabetes, pernicious anemia, psoriasis, primary biliary cirrhosis, etc. (10).

Relapsing polychondritis is a multisystemic disease with the following clinical features (11): Musculoskeletal-nonerosive seronegative inflammatory polyarthritis, myalgias, back pain and migratory or generalized arthralgias; Audiovestibular damage: especially nocturnal ear pain, sudden loss of hearing, vertigo and tinnitus; Respiratory tract chondritis: dyspnea, wheezing, hoarseness, cough, recurrent pneumonia; Nasal: saddle-shaped nose, nasal obstruction, rhinorrhea, epistaxis; Ocular - decreased visual acuity, conjunctivitis, episcleritis, scleritis, diplopia, eyelid edema, cataracts, optic neuritis, oculomotor nerve palsy, retinal vasculitis; Cardiovascular disease: aortic insufficiency, pericarditis, myocarditis, conduction abnormalities, myocardial infarction; Renal: edema, hematuria; Neurological abnormalities: headache, ataxia, confusion, cranial nerve palsy, sensation changes, dementia, seizures.

Auricular chondritis is the most frequent manifestation of relapsing polychondritis (85% - 95% of patients), affecting usually both ears. Patients have severe pain, tenderness and swelling of the cartilaginous portion of the ear. The ear lobes are not affected.

The prolonged or recurrent episodes of RP lead to a flaccid appearance of the ear (cauliflower appearance).

Our patient fulfills the diagnostic criteria (table 1) proposed by McAdam et al., Damiani and Levine, Michet et al., thereby supporting the diagnosis of relapsing polychondritis (6-9).

The differential diagnosis of RP was made with: skin tumors (squamous cell carcinoma, basal cell carcinoma), skin infection (cellulites, tuberculosis, leprosy, syphilis), contact dermatitis, gout, lupus erythematosus, cystic chondromalacia of the ear.

The episodic character of the disease leads to a delay in diagnosis.

In a study involving 66 patients, Trentham et al. observed that the elapsed time from patient presentation for medical care to the diagnosis of polychondritis was reported to be 2.9 years (12).

The presence of nasal chondritis, systemic vasculitis, laryngotracheal stricture, arthritis and anemia in patients younger than 50 years, contribute to a negative prognosis. Renal involvement is a negative prognostic factor at all ages. The goal

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Virgil Pătrașcu, Raluca Ciurea, Andreea-Oana Enache

Table 1. Diagnostic criteria for Relapsing polychonditis

McAdam et al.

1. Bilateral auricular chondritis 2. Nonerosive seronegative inflammatory polyarthritis 3. Nasal chondritis 4. Ocular inflammation 5. Respiratory tract chondritis 6. Audiovestibular damage 3 of 6 clinical features necessary for diagnosis

Damiani and Levine

1. Three McAdam et al criteria 2. One McAdam et al criteria plus positive histology results 2. Two McAdam et al criteria plus therapeutic response to corticosteroid or dapsone therapy

Michet et al.

1. Proven inflammation in 2 of 3 of the auricular, nasal, or laryngotracheal cartilages 2. Proven inflammation in 1 of 3 of the auricular, nasal, or laryngotracheal cartilages plus 2 other signs including ocular inflammation, hearing loss, vestibular dysfunction, seronegative inflammatory arthritis,

of the treatment is to reduce the symptoms and to maintain the integrity of cartilaginous structures.

McAdam et al showed that continuous treatment with Prednisone (20-60 mg/day in acute phase, 5-25 mg/day maintenance dose) decreases severity, duration, and frequency of relapses (13). Other treatment options include: Dapsone (25-200 mg / day), Methotrexate (7.522.5 mg /week), Colchicine (0.6 mg x 2 / day), Azathioprine, Cyclophosphamide, Cyclosporine, Leflunomide (14).

Recent studies show the effectiveness of biological therapy in RP treatment (Infliximab, Etanercept, Adalimumab, Rituximab) (15-17).

Complete resolution after autologous stem cell transplantation has been reported, and Navarro et al reported an adequate response after daily use of hydrolyzed collagen type II (bovine) (18).

Conclusions Relapsing polychondritis is a rare condition that due to its episodic character may result in a delayed diagnosis, with multiple problems of differential diagnosis.

Given the frequent association of relapsing polychondritis with other autoimmune diseases, the patient will be monitored closely to detect early other pathological conditions that can worsen the vital prognosis.

The authors have declared no conflict of interest.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

Bibliography 1. Mathew SD, Battafarano DF, Morris MJ. Relapsing polychondritis in the Department of Defense population and review of the literature. Semin Arthritis Rheum 2012; 42:70.

2. Patel K. Relapsing polychondritis - delayed diagnosis and fatal outcome. Indian J Dermatol Venereol Leprol 2010; 76:67-9.

3. Knipp S, Bier H, Horneff G, Specker C, Schuster A, Schroten H, Lenard HG, Niehues TSO. Relapsing polychondritis in childhood-case report and short review. Rheumatol Int. 2000; 19(6):231.

4. A.C Pérez Gudiño, G.E. LugoZamudio, A.S. Vargas Aviles. Relapsing Polychondritis: An Analysis of 11 Patients. Reumatol Clin 2007; 3(4):166-70.

5. P. D. Kent, C. J. Michet Jr., and H. S. Luthra. Relapsing polychondritis. Current Opinion in Rheumatology 2004, 16 (1):56–61.

6. Buckner JH, Van Landeghen M, Kwok WW, et al. Identification of type II collagen peptide 261-273-specific T cell clones in a patient with relapsing polychondritis. Arthritis Rheum 2002, 46:238-244.

7. Labarthe MP, Bayle-Lebey P, Bazex J. Cutaneous manifestations of relapsing polychondritis in a patient receiving goserelin for carcinoma of the prostate. Dermatology 1997, 195(4):391-4.

8.Alissa H,Kadanoff R,Adams E: Does mechanical insult to cartilage trigger relapsing polychondritis?

Scand J Rheumatol 2001, 30:311.

9. Gergely P Jr, Poor G. Relapsing polychondritis. Best Pract Res Clin Rheumatol 2004,

18:723–738.

10.A. Sharma,A.D. Law, P. Bambery,V. Saga. Relapsing polychondritis: clinical presentations, disease activity and outcomes. Orphanet Journal of Rare Diseases (2014) 9:198.

11. Joseph M., Damiani M.D., Howard L., Levine M.D. Relapsing polychondritis — Report Of Ten Cases.The Laryngoscope Volume 89, Issue 6, pages 929–946.

12.Trentham DE, Le CH. Relapsing polychondritis.Ann Intern Med, 1998; 129(2):114-22.

13. McAdam LP, O’Hanlan MA, Bluestone R, Pearson CM. Relapsing polychondritis: prospective study of 23 patients and a review of the literature. Medicine (Baltimore). 55(3):193-215.

14. Handler RP. Leflunomide for relapsing polychondritis: successful longterm treatment.

J Rheumatol 2006; 33(9):1916-7.

15.Ratzinger G,Kuen-Spiegl M,Sepp N.Successful treatment of recalcitrant relapsing polychondritis with monoclonal antibodies.J Eur Acad Dermatol Venereol 2009; 23(4):474-5.

16. Seymour MW, Home DM, Williams RO, Allard SA. Prolonged response to anti-tumour necrosis factor treatment with adalimumab (Humira) in relapsing polychondritis complicated by aortitis.

Rheumatology (Oxford) 2007; 46 (11):1738-9.

17. Wendling D, Govindaraju S, Prati C, Toussirot E, Bertolini E. Efficacy of anakinra in a patient with refractory relapsing polychondritis.Joint Bone Spine 2008; 75(5):622-4.

18. Navarro MJ, Higgins GC, Lohr KM, Myers LK. Amelioration of relapsing polychondritis in a child treated with oral collagen. Am J Med Sci. 2002; 324(2):101.

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SKIN VISION – A SKIN CANCER AWARENESS, PREVENTION AND DETECTION APP FOR EVERYONE - TOGETHER WE CARE -

SkinVision is built around the idea that everybody should be informed regarding skin cancer risks, prevention methods and benefit from an early diagnosis method and easy access to a doctor. Smartphones make this possible in a very convenient way and independent of the patient’s location.

In this context, SkinVision offers an app for dermatologist – patient communication and a mathematical based algorithm for skin lesion risk assessment that can be used by patients as a self-monitoring tool. To complement these features and, also, ease the communication with the doctor, the user can create his own gallery saving the lesion’s evolution; answer a set of questions for skin type identification and, respectively, for skin cancer risk profiling; continuously check out the UV index no matter where they

are in order to take preventive measures and receive personalized (self) monitoring reminders.

Our goal is to educate the individuals in regard to their skin, offer an initial evaluation of the risk raised by a lesion and facilitate the contact with the dermatologist (in-between regular dermatological consults and in case of remote area users).

SkinVision makes use of the smartphone’s capabilities and helps the users acquire high resolution images of a skin lesion that can be archived and shared with the dermatologist and, also, analyzed by an automatic algorithm that provides the associated degree of risk raised by each lesion. The app presents the risk level by using a traffic light representation: red (indication towards skin cancer), orange (suspicious) or green (no obvious

signs of cancer). In all these cases, the patient is referred to a dermatologist. The application does not claim to be a diagnostic device that can replace a visit to the doctor. The risk assessment algorithm has been initially evaluated at the Department of Dermatology, University Hospital of Munich, Germany, scoring a sensitivity of 73% and a specificity of 83% in detecting melanoma. Considering these results, SkinVision obtained the European Certification as a medical device last year.

The endeavours to improve the algorithm continued afterwards and, currently, a second clinical study is taking place at Catharina Hospital, Eindhoven, Netherlands, where the algorithm is tested for sensitivity regarding nonmelanoma skin cancer. The sensitivity on 105 cases of BCC and SCC is 84%.

These initial results were presented at the 4th Munich International Summer Academy ISA of practical Dermatology this summer.

These are the first clinical studies performed in order to test the accuracy of an app for skin cancer diagnosis. The efforts made to offer a complete skin solution were appreciated by the public. The need for this type of application is clear with more than 90 000 downloads during May 2015 and the positive feedback received from users and also their dermatologists.

The need in the general population for personalized mHealth solution has not been missed by others entities that provide medical solutions for skincare. LEO Pharma, a global healthcare company dedicated to helping people achieve healthy skin, invested over 3 million EURO in SkinVision B.V. in august 2015.

This agreement is one in a series of recent LEO Pharma actions to provide easy access to better care solutions for people with skin diseases justified by the fact that: “The Internet is dramatically changing how consumers manage their

health and this creates new opportunities for us to deliver innovative, value-added services and LEO Pharma wants to be at the forefront of that trend,” (Kim Kjoeller, Senior Vice President of Global Development at LEO Pharma).

“I’m very pleased to announce our investment in SkinVision as this deal will provide access to unique digital learnings that will ultimately help us address the unmet needs of individual patients in an ever changing and increasingly digital health care environment.”, he also said.

SkinVision’s partnership with LEO Pharma creates the opportunity to explore other skin disease areas: “We are delighted to reach this agreement with LEO Pharma, because it will enable us to expand into new areas and it validates our approach,” said Dick Uyttewaal, CEO of SkinVision B.V. “LEO Pharma has a great reputation and range of products in the treatment of skin conditions, so there is clear synergy between the two companies. We want to be the leading provider of digital solutions for skin conditions and together with LEO Pharma we believe we can provide consumers with even more personalised, informative healthcare services.”

But, how can this also help the dermatologists? By educating and making patients aware of skin related risks, they will reach out for care earlier and a larger percentage of the population can be monitored. Patients will be more engaged: regular consults will be more of a habit due to a familiar environment and the online presence between appointments will help in bridging the gap in the patient – doctor relationship.

SkinVision also encourages dermatologists to be early adopters of the mHealth solutions that we provide so please contact us directly at info@skinvision.com.

The SkinVison iPhone medical app is available on the Apple App Store.

You can also find more about us and our sy stem at www.skinvision.com

Case Presentation

The advantages of digital dermoscopy

THE ADVANTAGES OF DIGITAL DERMOSCOPY AVANTAJELE DERMATOSCOPIEI DIGITALE Dr. Radu-Nicolae Grigore(1), A/Prof. Klaus Fritz(2, 3), Prof. Dr. George Sorin Ţiplică(1, 2), A/Prof. Dr. Carmen Maria Sălăvăstru(2, 4) 1) nd 2 Clinic of Dermatology, Colentina Clinical Hospital, Bucharest, Romania; 2) University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania; 3) Dermatology and Laser Center, Landau, Germany; 4) Dermato-Paediatric Clinic, Colentina Clinical Hospital, Bucharest, Romania Corresponding author: Prof. Dr. George Sorin Ţiplică Clinica Dermatologie 2, Spitalul Clinic Colentina, Sos. Stefan cel Mare nr. 19-21, sector 2, Bucharest, Romania; E-mail: tiplica@upcmail.ro

Open Access Article

Abstract Keywords: digital dermoscopy, melanoma, dysplastic nevi, total body mapping

Dermoscopy improves the diagnostic accuracy for melanoma compared with naked eye examination and has shown to increase the sensitivity in the clinical diagnosis of melanoma from 60 to 90%. Melanoma high-risk patients, including those with familial melanoma benefit most from total body mapping combined with serial digital dermoscopy, due to the increased accuracy in the diagnosis of melanomas in their initial stages. We present the case of a 27 year old female patient with a family history of melanoma, who had a large number of melanocitic lesions. Digital dermoscopy and total body mapping were performed and 3 lesions with clinical and dermatoscopic atypia were identified and excised. Pathology revealed that all the lesions were dysplastic nevi. Digital dermoscopy and total body mapping follow-up improve the prognosis of the patient, because the most subtle changes can be detected with the aid of these digital methods, compared with simple dermoscopic examination.

Rezumat Cuvinte-cheie: Dermatoscopie digitală, melanom, nevi displazici, total body mapping.

Cite this article: Radu-Nicolae Grigore, Klaus Fritz, George Sorin Ţiplică, Carmen Maria Sălăvăstru.

The advantages of digital dermoscopy.

RoJCED 2015; 2(3):196-200

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Dermatoscopia îmbunătățește mult acuratețea diagnosticării melanomului comparativ cu examinarea cu ochiul liber a leziunilor.

Senzitivitatea diagnosticului clinic al melanomului prin această metodă crește de la 60 la 90% comparativ cu examinarea cu ochiul liber. Pacienții aflați la risc înalt de melanom, inclusiv cei cu istoric familial de melanom au cel mai mare beneficiu în cazul combinării tehnicilor de total body mapping cu dermatoscopia digitală, datorită acurateții înalte pe care acestea le au în diagnosticarea melanomului în stadiile incipiente. Prezentăm cazul unei paciente în vârstă de 27 de ani cu istoric familial de melanom, la care examenul clinic a evidențiat un număr mare de leziuni melanocitare.

S-au efectuat dermatoscopie digitală și total body mapping și s-au identificat 3 leziuni cu atipie clinică și dermatoscopică. Acestea au fost excizate, iar examenul histopatologic a relevat faptul că leziunile erau nevi displazici.

Urmărirea pacientei pe viitor cu tehnici de dermatoscopie digitală și total body mapping îmbunătățesc semnificativ prognosticul bolii, deoarece aceste mijloace pot detecta cele mai subtile modificări ale nevilor, comparative cu dermatoscopia tradițională.

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Radu-Nicolae Grigore, Klaus Fritz, George Sorin Ţiplică, Carmen Maria Sălăvăstru

Introduction MoleMax (figure 1) is the first integrated system for digital epiluminescence microscopy and macro imaging in the world. The first units were released in May 1997 and soon after was introduced internationally in June 1997 at the Melanoma World Convention and the subsequent Dermatologists World Convention, and since then, MoleMax became the worldwide accepted clinical standard(1).

The system has three specially developed cameras for dermoscopy (Epiluminescence Microscopy) and macro imaging requirements. The cameras are optimized for instantaneous live video image and capture and employ patented light polarisation which enables top dermoscopy images without the need for immersion fluids(2). They can reach an optical zoom of 100x and the digital camera is capable of high resolution images.

Its software includes a patient management system for clinical and dermoscopic image storage and monitoring. It is capable of real time overlay follow-up, automatic lesion count and image analysis functions that uses the clinically well-known ABCD Rule or Seven Point Checklist to support the classification of lesions being diagnosed. The scoring system of the lesions is performed comparing the features of the lesions being analyzed with lesions exhibiting similar features from the large image database that is preloaded into the software.

It’s digital dermoscopy capabilities combined with total-body mapping techniques, are particularly recommended in the follow-up of patients at high risk of developing melanomas(3).

But atypical nevi and melanomas are not the only lesions that can be diagnosed with the aid of dermoscopy. Dermoscopy can facilitate the diagnosis of scabies due to the presence of the pathognomonic “jet with contrail” sign(4,5,6). Other skin infections and infestations may be differentiated with increased confidence, including pediculosis, phtiriasis, tungiasis, Tinea nigra, and molluscum contagiosum(4). Among the most common inflammatory skin disorders – psoriasis and lichen planus – the use of dermoscopy allows the visualization of specific submacroscopic features, such as the “red dots” pattern in psoriasis and the “whitish striae” pattern in lichen planus(4,7-12).

Some studies show that more than 35 different inflammatory and infectious skin diseases can be diagnosed with the aid of dermoscopy(4,13).

Case report A 27-year-old woman presented to our Clinic with multiple melanocitic lesions located mostly on the torso and upper limbs. She had a Fitzpatrick 2 skin type and no history of blistering sunburn during childhood. Her family history revealed that she had an aunt diagnosed with melanoma. Her medical history was unremarkable. A physical examination showed multiple melanocitic lesions located on the anterior chest, back, lumbar region and upper limbs (Figure 2). Some of the lesions presented clinical atypia. None of the lesions had a

Figure 1.

MoleMax 3 digital dermoscopy system

history of evolvement during the last years, but the family history, the large number of lesions and the presence of some clinically atypical lesions were a clear indication for the use of digital dermoscopy for evaluation and follow-up purpose.

Total body mapping was performed and dermoscopy images of the clinically atypical lesions were acquired, using the MoleMax 3 Digital Dermoscopy System (CDPC Project/ SIMS code 112).

Dermoscopy revealed three lesions that had alarming features. One of the lesions was located on the right scapular region, the other one was located on the superior medial quadrant of the left breast and the third lesion was situated on the left lateral thoracic region.

Scoring was performed for all the three lesions with the aid of the digital dermatoscope’s software, using the 7 point check list and the ABCD rule.

The highest scores were obtained for the lesion situated on the right scapular region (Figure 3).

This lesion presented atypical pigment network with asymmetry in both axes, abrupt cutoff of the pigment in six segments, exhibited dark brown and light brown colors and had the following structural components: homogeneous areas, dots and globules, beside the asymmetrical pigment network. It scored 6.2 using the automated ABCD scoring provided by the software and 4 using the 7 point check list. Both scores predicted that the lesions was malignant. By score, the right scapular region lesion was followed by the one situated on the left thoracic region (Figure 4A), which exhibited asymmetry in both axis, abrupt cutoff of the pigment in 2 segments, presented dark brown, light brown and white colors and had dots and homogenous areas. It scored 5.8 with ABCD rule and 4 with 7 point check list. The lesion situated on the left breast (Figure 4B) had a symmetrical pigment network, but presented abrupt cutoff of the pigment in 7 segments, had dark brown, light brown September 2015

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Case Presentation

The advantages of digital dermoscopy

Figure 2. Multiple melanocitic lesions located on the back and lumbar region

Figure 3. The lesion situated on the right scapular region, with calculated ABCD score and red colors, homogeneous areas, branched streaks and globules. It scored 4.2 with ABCD rule and 4 with 7 point check list. The suspect lesions were excised and pathology revealed that all three lesions were dysplastic nevi. Evolution after excision was good, with no complications or signs of recurrence.

The prognosis is good for the patient if regular follow-up is done. Again, digital dermoscopy will play an important role in the follow-up process as it did in establishing the diagnosis. With the aid of live overlay follow-up, the most subtle modifications of the lesions can be detected and thus prompt treatment can be employed.

Discussions Meta-analyses performed on studies in a variety of clinical and experimental settings have shown that dermoscopy improves the diagnostic accuracy for melanoma compared with naked eye examination (14) and has shown to increase the sensitivity in the clinical diagnosis of melanoma from 60 to 90% with specificity as high as 95% (15).

Serial digital dermoscopy increases the probability of diagnosing melanomas in their initial stag-

198

es and minimizes the dimensions of excision of benign lesions (16,17). Total body mapping allows the detection of macroscopic changes in pre-existing lesions as well as the diagnosis of new suspicious lesions. The combination of those two techniques is deemed the best follow-up method for high-risk patients (16,18).

Incipient melanomas can be missed by dermoscopy on first visit because they do not exhibit typical features from this early stage. It these cases, dermoscopic evaluation during subsequent visits will be able to detect the evolution of the lesion and the appearance of new features of malignancy. Digital dermoscopy is even better for these cases because it can store and compare images of the suspect lesion acquired during multiple visits.

It is recommended that the first return visit takes place after three months to allow the detection of uncharacteristic and fast-growing melanomas; any change occurring in that interim would indicate exeresis (16,19).

The second dermoscopic return visit should take place 6-12 months after the first examination in order to diagnose slow growing melanomas and/ or new melanomas or even the malignization of

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Radu-Nicolae Grigore, Klaus Fritz, George Sorin Ţiplică, Carmen Maria Sălăvăstru

Figure 4.

A – Lesion situated on the laterothoracic region. B – Lesion situated on the left breast

pre-existing nevi. The excision of the lesion should be considered when changes in the size, shape, or pigmentation are verified, or when there is regression or melanoma-specific dermoscopic structures (16-18,20).

High-risk patients, including those with familial melanoma, patients with multiple melanoma, and/ or atypical nevus syndrome, benefit most from total body mapping combined with serial digital dermoscopy, due to the increased accuracy in the diagnosis of melanomas in their initial stages (16-17,21) . In the case of our patient, excision of the suspect lesions was performed giving the family history and the strong clinical and dermatoscopic suggestion that those lesions were malignant. The pathologic examination showed no sign of malig-

nant dissemination. The patient can now benefit of future digital dermoscopy check-ups that will detect any possible malignant transformation in an early stage, thus giving the patient a very good prognosis.

Conflicts of interest The authors declare no conflicts of interest for this paper.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

Bibliography 1. (Internet) 2015 (cited 2015 Aug 31). Available from: http://www. dermamedicalsystems.com/index.php?menu_id=104 2. (Internet) 2015 (updated 2015, cited 2015 Aug 31). Available from: http:// equipmed.com/dermatology/molemax/molemax-iii 3. Gadens GA, Lack of compliance: a challenge for digital dermoscopy followup, An Bras Dermatol. 2014;89(2):242-4.

4. Argentiano G, Ferrara G, Francione S, et al., Dermoscopy—The Ultimate Tool for Melanoma Diagnosis, Seminars in cutaneuous Medicine and Surgery:142-148, Elsevier, 2009 5. Argenziano G, Fabbrocini G, Delfino M: Epiluminescence microscopy.

A new approach to in vivo detection of Sarcoptes scabiei. Arch Derma-tol 133:751-753, 1997 6. Dupuy A, Dehen L, Bourrat E, et al: Accuracy of standard dermoscopy for diagnosing scabies. J Am Acad Dermatol 56:53-62, 2007 7. Micali G, Nardone B, Scuderi A, et al: Enhances the diagnostic capability of palmar and/or plantar psoriasis. Am J Clin Dermatol 9:119-122, 2008 8. Vázquez-López F, Zaballos P, Fueyo-Casado A, et al: A dermoscopy subpattern of plaque-type psoriasis: Red globular rings. Arch Dermatol 143:1612, 2007 9. Zalaudek I, Argenziano G: Dermoscopy subpatterns of inflammatory skin disorders. Arch Dermatol 142:808, 2006 10. Vázquez-López F, Manjón-Haces JA, Maldonado-Seral C, et al: Dermoscopic features of plaque psoriasis and lichen planus: New observa-tions.

Dermatology 207:151-156, 2003 11. Vázquez-López F, Gómez-Díez S, Sánchez J, et al: Dermoscopy of active lichen planus. Arch Dermatol 143:1092, 2007 12. Vázquez-López F, Maldonado-Seral C, López-Escobar M, et al: Dermoscopy of pigmented lichen planus lesions. Clin Exp Dermatol 28: 554-555, 2003

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13. Zalaudek I, Argenziano G, Di SA, et al: Dermoscopy in general dermatology. Dermatology 212:7-18, 2006 14. Menzies SW, Evidence-Based Dermoscopy, Dermatol Clin 31 (2013) 521–524 15. Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J AmAcad Dermatol. 2003;48(5):679-93.

16. Brandão FV, Sá BCS, Pinto CAL, Duprat Neto JP, Digital dermoscopy in early diagnosis of melanoma and histopathology for high-risk patients, Surg Cosmet Dermatol. 2012;4(3)281-3 17. Argenziano G, Mordente I, Ferrara G, Sgambato A, Annese P, Zalaudek I. Dermoscopic monitoring of melanocytic skin lesions: clinical outcome and patient compliance vary according to follow-up protocols. Br J Dermatol. 2008;159(2):331-6 18. Silva JH, Sá BCS, Ávila ALR, Landman G, Duprat Neto JP. Atypical mole syndrome and dysplasic nevi: identification of populations at risk for developing melanoma. Clinics (São Paulo). 2011; 66 19. Ferrara G, Argenziano G, Giorgio CM, Zalaudek I, Kittler H. Dermoscopicpathologic correlation: apropos of six equivocal cases. Semin Cutan Med Surg. 2009;28(3):157-64.

20. Bauer J, Blum A, Strohäcker U, Garbe C. Surveillance of patients at high risk for cutaneous malignant melanoma using digital dermoscopy. Br J Dermatol. 2005;152(1): 87-92 21. Haenssle HA, Korpas B, Hansen-Hagge C, Buhl T, Kaune KM, Johnsen S, et al. Selection of patients for long-term surveillance with digital dermoscopy by assessment of melanoma risk factors. Arch Dermatol. 2010; 146(3):257-64

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A biobank supporting rare disease research in Dermatopathology. Our experience in establishing a biobank

A BIOBANK SUPPORTING RARE DISEASE RESEARCH IN DERMATOPATHOLOGY. OUR EXPERIENCE IN ESTABLISHING A BIOBANK BIOBANCA-SUPORT ÎN CERCETAREA AFECȚIUNILOR RARE DERMATOLOGICE. EXPERIENȚA NOASTRĂ ÎN ÎNFIINȚAREA UNEI BIOBĂNCI Manfred Beleut, PhD1, Edward Seclaman, PhD1, Michael Baudis, MD2, Ancuta Nicula MD3, Caius Solovan, MD1,3 1.

University of Medicine and Pharmacy “Victor Babes”, Timisoara, Romania 2.

University of Zurich, Institute of Molecular Life Science, Zurich, Switzerland 3.

Dermatology Department, Emergency City Hospital Timisoara, Romania Corresponding author: Nicula Ancuta – dermato-venereology resident doctor, Dermatology Department, Emergency City Hospital Timisoara, Romania Adress: Str. Marasesti nr 5 , Timisoara, Romania Phone number : 0256-202619, E-mail: niculaancuta@gmail.com

Open Access Article

Abstract Keywords: biobank, research, samples, dermatopathology

Cite this article: Manfred Beleut, Edward Seclaman, Michael Baudis, Ancuta Nicula, Caius Solovan. A biobank supporting rare disease research in Dermatopathology.

Our experience in establishing a biobank.

RoJCED 2015; 2(3):202-206

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Biobanks of human patient sample tissues and blood fractions are increasingly recognized as major assets in disease research. We aim to identify DNA copy number and gene expression aberrations typical of different cutaneous pathologies. Another goal is the identification of circulating biomarkers both as prognostic, therapyresponsive and/or therapy-monitoring factors and as disease classifiers and subclassifiers. We established a complex biobank, the first as such in Romania, based on fresh frozen material and formalin fixed parafine embedded specimen, backed up by an exhaustive database with focus on cases of cutaneous lymphoma and inflammatory diseases, but also basal cell carcinomas, squamous cell carcinomas, melanomas. At present, the biobank contains 320 patients peripheral blood ,tissue samples and extracted DNA specimens , with full authorization of the donors for use in research activities and approval by ethic committees and authorities. An important feature of our genomic data analysis is the integration of molecular data generated during our studies to results deposited in genomic data repositories (www.progenetix.net). We expect a high level of impact of our research for the development of diagnostic tools and identification of candidate molecules for targeted therapies.

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Manfred Beleut, Edward Seclaman, Michael Baudis, Ancuta Nicula, Caius Solovan

Rezumat Cuvinte-cheie: biobancă, studiu, probe, dermatopatologie

Biobăncile care prezervă probe proaspete de ţesut şi sânge au devenit în ultimii ani din ce în ce mai recunoscute ca având un rol major în progresul cercetărilor medicale. Scopul proiectului nostru este de a identifica aberaţiile care pot apărea în replicarea ADN şi expresia genică şi sunt sau pot fi implicate în apariţia sau declanşarea unor diferite patologii cutanate.

Alt obiectiv foarte important al acestui studiu este acela de a identifica biomarkeri celulari, tisulari şi circulanţi, care ar putea avea un rol important în prognosticul, răspunsul la tratament şi monitorizarea evoluţiei pe parcursul tratamentului, dar ar putea ajuta şi la clasificarea sau subclasificarea mai precisă a unor afecţiuni. În cadrul acestui proiect de cercetare a fost înfiinţată prima biobancă din România în care se păstrează probe proaspete de ţesut cutanat conservate la minus 80 de grade Celsius, probe de sânge fracţionat, specimene fixate în formol şi incluse la parafină, material genetic (ADN) extras, împreună cu o bază de date sub forma unui registru cu informaţii clinice despre pacienţii incluşi în studiu. Colecţia de probe de ţesut cutanat se axează în principal pe tipuri rare de limfoame cutanate şi afecţiuni inflamatorii cutanate – dermatoze inflamatorii –, dar include şi alte neoplazii cutanate, precum melanoame şi carcinoame bazocelulare. În prezent, biobanca conţine probe de sânge periferic, probe de ţesut cutanat şi extract genomic de ADN de la 320 pacienţi, obţinute cu consimţământul scris al donorilor pentru a fi folosite în scop de cercetare, respectând toate normele etice impuse. Datele obţinute în urma acestui studiu vor completa bazele de date internaţionale prin intermediul platformei Progenetix (www.progenetix.net). Sperăm ca rezultatele cercetărilor noastre să aibă un impact major în dezvoltarea unor noi metode de diagnostic şi în identificarea unor noi molecule candidate pentru terapii ţintite.

Introduction Biobanks of patients’ tissue specimen, corresponding blood samples and associated clinical data are increasingly recognized as major assets in clinical diagnostics and biomedical research. Here, we present the first biobank of dermatologic samples in Romania, established in the frame of a recently funded Swiss-Romanian research program. We present and underline aspects regarding the founding of a biobank based on our experience (1).

Quality of materials and operations The biobank currently includes fresh frozen material, extracted genomic DNA, fractionated blood samples from 170 patients, as well as formalin fixed paraffin embedded specimen from 150 patients, with a supporting database of clinical information. The sample collection is focussed on rare types of cutaneous lymphoma and inflammatory skin diseases, but extends to other cutaneous neoplasia (basal cell and squamous cell carcinomas, melanomas) (2).

The fast growing collection contains full donor authorization and ethics committee approval for use in research activities. Patient consent is fundamental to the ethical guidelines for obtaining and storing samples. Our project aims to support external participants both through archiving submissions of material, and through enabling the use of the material and anonymized supporting information in research studies (3).

With regard to sample processing, our focus is directed on the use of standardized protocols covering all steps from sample extraction, preparation and fractionation to appropriate long term storage. The team involved consists of both senior and young researchers with multidisciplinary scientific backgrounds (physicians, biologists and biochemists). Sample collection and preparation follow previously established protocols (4). We aim at collecting and processing participant samples as quickly as possible after extraction. Sample collection is performed in the clinical routine setting and the corresponding blood samples are processed in parallel and within a few hours by local September 2015

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Figure 1.

Representative DNA peak isolated from our FFPE samples (left) and fresh frozen samples (right)

laboratories. In surgically obtained tumor samples, two pathologists independently confirm a presence of at least 80% malignant cells by means of H&E staining prior to storage. For the tissue samples, time between collection and cryopreservation at -80° C is kept at a minimum to avoid degradation of labile specimen or components (e.g. RNA) (5).

Transparency (outreach activities and donor relations) We believe that biobanks need to engage patients starting with well structured informed consent. This issue is central in our organization, and maintaining a strong link between the donorâ&#x20AC;&#x2122;s consent and the use of his or her data is a legal and ethical obligation in the collection, storage and use of biospecimens and data for research purposes. All the samples in our biobank were collected with full donor authorization based on adequate information and mutual agreement for the proposed research and the modalities of individual participation (6).

The collection of biological material for diagnoses and research is of high and further increasing importance. Patient material for pathological, cellbiological, and molecular-biological investigations is essential (7). For dermatology this concerns in the first-line skin as well as blood. This is related to the fact that several dermatological diseases seem to be systemical diseases and not entirely restricted to the skin.

Besides insuring a high quality diagnostic service, our intention is to also present our results in scientific papers published in prestigious MEDLINE and/or ISI indexed journals, communications in national and international symposia, conferences and congresses. We currently organize workshops to present and discuss our results with Romanian and foreign researchers and health care providers to obtain an extensive dissemination of our findings (8).

Usage (sample turnover) One of our most outstanding features is that our biobank focusses in particular on rare skin diseases. In line with current scientific knowledge we

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have sampled, processed and are currently molecularly analyzing seldom inflammatory dermatoses assumed to progress to cutaneous lymphomas(9).

In an accompanying research study performed in collaboration with the University of ZĂźrich, we specifically aim to: - identify DNA aberrations and gene expression changes typical for different, previously understudied cutaneous pathologies - investigate the tissue and circulating biomarkers (circulating immune cells, circulating cancer stem cells, immune molecules, chemokines, angiogenic and growth factors) related to the various aspects of skin diseass (clinical and histopathologic appearance, prognosis and treatment) - transpose genetic data in reliable tissue & circulating biomarkers; - establish an integrated guide to good practice for diagnosis/prognosis/therapeutic approaches in cutaneous pathologies.

To date, genomic DNA was extracted from 87 FFPE specimens using QIAamp DNA FFPE Tissue Kit and 75 fresh frozen materials using PureLink Genomic DNA mini kit. The elution buffer contains 10 mMTris-HCl and 0.1 mM EDTA. The absolute yield of extracted DNA was assessed using a NanoDrop ND-1000 (Figure 1). The spectrophotometric analysis resulted in an average 1.8 for A260/280, indicating that the extracted DNA from the biobank samples showed a high quality and was free from protein contamination.

To further confirm sampling quality and exclude DNA fragmentation, for sensitive microarray analytical processes, extracted DNA of fresh frozen materials is further and routinely validated by tight bands on 1% agarose gel electrophoresis. The sizes of well purified DNA fragments can be detected between 20 and 30 kb as confirmed in Figure 2.

Extracting DNA from FFPE tissues is generally regarded as a challenge. Based on available literature data we expect to obtain fragmented DNA, most fragments appear to be less than 400 - 600 bp in length. Predesigned TaqMan SNP genotyping products rs3892097 and rs1057910 (Life Technologies) are used to evaluate the FFPE DNA integrity. Real time PCR was performed in an ABI 7900 (Life Technologies) in 7 yl total volume with

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Manfred Beleut, Edward Seclaman, Michael Baudis, Ancuta Nicula, Caius Solovan

Figure 2.

Electrophoretic analysis of total genomic DNA on 1% agarose gel (DNA from fresh frozen samples in line 1-3, molecular weight ladder in line M)

1 ng of DNA/reaction. The mean Ct value was 34 (Figure 3), suggesting an excellent quality also for DNA isolated from the FFPE samples and thus supporting our strict storage conditions (10).

Connectivity (integration into Biobank networks and trans-institutional infrastructure) All the people involved in the research processes benefit from collaboration with highly respected experts of impressive academic level and are exposed to a highly stimulating environment.

The research teams are able to complete laborious and difficult tasks and the accumulated experience is the fundament for future projects and collaborations.

The integration with external datasets using the Progenetixplatform as well as the sharing with the research community through our web portal atcnhl. progenetix.org are important features intended for the molecular screening data generated in our studies. The Group at the University of Zurich is one of the leaders in the field of large scale meta-analyses of oncogenomic copy number data and maintains the largest collection of annotated CNA data in cancer (www.progenetix.net). Recently, the group has launched a reference resource for oncogenomic array data (www.arraymap.org). A continuous integration of original study data with related information is an element in the benchmarking of our performances guarantees the reliable identification of new biological marker through integration with molecular profiles beyond the limits of single experimental series (11).

Figure 3.

Representative Real Time PCR amplification curves for quality control of DNA extracted from FFPE samples stored in our biobank

For the future improvement and long term development of archival procedures and facilities, we are currently preparing an integration of our efforts with the “HoriaCernescu-Research Unit” of the University of Agricultural Sciences and Veterinary Medicine of Banat “King Michael the 1st of Romania”, Timisoara. While the infrastructure of this facility so far has been used for the collection of non-human samples, making use of the expertise and existing infrastructure of both institutions would significantly expand our scope, and potentially be instrumental in future projects utilising distinct animal models in pre-clinical human rare disease research.

Innovation (innovative solutions for any kind of biobank-related problems) Our biobank, consisting of nucleic acids, corresponding blood and tissue samples accompanied by detailed long term follow up data, is the first dermatologic samples bank in Romania. This institution in conjunction with the national and international collaborations present a Multidisciplinary Research Core Unit at our university, in which medical doctors, graduate and undergraduate students of different professions are directly involved in clinical research and project development. The senior scientists with internationally recognized research background provide the high quality scientific milieu required. Our biobank in conjunction with all the resulting scientific research efforts around, is providing the international guarantee for increased Romanian research visibility, sustaining the projects’ development towards September 2015

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an increased dissemination of obtained results within the international scientific community (12).

Sustainability (outline of business model) The biobank is currently linked to the infrastructure of the Victor-Babes University of Pharmacy and Medicine Timisoara and is financed by the end of 2015 by the Romanian-Swiss Research Programme (RSRP; research grant SNF142305).

By the end of this year, we plan to reconstitute the biobank as an independent institution upon joining with the facilities for non-human research of the “HoriaCernescu Research Unit”. Sustained financing would be ensured by national grants linked to the development of the medical infrastructure in Romania. As we envision however becoming a nation-wide center of competence we currently discuss the possibility to sub-contracting as non-profit “service providers” with individual research projects in which bio-banking expertise and data is required. This way we would also raise interest for our institution within other hospitals throughout the country and ensure a standardized protocol and sustained quality for human medical research (13).

This study was performed respecting all the international ethical guidelines for human biomedical research . All the samples in our biobank were collected with full donor authorisation based on sufficient information and adequate understanding of both the proposed research and the implications of participation in it .

Acknowledgements This work was supported by the project „From chronic inflammatory dermatoses to cutaneous lymphoma: molecular cytogenetic and gene expression profiling” with number IZERZ0_142305, from the UEFISCDI Romania in collaboration with Romanian Minister of Education, Science, Youth and Sport, „Victor Babes“ University of Medicine and Pharmacy and FNSNF – Swiss National Science Foundation under the auspice of RomanianSwiss Research Programme (RSRP).

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

Bibliography 1. Judit Sándor and Petra Bárd- “ The Legal Regulation of Biobanks. National Report : Romania “ 2009 Center for Ethics and Law in Biomedicine (CELAB) .

2. H. Peter Soyer, MD, FACD1,2; Lynlee L. Lin, BSc1; Tarl W. Prow, PhD1 - “ A Plea for Biobanking of All Equivocal Melanocytic Proliferations“; JAMA Dermatol.

2013;149(9):1023-1024. doi:10.1001/jamadermatol.2013.4478.

3. Simon. J., Blohm-Seewald, C., Paslack, R., Robienski, R -“ Privacy und Policy – Rechtspolitische und ethischeAspekte von Biobanken “ ,Lüneburg (2005) 4. Grüber, K., Hohlfeld, R.” Biobanken – Konzepte und Umsetzung“ .Institut Mensch, Ethik und Wissenschaft (IMEW), Berlin; (2005) 5. Yuille M. Illig T. Hveem K, et al. Laboratory management of samples in biobanks: European Consensus Expert Group Report. BiopreservBiobanking.

2010;8:65–69.

6. Marco A. Pierotti, Claudio Lombardo - “From the biobank to the research biorepository: ethical and legal recommendations ” 2010,OECI ( Organisation of European Cancer Institute )

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7. MacLean ,VA : American Associacion of Tissue Banks - “Standards for Tissue Banking “ 12th edition –2009 8. Vaught J. Kelly A. Hewitt R. “ A review of international biobanks and networks: success factors and key benchmarks. BiopreservBiobanking “.

2009;7:143–150.

9. Dominique de Valeriola, Claudio Lombardo- OECI ( Organisation of European Cancer Institute ) Yearbook 2014-2015 10. Haga SB. Beskow LM.” Ethical, legal, and social implications of biobanks for genetics research.”Adv Genet. 2008;60:505–544. [PubMed] 11.UK Biobank Ethics and Governance Framework. Version 3.0, October 2007, at http://www.ukbiobank.ac.uk/docs/EGF20082.pdf 12.George Galea - “Essentials of Tissue Banking “ 2010th Edition 13. Cambon-Thomsen A. Rial-Sebbag E. Knoppers BM.” Trends in ethical and legal frameworks for the use of human biobanks“ .EurRespir J. 2007;30:373–382.

[PubMed]

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Rosacea and technology – diagnosis and treatment

ROSACEA AND TECHNOLOGY – DIAGNOSIS AND TREATMENT ROZACEEA – TECHNOLOGII UTILIZATE ÎN SCOP DIAGNOSTIC ȘI DE TRATAMENT Cristiana Voicu¹, Victor Gabriel Clătici¹, Leonardo Marini² ¹ Dermatology Department, Elias Emergency Hospital, Bucharest, Roamania. ² Skin Doctors Center, Trieste, Italy.

Corresponding author: Victor Gabriel Clatici, 17 bd Marasti Street, Sector 1, Bucharest, Phone 021 / 3161600 – 190 / 224, fax 021 / 3173052, Email claticiv@yahoo.com

Open Access Article

Abstract Rosacea is one of the most common inflammatory skin conditions in Caucasian patients oftentimes associated with “sensitive skin” reactivity.

Modern dermatologic technologies have contributed significantly to improve diagnostic and treatment procedures in this particular skin alteration. Computerized skin analysis imaging systems and confocal microscopy are just two of the most advanced tools to help physicians to proper diagnose and monitor the evolution of rosacea before and after medical and EBD-assisted procedures. When we consider innovative treatment scenarios, extremely versatile powerful light sources have been successfully used to treat clinical aspects of rosacea that were once considered impossible or quite difficult to durably and consistently improve, such as mild diffuse erythema, variable size irregularly distributed telangiectasias and rhynophyma. The authors performed an extensive review of the most recent dermatologic literature and contributed with their own personal experience on clinical and therapeutical aspects linked with this widespread topic.

Keywords: rosacea, laser, non-invasive skin assessment.

Rezumat Cuvinte-cheie: rozacee, laser , evaluare cutanată noninvazivă.

Cite this article: Cristiana Voicu, Victor Gabriel Clătici, Leonardo Marini.

Rosacea and technology – diagnosis and treatment.

RoJCED 2015; 2(3):208-214

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Rozaceea este una dintre cel mai des intâlnite afecțiuni cutanate inflamatorii la pacienții caucazieni, frecvent asociată cu sensibilitate cutanată reactivă. Tehnologiile dermatologice moderne contribuie semnificativ la îmbunătățirea procedurilor diagnostice și terapeutice în cazul acesteia. Sistemele computerizate de analiză cutanată și microscopia confocală sunt doar două dintre cele mai avansate tehnici care ajută medicul în diagnosticul și monitorizarea evoluției rozaceei, înainte și după procedurile medicale asistate-EBD. În ceea ce privește opțiunile terapeutice inovatoare, surse de lumină puternice și extrem de versatile sunt utilizate în prezent cu succes pentru a trata aspecte clinice ale rozaceei care erau considerate în trecut dificil sau imposibil de abordat, cum ar fi eritemul difuz, telangiectazii de variate dimensiuni, cu distribuție neregulată și rinofima. Autorii au realizat o revizuire extensivă a literaturii dermatologice de ultimă oră, contribuind în același timp cu informații provenite din experiența personală privind aspecte clinice și terapeutice asociate acestei afecțiuni extrem de răspândite.

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Cristiana Voicu, Victor Gabriel Clătici, Leonardo Marini

INTRODUCTION: Rosacea is one of the most commonly encountered inflammatory skin conditions on the rise predominantly within Caucasian populations. Currently available topical and systemic therapies remain only partially successful in improving and effectively controlling the evolution of rosacea.

Flushing, localized persisting erythema, telangiectasias and rhynofima – mostly evident in male patients - are among the main features of this extremely variable skin condition. To address these skin alterations, the best therapeutic options rely on LED photo-assisted tissue bio-modulation and and more specific high energy light devices, particularly lasers and other light-based systems (1).

The treatment of choice for facial telagiectasias and localized erythema is a combination of vascular lasers and light-based systems such as Intense Pulsed Light devices. These kinds of light-based devices are also beneficial to papulo-pustular forms of rosacea, both to shorten their active fases and to prevent further relapses. Diffuse erythema responds quite well but usually requires more laser sessions (2).

Ablative lasers, electro-surgical devices, and mechanical dermabrasion have been successful in treating rhynophima and other phymatous conditions, contributing to partially improve inflammatory rosacea-related textural alterations.

Unfortunately, due to the very nature of rosacea, skin symptoms and related alterations tend to recur requiring periodic light-based treatments to provide good clinical control (1).

Figure 1.

Advanced treatment procedures can be used more effectively when proper non-invasive preand post-procedural clinical evaluations can be performed. Computerized, high resolution imaging devices and detailed skin features analysis systems, have proven quite helpful in assessing baseline and post-treatment skin chatacteristics (3).

ADVANCED SKIN ANALYSIS SYSTEMS: Skin analysis imaging devices are able to perform a detailed assessment of epidermal and dermal layers according to standardized, reproducible, non-invasive protocols (4). High resolution digital photography, associated with conventional, polarized, and UV light sources, help complex integrated softwares to perform their job in a very efficient and reproducible way (4, 5-7). This kind of digital analysis platforms have been successfully used to assess and monitor patients affected by rosacea (4) and acne (8,9, 10). Confocal laser scanning microscopy (CLSM) is another revolutionary technology which has the ability to microscopically visualize the structural details of the superficial layers of the skin, including detection and quantification of Demodex Folliculorum in vivo and in a non-invasive fashion. Mites appear as cone-shaped structures within facial skin layers of rosacea patients (11).

TELANGIECTASIAS AND ERYTHEMA: Telangiectasias and erythema can be approached by a variety of light devices targeting hemoglobin as a main light-absorbing chromophore, such as 577-595-nm PDL (pulsed dye laser), 532-

Erythematous-telangiectatic rosacea in 45 y.o. patient. Before and after clinical pictures of combined multilayer laser + LED treatment. First pass 1064nm Nd:YAG laser short pulse (6mm spot scanner operated - 0.3ms) followed by a second pass of 1064nm Nd:YAG laser long pulse (6mm spot scanner operated - 35ms); third pass: 595nm PDL (7mm spot 1.5ms); fourth pass: 630nm LED photobiomodulation – 1 session. Post-TX picture was taken 60 days after combined laser + LED procedure. Personal archive of Leonardo Marini.

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Figure 2.

Figure 3.

Erythematous-telangiectatic rosacea in 40 y.o. patient. Before and after clinical pictures of combined IPL (spectral band 500-950nm – 7ms x 2 – interpulse delay 22ms) and 15% TCA chemical peel (PhotoPeel): 1 session. Post-TX picture was taken 60 days after procedure. Personal archive of Leonardo Marini.

Erythematous-telangiectatic rosacea in 39 y.o. patient. Before and after clinical pictures of sequential multilayer variable pulsewidth 595nm PDL: 7mm spot 1st pass 1.5ms; 2nd pass 3ms; 3rd pass – 1 session. Post-TX picture was taken 60 days after procedure. Personal archive of Leonardo Marini.

nm KTP laser (potassium titanyl phosphate), 1064nm Nd:YAG laser and non-coherent IPL (intense pulsed light) sources.

Modern PDLs (585-595 nm) have the possibility to variably modulate pulse widths and deliver their beams through circular or oval spot sizes, ideal for targeting diffuse telangiectasias and more evident micro-reticular dermal vessels. Similarly to 577-nm PDL systems, 585-595nm units still have the potential to cause purpura, but this side effect

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can be minimized by using longer pulse widths and multiple passes according to a “subpurpuric dosing” approach. Linear vessels and erythema require specific parameters which are quite different from those used to treat larger vessels (12). PDL microphotocoagulation has been shown to significantly improve telagiectasias, erythema as well as favourably control rosacea-associated vasoreactive symptoms (13). A recent study aiming at investigating the impact of PDL laser microcoagulative

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

Cristiana Voicu, Victor Gabriel Clătici, Leonardo Marini

Figure 4.

Erythematous-telangiectatic rosacea in 38 y.o. patient. Before and after clinical pictures of sequential multilayer variable pulsewidth 595nm PDL: 7mm spot 1st pass 1.5ms; 2nd pass 3ms; 3rd pass – 1 session. Post-TX picture was taken 60 days after procedure. Personal archive of Leonardo Marini.

treatment on the QoL (measured by the DLQI) concluded that all patients enrolled experienced a statistically significant improvement in their quality of life post-procedure (14).

The yttrium-aluminium-garnet (Nd:YAG 1064nm) laser is another light source which has been successfully used to treat erythemato-telagiectasic alterations associated with rosacea. Studies performed to compare PDL 595-nm microcoagulative clinical response with 1064-nm Nd:YAG laser treatments revealed contradictory results. In one study, 1064-nm Nd:YAG was rated as being less painful, but participants declared to be more satisfied with the results induced by PDL treatment (15), while another found no statistically significant results regarding patient satisfaction scores between the two laser systems (12). A study comparing the two laser sources, regarding both clinical aspects of erythemato-telangiectatic rosacea and immunohistochemically cutaneous substance P expression, revealed similar results regarding clinical improvements and a decrease in the concentration of substance P in the skin, the last finding being more pronounced after 1064-nm Nd:YAG laser treatments (16).

Recently, Q-switched 595-nm neodymiumdoped yttrium aluminum garnet (Nd:YAG) laser with low non-purpuragenic fluences has been used to treat erythemato-telangiectatic rosacea at its early stages and proved to be both safe and effective, not only for rosacea but also for melasma (17) , nevertheless due to the low number of patients studied, future research will be required to confirm these interesting findings. According to our personal experience, we believe that sequential laser and IPL sources layering strategies provide better clinical improvements than single light source

treatments, minimizing side effects. Currently our treatment approach consists in one or two passes with moderate energy 1064-nm Nd:YAG laser – 2-3 mm spot to target superficial microvessels followed by 4-5-6 mm spot to target deep vessels followed either by IPL (spectral band 560-950nm) or 595nm PDL. This strategy allows to address both the vascular and microstructural dermal alterations of rosacea.

Potassium titanyl phosphate (KTP 532-nm) lasers have shown to have beneficial effects in reducing the size of superficial facial skin vessels up to 1-3 mm below skin surface, linear and discrete telangiectasias, but, due to its short wavelength it is quite absorbed my melanin which can therefore be considered as a competive chromophore. Its main disadvantage in treating superficial vascular targets on sun-exposed skin is therefore linked to the melanin absorption, which is inevitably associated with a higher potential risk of developing PIH (post-inflammatory hyperpigmentation).

It should be limited to treat type 1-2 Fitzpatrick phototype patients (12). Comparing PDL and KTP laser photocoagulation the second light system has proven to be superior when immediate and longterm clinical improvements of rosacea-associated vascular alterations has been considered, even if photo-coagulative treatments were reported more painful, and associated with PIH and purpura (13).

Multiple photocoagulative sessions with 532-nm KTP may therefore become a possible effective alternative to PDL for lighter skin patients. Intense Pulsed Light (IPL 500-1200 nm) devices rely on non-coherent spectral bands to induce selective foto-thermolysis on red and brown skin targets, being effective for both deeper and superficial blood vessels, when proper cut-off filters are used. Side September 2015

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Figure 5.

Erythematous-telangiectatic rosacea in 57 y.o. patient Before and after clinical pictures of combined IPL (spectral band 500-950nm – 7ms x 2 – interpulse delay 22ms) and 15% TCA chemical peel (PhotoPeel): 1 session. Post-TX picture was taken 60 days after procedure. Personal archive of Leonardo Marini.

Figure 6.

VISIA evaluation for rosacea - Personal archive of Victor Gabriel Clatici

effects have been reported minimal (12). IPL proved to be effective in treating erythemato-telangiectatic rosacea, particularly when severe forms were considered, younger patients (18) as well as in perilesional erythema (19). Clinical results have been evident for up to 6 months after treatment (20) . It also appears that IPL treatment induce similar results as those visible after PDL, but there is still insufficient evidence to sustain this conclusion (15).

Photodynamic therapy (PDT) has also been used in the management of rosacea, but its mechanism of action remains unclear (12).

Low level laser light therapy (LLLT) and LED photobio-modulation has shown a profound reduction of erythema index in irritated skin. This technology might be considered as safe and effective stand-

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ing alone or ancillary treatment associated with other laser sources for the treatment of rosacea and sensitive skin patients (21).

PHYMATOUS LESIONS: Rhinophyma represents a benign yet devastating, progressively disfiguring complication of end stage rosacea. It is characterized by slowly progressing hyperplasia and hypertrophy of sebaceous glands and connective tissue of nasal skin.

The main treatment strategies focused on surgical techniques (cold steel, hot RF loop, scalpel excision) (13), mechanical dermabrasion, cryosurgery, 10.600-nm CO2 laser photo-sculpting or 2940-nm Er:YAG laser controlled photo-ablation (2).Some Authors consider results produced by cold blade

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Cristiana Voicu, Victor Gabriel Clătici, Leonardo Marini

tangential excision techniques similar to those obtained after CO2 lasers, but the ease of use and the precision of lasers do not justify the increased costs (22).

CO2 and Er:YAG laser systems are presently considered the first line options by many authors (13).

These reports are based on post-treatment clinical observations performed on patients affected by mild rhinophyma. Laser-assisted photo-sculpting confirmed also with a better post-treatmet side-effect profile than conventional surgery (23), with faster healing and good cosmetic results (24). All procedures proposed to correct and improve rinophyma can be potentially associated with side effects such as: abnormal scarring, dyspigmentation, prolonged edema, persistent erythema and prolonged crusting (13). A combination therapy of surgical debulking followed by fractionated CO2 laser therapy has also been advocated. This method proved to have some clear benefits: the amount of time needed for the procedure has been substantially reduced and specimens could be sent for histopathology examination.

In addition, due to the use of fractionated CO2 laser after debulking, some complications of non-fractionated lasers have also been avoided, such as pigmentary changes, scarring and persistent erythema (25).

CONCLUSIONS: Modern technology brought important benefits in different fields of medicine, including dermatology. Rosacea, a common dermatological skin condition, with important impact on patient’s quality of life, is one of the many beneficiary of the latest achievemnts in this continuously evolving field of research. Moving from novel skin analysis and imaging devices, that can provide a better non invasive assessment of the extend, severity and evolution of rosacea-associated skin lesions to recently introduced confocal microscopy skin scanners, which have the ability to visualize the superficial layers of the skin with a non-invasive, in vivo approach, physicians have very important tools to better understand and monitor their treatment strategies .

Rosacea treatments have been revolutionized by the use of lasers, IPL sources, and LED photobiomodulation, which have proven highly effective, particularly in the management of diffuse and localized telagiectasias and rosacea-associated

erythema. The main light sources used for this purpose have been identified with PDL and KTP laser systems (26). Reactive rosacea and sensitive skinassociated erythema represent a more difficult alteration to be effectively reduced and controlled.

These unstable vascular alterations are deeply influenced by many endogenous and exogenous factors which are not always controllable and usually require more treatment sessions (2). PDL is still considered the most effective treatment by many authors, but possible side-effects (prolonged purpura) might not rank this photocoagulative strategy as highly preferable by some patients (26).

1064-nm Nd:YAG lasers need to be properly used, carefully selecting treatment parameters, since its absorbtion by haemoglobin is less efficient than PDL. Atrophic scars can be induced, should excessive light energy be delivered to skin tissues (26).

Papulo-pustular rosacea can be addressed by laser treatment once the inflammatory process has been successfully controlled by soft-form of photobiomodulation induced by LED and laser sources (2).

Hypertrophic forms of rosacea, like rhinophyma, are best treated by surgical approaches, CO2 or Erbium:YAG lasers either full- or fractional-beam at suitably high energies, compared with those used to treat vascular targets such as facial telangiectasias by vascular-specific lasers (2). In spite of encouraging clinical improvements, patients need to be properly informed that variable degrees of rosacea recurrences are quite common, since this particular skin disease has a multifaceted origin and difficult to predict evolution. Repeated treatment sessions will betherefore required to effectively control its clinical manifestations. Sequentially associating different light sources have proven quite effective minimizing each light source side effects and optimizing shortand long term clinical results. Proper dietary behavior and topical treatments should be implemented as part of a well balanced management of rosacea.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

Bibliography 1. Tanghetti E, Del Rosso JQ, Thiboutot D, Gallo R, Webster G, Eichenfield LF, SteinGold L, Berson D, Zaenglein A; American Acne & Rosacea Society. Consensus recommendations from the American acne & rosacea society on the management of rosacea, part 4: a status report on physical modalities and devices. Cutis. 2014 Feb;93(2):71-6.

2. Dahan S. Laser and intense pulsed light management of couperose and rosacea.

Ann Dermatol Venereol. 2011 Sep;138 Suppl 2:S167-70.

3. http://www.canfieldsci.com/imaging-systems/visia-complexion-analysis (accesed online 03.09.2015).

4. C Voicu, C Ditescu, M Andrei, C Medeleanu, A Duta, M Maftei, VG Clatici. ROZACEEA PAPULO – PUSTULOASĂ : CONDUITĂ PRACTICĂ ȘI ABORDARE MULTIDISCIPLINARĂ.

ORL.RO, Anul VII, Nr.23(2/2014), p26-31, ISSN 2067-6530 5. S, Westerhof W, Im S, Lim J. Noinvasive techniques for the evaluation of the skin. J

Am Acad Dermatol. 2006;54(5 Suppl 2):S282-90.

6. Canfieldsci.com [homepage]. Dermirli R, Otto P, Viswanathan R, Patwardhan S, Larkey J. RBX Technology Overview. http://www.canfieldsci.com/FileLibrary/RBX%20 tech%20overview-LoRz1.pdf.

7. RC Spitale, MY Cheng, KA Chun et al. Differential effects of dietary supplements on metabolomic profile of smokers versus non-smokers. Genome Med. 2012; 4(2): 14.

8. VG Clatici. ADULT FEMALE ACNE – AN HOLISTIC APPROACH, FROM DIETARY MANIPULATION TO LASER SURGERY, Laser Medical application on Head and Neck, Opatija, Croatia, 27-30 June, 2013.

9. VG Clatici, EFICIENȚA ASOCIERII IHTIOL ALB – PIROCTON OLAMINĂ IN REDUCEREA INFECTIEI CU PROPIONIBACTERIUM ACNES LA NIVELUL FEȚEI, Al 11 lea Congres national de Dermatologie cu Participare Internationala, Cluj-Napoca, 24-27 octombrie 2012.

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10. VG Clatici, O Clatici, ER Kasimati, AM Draganita, ACNEE VULGARĂ – EVALUARE COMPUTERIZATĂ VISIA, ABORDARE COMPLEXĂ ȘI TRATAMENT LASER 4th International Conference on Lasers in Medicine, Sibiu, 22-24 Septembrie, 2011.

11. Sattler EC, Maier T, Hoffmann VS, Hegyi J, Ruzicka T, Berking C. Noninvasive in vivo detection and quantification of Demodex mites by confocal laser scanning microscopy. Br J Dermatol. 2012 Nov;167(5):1042-7.

12. Mansouri Y, Goldenberg G. Devices and topical agents for rosacea management.

Cutis. 2014 Jul;94(1):21-5.

13. Allison P Weinkle,Vladyslava Doktor, and Jason Emer. Update on the management of rosacea. Clin Cosmet Investig Dermatol. 2015; 8: 159–177.

14. Shim TN, Abdullah A.The effect of pulsed dye laser on the dermatology life quality index in erythematotelangiectatic rosaceapatients: an assessment. J Clin Aesthet Dermatol. 2013 Apr;6(4):30-2.

15. van Zuuren EJ, Fedorowicz Z, Carter B, van der Linden MM, Charland L. Interventions for rosacea. Cochrane Database Syst Rev. 2015 Apr 28;4:CD003262.

16. Salem SA, Abdel Fattah NS, Tantawy SM, El-Badawy NM, Abd El-Aziz YA. Neodymium-yttrium aluminum garnet laser versus pulsed dye laser in erythematotelangiectatic rosacea: comparison of clinical efficacy and effect on cutaneous substance (P) expression. J Cosmet Dermatol. 2013 Sep;12(3):187-94.

17. GooBL, KangJS, Cho SB. Treatment of early-stage erythematotelangiectatic rosacea with a Q-switched 595-nm Nd:YAGlaser. J Cosmet Laser Ther.2015 Jun;17(3):139-42.

18. Lim HS, Lee SC, Won YH, Lee JB. The efficacy of intense pulsed light for treating erythematotelangiectatic rosacea is related to severity and age. Ann Dermatol. 2014

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19. Liu J, Liu J, Ren Y, Li B, Lu S. Comparative efficacy of intense pulsed light for different erythema associated with rosacea. J Cosmet Laser Ther. 2014 Dec;16(6):324-7.

20. Papageorgiou P, Clayton W, Norwood S, Chopra S, Rustin M. Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. Br J Dermatol. 2008 Sep;159(3):628-32.

21. Choi M, Kim JE, Cho KH, Lee JH. In vivo and in vitro analysis of low level light therapy: a useful therapeutic approach for sensitive skin. Lasers Med Sci. 2013 Nov;28(6):1573-9.

22. Lazzeri D,Larcher L,Huemer GM,Riml S,Grassetti LPantaloni M,Li Q,Zhang YX,Spinelli G, Agostini T. Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience. J Craniomaxillofac Surg.2013 Jul;41(5):42936.

23. Meesters AA,van der Linden MM, De Rie MA, Wolkerstorfer A. Fractionated carbon dioxide lasertherapy as treatment of mild rhinophyma: report of three cases.

Dermatol Ther. 2015 May-Jun;28(3):147-50.

24. Bassi A, Campolmi P, Dindelli M, Bruscino N, Conti R, Cannarozzo G, Pimpinelli N. Laser surgery in rhinophyma. G Ital Dermatol Venereol. 2014 Sep 18. [Epub ahead of print] (accesed 04.09.2015).

25. Kassir R, Gilbreath J, Sajjadian A. Combination surgical excision and fractional carbon dioxide laser for treatment of rhinophyma. World J Plast Surg. 2012 Jan;1(1):36-40.

26. Mazer JM. Role of laser in the treatment of rosacea. Ann Dermatol Venereol. 2014 Sep;141 Suppl 2:S175-8.

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Oncology & Dermato-Oncology

Radiation therapy skin toxicity

RADIATION THERAPY SKIN TOXICITY AFECTAREA CUTANATÃ INDUSÃ DE RADIOTERAPIE Ciprian Enachescu1, Sena Yossi1, Tristan Brahmi1, Victor Gabriel Clatici2 , Alina Tita3 Centre Hospitalier Lyon Sud, 165, Chemin du Grand Revoyet, 69495 Pierre-Bénite cedex, France.

2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania.

3 Medical Student, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania.

Corresponding author: Ciprian Enachescu, Département de Radiothérapie et Oncologie, Centre Hospitalier Lyon Sud, Chemin du Grand Révoyet, 69495 Pierre-Benite Cedex, France, E-mail: ciprian.enachescu@lyon.fr

1

Abstract Keywords: skin toxicity, radiotherapy, side-effects, pathophysiology, treatment

Skin toxicity induced by radiation therapy is a complex adverse event which can affect all the layers of the skin or its appendages.

Depending on the time of occurrence, the radiation toxicities are classified in early side effects, that occur during the treatment and late side effects, that occur more than 6 months completing the irradiation.

From the point of view of causal mechanisms, radiation effects are due to cellular depletion and to cellular and tissue dysfunction/ reaction. The early effects concern the rapid proliferating tissue in the superficial layers of the skin (epidermis), while the later ones involve the slow proliferating tissues in dermal stroma and vascular network.

The side effects are classified according to the National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events, (CTC-AC) and Radiation Therapy Oncology Group (RTOG) in 4 grades, each with specific treatment.

Rezumat Cuvinte-cheie: toxicitate cutanată, radioterapie, efecte adverse, fiziopatologie, tratament

Cite this article: Ciprian Enachescu, Sena Yossi, Tristan Brahmi, Victor Gabriel Clatici, Alina Tita. Radiation therapy skin toxicity.

RoJCED 2015; 2(3):216-228

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Toxicitatea cutanată indusă de radioterapie este un fenomen complex ce poate afecta toate straturile pielii și anexelor sale. În funcție de momentul apariției, toxicitatea produsă de iradiere este clasificată în toxicitate acută, care apare în timpul tratamentului, și toxicitate tardivă, care apare dupa cel puțin 6 luni de la terminarea iradierii. Din perspectiva mecanismelor cauzale, efectele iradierii se datorează depleției celulare și reacției și disfuncției celulare și tisulare. Efectele adverse acute privesc țesuturile cu rata rapidă de proliferare din straturile superficiale ale pielii (epiderm), în timp ce toxicitatea tardivă privește țesuturile cu proliferare lentă din stroma si retelele vasculare. Efectele adverse sunt clasificate conform recomandărilor National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events, (CTC-AC) și Radiation Therapy Oncology Group (RTOG) în 4 grade, fiecare cu tratamentul său specific.

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Ciprian Enachescu, Sena Yossi, Tristan Brahmi, Victor Gabriel Clatici, Alina Tita

INTRODUCTION: Skin toxicity induced by radiation therapy is a complex adverse event which can affect all the layers of skin or its appendages. Due to its ubiquitous position between the region of interest and the accelerator, it is a fact to be taken care in each case, at various degrees. Through this literature review, we describe this potentially limiting side-effect from the pathophysiology to treatment considering each skin layer or cellular type.

RADIOBIOLOGY: Radiation causes a wide range of Deoxyribonucleic acid (DNA) lesions like double strand breaks, single strand breaks and base damages, a dose of 1-2 Gy (dose usually used in conventional fractionated external irradiation) producing aproximativelly 1000 single strand breaks and base damages and 40 double strand breaks (1). The balance between the DNA lesions production and reparation decides the cell outcome: a) DNA lesions remains unrepaired and cause permanent cell cycle arrest, induction of apoptosis or mitotic cell death; b) DNA lesions are incorrectly repaired and induce chromosomal rearrangements which can lead to carcinogenesis (2); c) DNA lesions are correctly repaired , so the cell survive with restitutio in integrum of their functions (3) From radiobiology point of view, cell death is defined as the loss of reproductive capacity .Thus irradiated cells do not die immediately, but may produce only a modest and limited family of descendants.

The effect of radiation is evaluated in vitro by cell survival curve which represents the surviving fraction as a function of the radiation dose(4). The tool used to describe cell killing for tumor and normal tissue is the Linear-Quadratic model (LQ) which enables in clinical practice, the comparison of different radiotherapy regimens in term of biologic effect (isoeffect dose) (5).

Normal tolerance dose for late toxicity is established for conventional radiotherapy fractionation, meaning 1.8-2 Gy per fraction, 5 fractions per weeks. To assess the risk of toxicity for altered fractionation regimens (more than 2 Gy per fraction) physical dose must be converted into an equivalent biological dose (6).

D1 d2 + a/b = D2 d1 + a/b D1, d1: Total Dose and dose per fraction for regimen 1 (Gy) D2, d2: Total Dose and dose per fraction for regimen 2 (Gy) a/b: Parameter which defines the tissue radiosensitivity (Gy) (7) Depending on the time of occurrence, the normal tissue responses to radiation are divided into two categories: early effects that occur during the treatment and late effects that occur more than 6 months after irradiation. Acute effects occur in

rapid renewal tissues due to the critical death of certain cell populations and are characterized by inflammation, oedema, denudation of epithelia and haemorrhage.

Chronic effects occur in slow renewal tissues and are characterized by fibrosis, atrophy, ulceration (8).

Cellsâ&#x20AC;&#x2122; radiosensitivity, according to law of Bergonie and Tribondeau is influenced by the stage of cellular differentiation and by cellular proliferating activity. Thus, less differentiated cells are more radiosensitive than highly differentiated cells and proliferating cells are more radiosensitive than non proliferating cells (9).

SKIN HISTOLOGY AND RADIOSENSITIVITY: Skin layers are the epidermis, a stratified squamous keratinized epithelium, the dermis, a subjacent conjunctive tissue that hosts vessels and nerves and the hypodermis, the deepest layer, which consists of pads of adipose tissue (10).

The epidermis is composed of the basal layer (germinative) that is mitotically active and with more superficial differentiated cell layers. Basal epidermal stem cells (basal keratinocytes) which have high proliferative potential, maintain the turnover responsible for continuous renewal of the epidermis. Only 15% of basal cells are mitotically active, the remaining ones being in a quiescent state (11).

Cell proliferation time in the basal cell monolayer is 2.6 days. About 4% of the new keratinocytes move toward the surface layers daily, maintaining constant population densities. The minimum transit time for a basal cell to reach the malpighian layer is 13 days which is nearly the same duration to pass through stratum comeum(12).

The dermis is a connective tissue which contains nerve and vascular networks. Dermal cells are fibroblasts, responsible for the synthesis and the degradation of fibrous and non fibrous connective tissue matrix proteins. Among acellular dermal fibres, the collagen represents 90% of dermal fibres (fibrilar type I and III) and is continuously synthesised by fibroblasts and degraded by collagenase.

This provides skin tensile strength and creates a fine network around dermal blood vessels.

Elastic fibres, representing 10 % of the fibres in the dermis, confer elasticity to the skin(13).

EARLY SKIN RADIATION SIDE EFFECTS: From a pathophysiological perspective, acute skin radiation effects can be classified into effects due to cellular depletion and effects related to cellular and tissue dysfunction/reaction(14). From radiobiology point of view, this cellular compartment is characterized by a high ι/β ratio, 7.5 Gy for erythema and 11.2 Gy for skin desquamation (7).

The cellular depletion is a consequence of disrupting the normal process of cell division and regeneration in the early-responding cellular compartment. That effect concerns epidermal epithelial cells, hair follicles cells and the sebaceous and sweat glands (15).

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Oncology & Dermato-Oncology Epidermal cells and hair follicles reaction: Epidermal cells. The basal layer of the epidermis proliferates rapidly , leading to a high radiosensitivity. Epidermal cells undergo a growth arrest that interrupts the epidermal repopulation process and weakens (break) the integrity of the skin(16). The basal cell loss begins once the radiation dose has reached 20–25 Gy, and the maximum depletion of basal cells occurs when the patient has received a dose of 50 Gy(17). Proliferative impairment of epidermal basal cells results in insufficient cellular supply to the spinous cell layer causing different degrees of epithelial atrophy.

When clonogenic cells in the basal layer are completely sterilised, the repopulation is stopped, the epidermis breaks inducing a moist desquamation occurs(18). Skin recovery after the end of radiation therapy depends on the importance of basal cell destruction, meaning the amount of surviving (stem) cells, which have a high migration potential.

Small areas of moist desquamation tend to heal from the basal layer of the same zone, whereas large areas of broken epidermis require cells to migrate from the surrounding epidermis(19). Hair follicle cells. Due to its rapidly proliferating matrix of keratinocytes, the hair follicle is highly sensitive to ionizing irradiation(20).Follicular cells response to radiation is apoptosis(21). Hair loss is a dosedependent effect that occurs in approximately 2–3 week after a fractionated radiation therapy (with standard 1.8-2 Gy per fraction) and is a reversible process for total skin dose up to 35 Gy.Temporary alopecia usually resolves within 2–3 months after the completion of radiotherapy(22). Doses greater than 35 Gy likely increase the risk of permanent alopecia, with a median risk rated at 5% for 36 Gy in 18 fractions and at 15% for 45 Gy in 25 fractions (23).

The skin glands damage: Irradiation can reduce the activity of the sweat gland causing dryness of the skin which can be temporary for total dose up to 36 Gy with conventional fractionation, or permanent for higher doses (24) . Cellular and tissue dysfunction represent a reactive early response of the stromal compartment, mainly characterized by increased vascular permeability and cytokine-mediated inflammation. This response can persist for several weeks or months until it fades (4).

Vascular permeability: The main cells responsible for radiation vascular effects are mast cells and endothelial cells (25).

The mast cell degranulation contributes to enhance vascular permeability following irradiation.

This phenomenon is strongly correlated with the radiation dose. In an experimental study on mice, vascular permeability increased following irradiation, reaching a peak at 24 hours after irradiation and thereafter gradually decreased and returned to the baseline level from 3 to 10 days (26).

Vascular and peri-vascular inflammation: The inflammation is initiated by cytokines and adhesion molecules, and then amplified by neutrophils. Interleukin 1 (IL-1) and tumour necrosis

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factor α (TNF-α) are the main cytokines involved in radio-dermatitis, and play an important role in the inflammatory skin injury (27, 28). Neutrophils are initially recruited by changes on the surface of the endothelium (activated endothelial cells), then undergo transendothelial migration into the tissue and release myeloperoxidase, which produces reactive oxygen species (ROS), which are ultimately responsible for inflammation (29, 30).

Clinical aspects of acute radiodermatitis: Early radiation skin reactions occur within 1 to 4 weeks of treatment and may persist for 2 to 4 weeks following treatment. These reactions can be shown as a continuum of symptoms ranging from erythema, dry to moist desquamation and in more severe cases, ulceration(31). Erythema may begin within hours or days from radiation therapy initiation due to the dilatation of dermal blood capillaries. Dryness and epilation may occur within days to weeks due to damage of sebaceous glands and hair follicles in the dermal layer (32). Dry desquamation, eventually associated with dryness and pruritus, can occur after the third week or after a cumulative dose of 30 Gy related to the destruction of regenerative basal cells and therefore may induce an outer skin peeling. Moist desquamation occurs after four to five weeks of therapy (45 to 60 Gy cumulative dose) due to the loss of integrity of the epithelial barrier and a decrease in pressure exerted by plasma proteins on the capillary wall (33).

Assessment and classification of early radiation skin reactions: The National Cancer Institute (NCI- Common Terminology Criteria for Adverse Events, version 4.0) and Radiation Therapy Oncology Group (RTOG) classify the skin acute reactions in 4 grades.

Grade 1: Faint erythema /epilation/or dry desquamation.

Grade 2: Moderate to brisk erythema or patchy moist desquamation, mostly confined to skin folds and creases; moderate oedema.

Grade 3: Moist desquamation in areas other than skin folds and creases; bleeding induced by minor trauma or abrasion.

Grade 4: Life-threatening consequences: Skin necrosis , ulceration of full-thickness dermis or haemorrhage (spontaneous bleeding from involved site) (34, 35).

Treatment of acute radiation dermatitis: Two types of local skin interventions can be generally defined: preventive or management strategies.

Preventive strategies include hygiene measures, like minimising friction, avoiding sun exposure and use of soap and deodorants.

The use of oral or topical preventing therapies(27), as local treatment with Hyaluronic acid or trolamine or washing with soap were reported to be ineffective for preventing the development of acute radiodermatitis.

Only steroidal creams (topical preparation containing prednisolone with neomycin) are suggested to have some local benefit (36). Management

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Revolutionary Synchronizing Technology Sequences Pulsed Dye and Nd:YAG Lasers The 595 nm pulsed dye laser and the 1064 nm Nd:YAG laser have, individually, been in common use among esthetic practitioners for more than a decade.

Cynergy™, the latest offering from Cynosure, Inc. (Mass., U.S.), combines the two in a single unit to treat undesirable vascular malformations and other conditions.

As a result, the Cynergy workstation is poised to become the new gold standard for the phototreatment of vascular lesions, according to Dominique Boineau, M.D. and Martine Darchy-Gillard, M.D., two of the first French doctors to use Cynergy with MultiPlex™.

“Combining these two versatile wavelengths in toone complete workstation allows us to treat a much wider variety of telangiectasis at a greater variety of depths,” said Dr. Darchy-Gillard. “The demands of our laser practice require a complete, innovative device for treating vascular lesions more efficiently and Leg veins before Tx with fewer side effects. Cynergy fulfills those expectations. Because it’s so versatile, it reduces the number of laser units we need to purchase for our practice,” Dr. Darchy-Gillard added. Theoretically, treating vascular malformations in MultiPlex mode, which synchronizes pulses of two different wavelengths to allow the first wavelength, usually the 595 nm pulsed dye laser, to alter the target in such a way as to make it more susceptible to treatment with the second avelength, usually the 1064 nm Nd:YAG laser. “Sequential lasering with the 595 nm pulsed dye laser and 1064 nm Nd:YAG laser dramatically increases efficiency and target response because the 595 nm wavelength changes the hemoglobin in treated vessels to methemoglobin, which the Nd:YAG laser can more effectively treat,” explainedDr. Darchy-Gillard. “And we can reduce fluences with 1064 nm wavelengths to minimize side effects.” According to Dr. Darchy-Gillard, the shorter, carefully timed pulses of each laser allows less energy to be delivered, which Leg veins after Cynergy Tx significantly reduces the likelihood of adverse effects. “Before now we, in the aesthetic community, weren’t usingdye and Nd:YAG lasers together on the same patient,” said Dr. Darchy-Gillard. “The sequential MultiPlexmode with two different wavelengths produces excellent results. Now we can use both wavelengths together with confidence.” “We use Cynergy to treat a complete range of vascular lesions including the various telangiectasis, rosacea, erythrosis, port-wine stains, spider veins on the face and trunk, leg veins, and small reticular veins,” she added. “We also use it for hair removal, especially for patients with higher [Fitzpatrick] skin types (IV through VI). We still use it on phototypes I, II or III.” “Having two wavelengths in the same platform permits the practitioner to use the two lasers individually, or simultaneously in MultiPlex mode, which is a tremendous advantage,” said Dr. Boineau.

Dr. Boineau has used a variety of laser platforms since 1990 and was very enthusiastic about Cynergy in comparison, especially with reductions in the required number of treatment sessions to achieve results. “In the past several months I have been using Cynergy to successfully treat vascular lesions such as large caliber venules on the side of the nose. Most of the time these seem to disappear after a single treatment session with Cynergy,” she remarked. “I have found the unit to be excellent for treating telangiectasia of various sizes on the lower limbs, which usually clear up within two or three sessions spaced six to eight weeks apart. This also seems to work well in conjunction with sclerotherapy.” “The platform has also proven itself effective for erythro-rosacea with thin or large vessels on light and dark skin, as well as on diffuse erythrosis, and we have successfully treated Facial veins before Tx spider veins and port-wine stains on the limbs,” Dr. Boineau continued. “Cynergy has shown much promise treating port-wine stains on the adult face, and in fewer sessions than traditional pulsed dye lasers.” Port-wine stains commonly require many monthly treatment sessions with pulsed dye lasers. Because the technology has not yet been fully explored, the unit may be adapted for a broad spectrum of conditions traditionally treated with light. Thus, the horizons for Cynergy and the MultiPlex sequential pulsing technology seem almost endless. “The concept of following the target change (hemoglobin to methemoglobin, for example) with a second pass by a different but complementary wavelength in sequence is extraordinary,” said Dr. Darchy-Gillard. “We firmly believe Cynergy will show itself useful for numerous other indications in the future, and we already expect interesting results for skin rejuvenation, acne inflammation and acne scars.” “It will be interesting to see how this new technology can be adapted to treat other indications,” said Dr. Boineau. “For example, how will it handle photorejuvenation of the face and neck?

That will require further investigation.”

Facial veins after one Cynergy Tx

Oncology & Dermato-Oncology strategies include active treatment of skin lesions with oral drugs or steroidal and non-steroidal topical preparations.

Oral systemic therapies: Wobe-Mugos, a combination of proteolytic enzymes containing papain (100 mg), trypsin (40 mg), and chymotrypsin (40 mg), proved to have a significant protection against radiation-induced skin reactions, reducing severity and duration of side effects (37). Oral zinc supplementation (25 mg daily) was also effective for reducing the radiodermatitis severity at the end of treatment (38).

Steroidal topical treatment: A phase III randomised study including 176 patients with invasive breast carcinoma treated by external beam radiotherapy on breast or chest wall (minimum prescription dose, 50.0 Gy , 2 Gy per fraction) between September 21, 2007, and December 7, 2007, evaluated the efficacy of mometasone furoate (0.1 %) in combination with an emollient cream on radiation dermatitis. Placebo or steroidal cream were applied once daily on the area undergoing treatment, not less than 4 hours before or after radiotherapy until completion of the prescribed course of irradiation. Even if no reduction in radiation dermatitis (maximum grade of radiation dermatitis, assessed with CTCAE version 3.0) was observed, the mometasone furoate cream reduced skin symptoms compared with placebo (pruritus, burning, redness)(39). In other small clinical trial, 0.1 % betamethasone and 0.1% methylprednisolone are also proved to be beneficial for reducing the maximum level of acute skin reactions (40, 41).

Non-steroidal topical treatment: Historically , the first most used cream in radiodermatitis treatment was trolamine, a non-steroidal anti-inflammatory (early recruitment of macrophages and stimulation of granulation tissue), but studies on head and neck patients and breast cancer patients receiving radiotherapy did not confirm superiority of trolamine over usual care (institutional preference) in reducing the incidence of grade 2 or higher radiation dermatitis. Moreover Trolamine failed improving patient quality of life (42, 43) . Hyaluronic acid, a natural polysaccharid representing the main component of the dermis extracellular matrix, plays an important role in skin healing process by stimulating fibroblast proliferation and fibrin development(44). It is important to note that if moist desquamation is developing, topical creams should be discontinued and replaced by hydrocolloid or hydrogel-based treatments, with or without moisturizing cream in order to promote a moist environment for reepithelization (45).

LATE SKIN RADIATION SIDE EFFECTS: Late radiotherapy side effects typically concern slowly proliferating tissues. These effects occur more than 6 months after completing therapy and produce both permanent (irreversible) tissular damages and disorganisation(4). From radiobiol-

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ogy point of view, the α/β ratio for late skin toxicity is low, near to 3 Gy (1.9 Gy for fibrosis and 3.9 Gy for teleangiectasia). (7, 46) The late skin toxicity results from a complex mechanism involving excessive fibroblast proliferation on one side and endothelial cells loss on the other side.

Stromal radiation-induced fibrosis Fibrosis is the formation of excess fibrous connective tissue in an end-stage response to tissue injury by enhanced fibroblast proliferation and secretion, with excessive extracellular matrix deposition(47;48). Fibroblasts are connective tissue secretory cells responsible for the generation, maintenance and degradation of the Extracellular Matrix (ECM), ensuring its balance between synthesis and degradation(49). After injury, including radiation dermal damages, new connective tissue needs to be synthesized, involving “activation” of mesenchymal fibroblasts, their proliferation, and migration into the wound .These cells synthesize elevated levels of matrix proteins, including collagen and fibronectin (50). Even several years after the end of the radiation therapy, abundant collagen I and III can be secreted and deposed in dermal ECM, leading to radiation fibrosis (51). This chronic, long-term fibroblast activation can be explained by an abnormal production of stimulating factors such as cytokines (the main one is TransformingGrowth-Factor TGF b1) and growth factors(52) . The studies of human fibrotic tissues distinguish two types of fibrosis, corresponding to two stages of development of the lesion: a) The inflammatory fibrosis (active) contains a large amount of activated fibroblasts with high proliferation rate and a high secretion of TGF-β1 (53). b) The non inflammatory fibrosis (poorly cellularized) contains senescent-like phenotype fibroblasts with reduced proliferation and a low secretion of TGF-β. This type of fibrosis corresponds to late post radiation therapy fibrosis (48).

Vascular late effects: Late damage to the skin is primarily a function of radiation effects on the vasculature (54). The vascular endothelium represents a slow renewal tissue, with only 0.1% of mitotically active cells and an endothelial turn-over of approximately 1 to several years (55). Vascular late effects include on one side reduction of capillary density, microvessels collapse and thickening of the basement membrane (capillary obliteration with dilation of the remaining vessels), and on the other side, persistence of an activated, pro-coagulant endothelial phenotype, that maintains a pro-inflammatory environment (56, 57).

Clinical aspects of late radiodermatitis: Chronic radiodermatitis, occurs months or years after radiation therapy, and represents permanent changes of dermal layer, resulting in fibrosis, telangiectasias, epilation and atrophy. Fibrosis clini) , the the location and size of the treatment field, and

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PicoSure Expands Clinical Value to All Skin Types via Diverse Tattoo and Skin Revitalization Treatments “Based on my picosecond wavelength clinical experiences, I believe that the combination of PicoSure’s 755 nm and 532 nm wavelengths provides unmatched tattoo clearance across the full color spectrum.”

The PicoSure platform impresses not only in terms of tattoo removal and for benign pigmented lesions, but also more recently as a skin revitalization tool encompassing a wide-range of aesthetic treatment options and increased efficacy. Additionally, the system continues to incorporate innovations with more robust features and applications in order to treat all tattoo ink colors and many skin conditions. For instance, PicoSure’s new 532 nm wavelength upgrade was cleared by the FDA in early 2015, and is designed to more effectively target red, orange and yellow inks. PicoSure is the only picosecond laser platform with a combination 755 nm / 532 nm wavelength option to treat the full color spectrum of tattoo inks in fewer sessions.

In a recent clinical study focused on removal of multicolor tattoos, Dr. Geronemus and colleagues found that the picosecond laser cleared tattoos faster than nanosecond technology. “Typically, in the past, removal of blue and green inks would have taken 10, 15, sometimes as many as 20 applications if we were lucky,” Dr. Geronemus noted. “With the Picosure laser, we can remove these inks in one to three sessions in most cases.”

Regarding the addition of the 532 nm wavelength option, Dr. Geronemus stated, “Based on my picosecond wavelength clinical experiences, I believe that the combination of PicoSure’s 755 nm and 532 nm wavelengths provides unmatched tattoo clearance across the full color spectrum.” In 2014, the system received additional FDA clearances for the treatment of acne scars and wrinkles. PicoSure’s unique energy delivery system, the FOCUS™ Lens Array, works in tandem with the device’s flat top beam to deliver better outcomes for a variety of indications using the 755 nm wavelength,” Dr. Weiss advised. These new capabilities have elevated the system’s use as an “all in one” platform that goes far beyond tattoo removal, he added. “It not only treats tattoos of all colors, but is also a great tool for pigmentation issues encompassing photo-aging, melasma, skin revitalization, wrinkle reduction and acne scarring.”

The picosecond technology that underlies the PicoSure operates at one trillionth of a second. These extremely short pulse durations take advantage of photomechanical impact and stress, rather than heat. Employed at a very high peak power level, these pulses can focus that energy in order to ablate target chromophores quickly and cleanly without damaging the underlying or surrounding areas.

This intense photomechanical impact creates pressure waves in the dermis that stimulate the production of new collagen and elastin with no damage to the skin. By comparison, nanosecond lasers only produce a small fraction of the photomechanical effect generated by a picosecond laser. Compared to fractional and ablative lasers, the FOCUS Lens’ unique mechanism of action results in new collagen and elastin production without the side effects. Significantly, safety is increased while practically eliminating physician preparation time and patient discomfort or downtime, and dramatically reducing the number of sessions required. Patients can quickly return to regular activities after treatment. One area in which the PicoSure excels is the treatment of benign pigmented lesions. Though some lesions are present at birth, most develop with age and / or exposure to sunlight. When the pigment is situated in the epidermis, light brown spots can occur, such as sun spots, freckles and cafe-au-lait birthmarks.

Before Tx

After five PicoSure treatments.

Photos courtesy of Clean Slate Laser

Before Tx

After six PicoSure treatments. Photos courtesy of Roy Geronemus, M.D.

When the pigment is found deeper in the skin, dark brown spots can result, such as Nevus of Ota or other moles. “There are so many unique things that we can do with PicoSure that couldn’t be done before,” Dr. Geronemus stated.

“It has established a very important place in our therapeutic armamentarium, but it may be too soon to extrapolate all of the implications of this laser for use in aesthetic procedures.” Patient satisfaction is also hinged upon the fact that PicoSure’s non-invasive treatments do not trade off patient comfort and downtime for less than satisfying clinical outcomes.

“With this technology, we are observing a sea change in the application of non-invasive procedures,”stated Dr. Tanghetti. “Up to now, people have associated non-invasive with less effective. With the PicoSure, and in particular with the FOCUS Lens we are starting to see impressive results, but without the familiar downtime and side effects.” Investigating the science behind the PicoSure has been equally rewarding.

“It has been a phenomenal experience,” he added.

Acne scars before Tx

Acne scars after four PicoSure FOCUS treatments. Photos courtesy of Roy Geronemus, M.D.

Oncology & Dermato-Oncology involves a loss of softness of the skin and indurations (a feeling of firmness to the touch) associated with a significant increase of the roughness of the irradiated skin and cutaneous microrelief modifications (58). Fibrosis can be more precisely evaluated by ultrasonography and reported in terms of skin thickness (59).A study on 89 patients with early breast cancer treated with conservative surgery followed by adjuvant breast radiotherapy shows a mean increment in skin thickness by 0.52 ± 0.67 mm compared to the healthy breast (60). Telangiectasias, areas with visible dilated and thin-walled vessels, can develop from 6 months to multiple years following the completion of radiotherapy and can progress for at least 100 months. Telangiectasia is a dose-dependent effect both in incidence (at 5 years after irradiation the rate of skin teleangiectasia being 10% for a dose of 50 Gy, 30% for 59 Gy and 65% for 70 Gy) and in progression (the higher the dose level is, the quicker the occurrence is)(61).

Post-inflammatory hypopigmentation and hyperpigmentation depends on the concentration of melanin pigment produced by melanocytes that survived irradiation. Chronic hyperpigmentation is observed in 17% of breast cancer patients treated with conventional radiation therapy and in only 7% in patients treated with intensity-modulated radiotherapy (IMRT) (62). Dermal necrosis can occur after high doses of irradiation months to years following the end of the treatment and is related to dermal microvascular changes and ischemia (63).

Assessment and classification of late radiation skin reactions Late radiation dermatitis. Radiation Therapy Oncology Group-European Organization for Research and Treatment of Cancer (RTOG-EORTC) classification: Grade 1: Slight atrophy. Increased density on palpation (discrete induration). Pigmentation change. Some hair loss.

Grade 2: Patch atrophy. Marked increase in density(moderate fibrosis). Moderate telangiectasia; Total hair loss.

Grade 3: Marked atrophy. Very marked density, retraction (more than 10%) or fixation. Gross telangiectasia.

Grade 4: Ulceration or Necrosis (64).

Treatment of late radiation dermatitis Radiation-induced telangiectasia can be effectively treated by the pulsed dye laser (PDL) with wavelengths of 585 and 595nm with a very low incidence of adverse effects(65). Radiation dermal fibrosis need a long-standing treatment with Pentoxifiline (400 mg, three times each day)and Vitamin E (400 I.U. twice a day), treatment that seems to be effective. The fibrosis regression is exponential, with a two-thirds maximum response obtained after a mean of 2 years (66). Hyperbaric oxygen therapy (HBOT) uses 100% oxygen at higher pressure than atmospheric pressure in several sessions in order to promote angiogenesis and hyperoxygenation of the irradiated tissues, thereby initiating slow healing of radionecrotic wounds (67).

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Surgical intervention must involved generous debridement with total excision of the ulcer and the surrounding irradiated tissue beyond the area of the telangiectasia followed by the coverage of the defect with well-vascularized non irradiated tissue (68) . The reconstructive options usually include skin grafts, local flaps, regional flaps, or free flaps, the regional flaps or free flaps with uninvolved tissue derived from outside of the irradiated field. This management is considered as the best option (69).

RISK FACTORS FOR RADIATION SKIN REACTIONS The incidence and severity of skin toxicity depends on the patient’s general health conditions, skin quality and technical details of irradiation.

PATIENT’S PREDISPOSITIONS AND COMORBIDITIES Genetic predisposition The cellular DNA repair is the main mechanism involved, on which depends the tissues reaction to radiation therapy, a reduced recovery capacity being associated with hypersensitivity to radiation.

DNA damage and its repair are more strongly associated with late rather than acute reactions(71).

The main DNA repair disorders that cause radiation hypersensitivity arethe autosomal recessive disorder Ataxia-telangiectasia, Nijmegen Breakage Syndrome and Fanconi anaemia (autosomal recessive DNA repair disorder) (72).

Comorbidities Non malignant systemic diseases, like collagen vascular diseases (Systemic lupus erythematosus, Scleroderma, Mixed connective tissue disease), uncontrolled arterial hypertension, diabetes mellitus and infections (particularly human immunodefiency virus-HIV) represents risk factors for radiation toxicity. All these pathologies have in common tissue hypoxia and ischemia caused by microvascular occlusive changes and arteriolar obliteration or by marked medial hypertrophy with luminal narrowing (73). Although numerous case reports suggest an increased risk of acute and late radiation toxicities in patients with collagen vascular diseases. The results from large retrospective series remain controversial. In conclusion, treatment decisions should be made in conjunction with the patient, the radiation volume, total dose and daily dose must be reduced and all patients should be monitored with long-term follow-up to evaluate for late toxicity (74). Poor nutritional status and smoking may exacerbate radiodermatitis by impairing wound healing.

Skin factors Pre-existing skin disease (psoriasis) , skin folds within the radiation field and application of skin creams on exposed areas immediately before treatment are factors that increase the risk for toxicity (75).

RADIOTHERAPY RISK FACTORS Treatment-related risk factors include: radiotherapy technique and dose (total dose and fractionation)

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Oncology & Dermato-Oncology the concurrent systemic therapy. Intensity Modulated Radiotherapy (IMRT ) has significantly improved the dose distribution compared with standard radiation and significantly decreased acute radiodermatitis (moist desquamation 31.2% with IMRT versus 47.8% with standard treatment)(76). Concurrent anticancer systemic therapies , like Vemurafenib (a BRAF inhibitor indicated for the treatment of metastatic melanoma) or Cetuximab (a monoclonal antibody against epidermal growth factor receptor used in Head and Neck , lung and colorectal cancers treatments ) have significantly increased and prolongs radiodermatitis (77, 78) . The concomitant use of Tamoxifen (an antagonist of the estrogen receptor) is significantly associated with an increased incidence of grade 2 or greater subcutaneous fibrosis, especially in radiosensitive patients (79).

PREDICTION OF RADIATION TOXICITY The most appropriate test to predict intrinsic dermal radiosensitivity is the skin fibroblast clonogenic assays but this test is time-consuming (2-3 months) and therefore cannot be used as a diagnostic assay in routine practice(80) . Lymphocyte apoptosis is a representative type of programmed cellular response to ionizing radiation damage and was developed as a rapid tool for characterization of normal tissue radiosensitivity. Hence, individual radiation late toxicity can be predicted by radiation-induced apoptosis of CD4 (Helper) and CD8 (cytotoxic, killer) T-lymphocytes. No association was found between early toxicity and T-lymphocyte apoptosis, but the late radiation toxicity is inversely correlated with CD4 and CD8 apoptosis values. In clinical studies, no grade 3 side effects have been observed for patients with CD4 apoptosis >15% and CD8 apop-

Radiation therapy skin toxicity

tosis >24%. (81) The individual radiosensitivity is correlated with the Single Nucleotide Polymorphism (SNP), a DNA sequence variation in the genome, variation in which a single nucleotide â&#x20AC;&#x201D;A (Adenine), T(Thymine), C (Cytosine) or G(Gua n i n e ), â&#x20AC;&#x201D;differs (82). Genes that were screened are involved in the protection against cell death like SOD2 (Superoxide dismutase 2), gene involved in DNA reparation like ATM (Ataxia Telangiectasia Mutated), XRCC 1 and 3 (X-ray RepairCross-Complementing) and RAD21 (Double-Strand-Break Repair Rad21) and gene involved in the control of cell proliferation, and apoptosis like TGFB1 (Transforming Growth Factor Beta1)(83). Clinical investigations on DNA isolated from blood samples obtained from patients have suggested that possession of multiple SNPs associated with radiosensitivity correlates with an increased probability for developing severe radiation side effects (84).

CONCLUSION Skin toxicity related to radiation therapy is a complex mechanism whose treatment is not well standardized. Multiple factors are implicated.

Although, the severity of this side effect has decreased thanks to the improvement of radiotherapy techniques, further studies are still needed to screen the patients in function of their intrinsic radiosensitivity and enhance therapeutic options according to toxicity grade.

This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the articleâ&#x20AC;&#x2122;s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/

Figure 1.

Dosimetric view of treatment by Tomotherapy in the same patient, in axial, sagittal and frontal views

Figure 2.

Examples of different skin toxicities in the same patient treated at Centre Hospitalier Lyon Sud, during cervical lymph nodes irrdiation Photos from personal archives of Dr Tristan Brahmi

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SKINCARE REVOLUTION DEVELOPED WITH RHA (Resilient Hyaluronic Acid)® INJECTABLE TECHNOLOGY A PERFECT COMPLEMENT TO FACIAL AESTHETIC PROCEDURES

September 2015 *the syringe in the picture is a Class 3 Medical Device manufactured by TEOXANE Laboratories and is not included in the skincare range.

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72. Pollard JM, Gatti RA. Clinical Radiation Sensitivity with DNA Repair Disorders: An Overview. International journal of radiation oncology, biology, physics.

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75. Hymes, S.R., Strom, E.A., & Fife, C. (2006). Radiation dermatitis: Clinical presentation, pathophysiology, and treatment 2006. Journal of the American Academy of Dermatology, 54(1 ) , 28-46 76. Pignol, J.P., Olivotto, I., Rakovitch, E., Gardner, S., Sixel, K., Beckham, W., Vu, T.T.T., Truong, P., Ackerman, I., & Paszat, L., A multicenter randomized trial of breast intensity-modulated radiation therapy to reduce acute radiodermatitis. Journal of Clinical Oncology 2008., 26(13), 2085-2092 77. Merten R, Hecht M, Haderlein M, Distel L, Fietkau R, Heinzerling L, Semrau S. Increased skin and mucosal toxicity in the combination of vemurafenib with radiation therapy. Strahlenther Onkol. 2014 Nov;190(12):1169-72.

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R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

INTERNATIONAL EVENTS CALENDAR

INTERNATIONAL EVENTS CALENDAR CALENDAR EVENIMENTE INTERNAŢIONALE

2015 OCTOMBRIE 1-4: 36 Annual Meeting of the International Society of Dermatologic Surgery, Seul, Corea www.isds2015.org 2-3: 8th Inter-academic Onychology Course (English session), Brussels, Belgium www.onychologycourse.eu 7-11: 24th EADV Congress, Copenhaga, Danemarca. www.eadv.org 8-10: ICAD 2015 - International Congress of Aesthetic Dermatology. Aesthetic Dermatology and Anti-Aging for the skin, Bankok, Thailand. www.euromedicom.com/icad-2015 21-22: ECAAM 2015 - EUROPEAN COURSE IN ANTIAGING MEDICINE, Paris, France. www.euromedicom.com/ecaam-2015 21-24: Romanian National Congress of Dermatology, Bucharest, Romania. http://www.srd.ro/ 23-24: AMEC 2015 - 11th Aesthetic & Anti-aging Medicine European Congress, Paris, France. www.euromedicom.com/amec-2015 25-27: ESPD Summerschool (European Society for Pediatric Dermatology), Lausanne, Switzerland. www.espd2015.com.

28-31: 11th EADO Congress and 8th World Meeting of Interdisciplinary Melanoma/Skin Centers, Marseilles, Franta. www.eado-melanomacentersmarseille2015.com th

NOIEMBRIE 6-7: 2nd AMWC - Latin America - Aesthetic & Anti-aging Medicine World Congress - Latin

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America. Aesthetic Dermatology and Surgery, Preventive and Anti-Aging Medicine, Medellin, Colombia. www.euromedicom.com/2nd-amwc---latinamerica 14-16: 10th World Congress of the International Academy of Cosmetic Dermatology (IACD), Rio de Janeiro, Brazilia. www.iacdRio2015.com.br 18-21: 9th World Congress on Pediatric Infectious Diseases, Rio de Janeiro, Brasil. www.wspid.kenes.com.

18-22: Psychodermatology Training Course, Venice, Italy www.psychodermatology.net 20-22: 3rd International Summit on Nail Diseases (ISND) and 4th ONYCHOCON, Mayur Vihar, Delhi, India, www.nailsocietyindia.com 19-21: I SMA 2015 (6th International Symposium on Molecular Allergology), Lisbon, Portugal. www.eaaci-isma.org 36th Symposium of the International Society of Dermato-Pathology, New Delhi, India. www.intsocdermpath.org 27-28: CLINICAL FACIAL ANATOMY ANATOMY DISSECTION & LIVE INJECTION COURSE. ACADEMIC ANATOMY & INJECTION COURSE, Amsterdam, Holland. www.euromedicom.com/cfa-amsterdam---winter session

DECEMBRIE 5-6: ICAAM 2015. Dubai, UAE. www.antiageingme.com

R O M A N I A N J O U R N A L o f C L I N I CA L a n d E X P E R I M E N TA L D E R M ATO LO GY

A patra ediție a revistei RoJCED va avea ca temă: Pielea și Infecțiile The fourth issue of RoJCED will have the topic: Skin & Infections

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