European Academy of Dermatology and Venereology Congress, 11-14 October, 2023, Berlin, Germany

The European Academy of Dermatology and Venereology (EADV) was founded in 1987 and has over 9,000 members from 120 countries dedicated to the betterment of patient care. Over 15,500 professionals attended the 2023 EADV Congress, which boasted 180 sessions and 600 notable expert speakers. The event highlighted an array of research, innovation, and breakthroughs in the fields of dermatology and venereal disease from across Europe and the rest of the globe. Novel therapies for common skin disorders such as eczema and psoriasis, the cutaneous microbiome and advances in skin cancer care were among the major themes during the event.

Significant improvements in AI to detect skin cancer

Skin cancer detection using artificial intelligence (AI) has rapidly and consistently improved, with the latest software reaching a 100 per cent detection rate for melanoma, attendees at the European Academy of Dermatology and Venereology Congress (EADV) 2023 heard.

Data from the recent research showed that alongside the precision and accuracy displayed in melanoma detection, the new software correctly detected 99.5 per cent (189/190) of all skin cancers and 92.5 per cent (541/585) of pre-cancerous lesions.

The findings relate to the third version of the AI technology, and mark a significant improvement from the first model, which was tested in 2021. The original software displayed moderate results and detected 85.9 per cent (195/227) of melanoma, 83.8 per cent (903/1078) of all skin cancers, and 54.1 per cent (496/917) of pre-cancerous lesions.  

Lead author Dr Kashini Andrew, Specialist Registrar at University Hospitals Birmingham NHS Foundation Trust, UK, said the advancements are “directly attributable to improvements in AI training techniques and the quality of data used to train the AI”.

“The latest version of the software has saved over 1,000 face-to-face consultations in the secondary care setting between April 2022 and January 2023, freeing up more time for patients that need urgent attention.”

Despite the impressive findings, the researchers emphasised the importance of input from a consultant dermatologist and highlighted the individual case that was not detected by AI and later diagnosed by a dermatologist “safety net” during the study.

Co-author Dr Irshad Zaki, Consultant Dermatologist at University Hospitals Birmingham NHS Foundation Trust, UK, reinforced the vital role of a dermatologist, and said: “We would like to stress that AI should not be used as a standalone tool in skin cancer detection and that AI is not a substitute for consultant dermatologists.”

Higher mortality in non-melanoma skin cancer than melanoma

Non-melanoma skin cancer (NMSC) is causing a greater number of fatalities worldwide than melanoma, according to a new study presented at the EADV Congress 2023. “Although NMSC is less likely to be fatal than melanoma skin cancer, its prevalence is strikingly higher,” said lead author Prof Thierry Passeron, Professor and Chair of Dermatology, University Hospital of Nice, France.

The study utilised data from the World Health Organisation International Agency for Research on Cancer to assess the overall burden of skin cancers and identify specific at-risk populations. In 2020, there were nearly 1.2 million reported cases of NMSC worldwide compared with 324,635 cases of melanoma, according to the data, with common types including basal cell carcinoma and squamous cell carcinoma.

The researchers also believe that NMSC is underreported and that the true impact of this disease may be even higher than estimated. Prof Passeron added: “As alarming as these figures are, they may, in fact, be underestimated. NMSC is often underreported in cancer registries, making it challenging to understand the true burden.” 

People who work outside, organ transplant recipients, and those who have the skin condition xeroderma pigmentosum were identified as being at the highest risk. A significantly high incidence of skin cancer in fair-skinned and elderly populations from the US, Germany, UK, France, Australia, and Italy was also noted. However, even countries such as Africa, that have a high proportion of dark phenotypes, were not immune to the risk of mortality from skin cancer.

Prof Passeron said it is “crucial to note that individuals with melanin rich skin are also at risk and are dying from skin cancer”, and that a major need exists “to implement effective strategies to reduce the fatalities associated with all kinds of skin cancers”. He also acknowledged the role clinicians outside of dermatology could play in reducing skin cancer fatalities.

“Our study did not find consistent evidence to suggest that having more dermatologists per capita could reduce mortality rates. Surprisingly, countries like Australia, the UK, and Canada, with fewer dermatologists, exhibited low mortality-to-incidence ratios. We therefore need to explore what strategies these countries are employing to reduce the impact of skin cancer in further depth.

“The involvement of other healthcare practitioners, such as GPs, in the identification and management of this disease may partly explain their success. There remains huge opportunity worldwide to elevate the role of GPs and other healthcare professionals in this process and train them to recognise suspicious lesions early.”

Seminal data on cutaneous microbiome dysbiosis in Darier’s disease

Findings from the first ever study to investigate the links between cutaneous microbiome dysbiosis and Darier’s disease (DD) were presented at the EADV Congress 2023. DD – a genodermatosis caused by mutations of the ATP2A2 gene that results in disrupted keratinocyte adhesion – is also known as keratosis follicularis.

Patients typically experience recurrent episodes of skin inflammation and infections with a typical malodour, attendees heard, which indicates a role for microbial dysbiosis and led to the study hypothesis and methodology.

The researchers used a metabarcoding approach of 115 skin swabs from 14 patients and 14 healthy volunteers to analyse changes in the context of DD malodour and the cutaneous DD transcriptome. Findings revealed a DD-specific cutaneous microbiome with a loss of microbial diversity and potentially beneficial commensals – highlighting the role of cutaneous microbiome dysbiosis in DD inflammation and malodour.

Strong associations were noted between disease severity and inflammation-associated microbes such as Staphylococcus aureus and Staphylococcus warneri, with malodour severity and specific species, including the Corynebacteria, Staphylococci, and Streptococci groups, also displaying strong correlations.

The researchers also identified a marked upregulation of epidermal repair and inflammatory and immune defence pathways, while barrier genes including claudin-4 and cadherin-4 were down-regulated.

Trial updates in atopic dermatitis

Results of the phase 2b TREK-AD study were among several trial updates presented at the EADV Congress 2023. Data showed that the first-in-class interleukin (IL)-13 inhibitor eblasakimab was superior to placebo for moderate-to-severe atopic dermatitis (AD) in most of the evaluated dosages.

Eczema Area and Severity Index scores decreased significantly at week 16, with marked differences noted in those with severe AD. Participants had been randomised to five different treatment arms with placebo every two weeks or eblasakimab monotherapy 400mg four-weekly.

Administration of the selective JAK1 (Janus family kinase 1) inhibitor upadacitinib over 140 weeks resulted in sustained skin clearance and resolution of itch in adolescents and adults with moderate-to-severe AD, according to separate data from three ongoing phase 3 trials presented at the conference.

In the Measure Up-1 and -2 trials, participants received oral upadacitinib 15mg, 30mg, or placebo once daily alone. In AD Up, patients also received concomitant topical corticosteroids. Efficacy results were sustained from week 16-to-140 in all three trials. Upadacitinib was well-tolerated and rates of adverse events were low and consistent.

The novel cream tapinarof, which contains the naturally derived aryl hydrocarbon receptor agonist, also featured at the congress, and is set to offer a new topical treatment in AD, according to data from the ADORING 1 and 2 trials.

“Topical therapy is the mainstay of therapy for all disease severity groups, and while we use topical corticosteroids as a first-line because they are cheap and accessible, there are certainly a lot of limitations, especially for sensitive skin areas. So, we have unmet needs for new and better nonsteroidal topical therapies,” said Dr Jonathan Silverberg, George Washington University, US, who presented the findings.

In phase 3, the cream demonstrated positive results in adults and children as young as two years of age in both trials. Almost half of participants (45 per cent) achieved the primary endpoint of clear or almost clear skin (using the validated Investigator Global Assessment for Atopic Dermatitis). Together, both trials included 813 adult and paediatric participants aged two years or older. One-fifth of participants were between two-to-six years old, and the cohort had a mean age of 16 years.

“The take-home message is that tapinarof is a novel nonsteroidal topical medication that has the potential to be used for the treatment of atopic dermatitis in patients down to two years without restrictions on duration, extent, or sites of application,” Dr Silverberg concluded.

IL-23 blockers may lower risk of inflammatory and psoriatic arthritis development

Findings from the second cohort study to reveal a lower risk of developing arthritis in patients receiving interleukin (IL)-23 inhibitors was presented at the EADV Congress 2023. An analysis of over 7,000 biologic-naïve patients with psoriasis revealed that those receiving IL-23 inhibitors are less likely to develop inflammatory or psoriatic arthritis (PsA) than patients receiving IL-17 or tumour necrosis factor inhibitors (TNFi).

Approximately one-quarter of patients with psoriasis will develop inflammatory or PsA, attendees heard, and the study was designed to assess whether the risk of inflammatory arthritis or PsA development can be delayed according to the type of biologic therapy patients are prescribed.

Biologic-naïve participants were assigned to four cohorts and followed for up to three years – until inflammatory arthritis developed, until they switched or discontinued their biologics, or were lost to follow-up. A total of 2,712 participants were treated with an IL-23 blocker; 1,078 with an IL12/23 blocker; 811 with an IL-17 blocker; and 2,744 were in the TNFi cohort.

Those in the IL-23 cohort were significantly less likely to develop inflammatory arthritis compared with the other groups. However, Prof Bruce Strober, Yale University School of Medicine, Connecticut, US, emphasised that bias is a potential limitation of this study as healthcare professionals may have preferentially prescribed IL-23 blockers to participants with early markers of PsA, but said the data warrants further investigation.

Sleep disturbance, stigma, and dermatological disease

Data from a global study presented at the EADV (EADV) Congress 2023 showed that almost half of people with dermatological disease experience sleep disturbances. Lead author Dr Charles Taieb, Head of European Market Maintenance Assessment, described the research as “the first to uncover the profound impact of sleep disturbances on the physical functioning of patients with skin disease”, and said the results “underscore the critical need for early detection and effective management of sleep disturbances”.

The ALL PROJECT analysed over 50,000 adults across 20 countries to assess the impact of skin diseases on patients, and found at least 42 per cent of people with a diagnosed disorder experienced sleep disturbance.

The primary factors disrupting the sleep of patients with skin disease were itching (60 per cent) and burning sensations or tingling (17 per cent). Notably, these sleep disturbances were found to have broader implications on overall quality-of-life. Nearly half (49 per cent) of patients with skin disease reported reduced productivity at work, in contrast with just one-in-five participants without a skin disease. Patients in the skin disease group also reported:

• Experiencing a feeling of fatigue as soon as they woke up (81 per cent vs 64 per cent in the non-skin disease cohort);
• Periods of drowsiness during the day (83 vs 71 per cent vs 64 per cent in the non-skin disease cohort);
• Tingling sensations in the eyes (58 per cent vs 42 per cent vs 64 per cent in the non-skin disease cohort);
• Repeated yawning (72 per cent vs 58 per cent vs 64 per cent in the non-skin disease cohort).

The ALL PROJECT study also investigated the impact of living with hidradenitis suppurativa, which affects approximately one-in-100 people. Findings from the study showed that 77 per cent per cent of patients with hidradenitis suppurativa reported a feeling of stigmatisation due to their condition, with 58 per cent experiencing ostracisation or rejection from others.

More than half of patients reported that people avoided touching them (57 per cent) and approaching them (54 per cent) because of their condition. Nearly 79 per cent of patients who exhibited poor adherence to therapy also reported a feeling of stigma.

Separate data presented at the EADV conference also highlighted significant stigma associated with female adult acne. The researchers assessed the effect of different anatomical variants of acne on natural gaze patterns and social perception by tracking the eye movements of 245 participants who viewed neutral and emotional faces of females with both clear skin and clinically relevant anatomical variants of acne.

Separately, a group of 205 online survey respondents were asked to rate the personality traits of the individuals depicted in the images. Faces with acne were seen as less attractive, trustworthy, confident, successful, dominant, and happy, according to the findings, with adult female acne having the strongest negative effect.

Lead author of the study Dr Marek Jankowski, Assistant Professor of Dermatology at the Nicolaus Copernicus University, Torun, Poland, said the results “clearly emphasise the emotional and psychological burden experienced by individuals with acne”.

“With over a decade of experience in the field, I’ve consistently seen that adult female acne leads to more social challenges compared to adolescent acne. The findings therefore, reaffirm this. However, what was truly surprising was images depicting generalised acne, covering a larger area with more lesions, received more positive ratings than images featuring adult female acne occurring in the ‘U-zone’.

“Treatment needs to focus on improving the quality-of-life of patients, not just reducing the surface area impacted by the acne. Unfortunately, this is not currently a goal when treating acne, with therapeutic guidelines still advocating for certain treatment modalities based on the number of lesions, irrespective of their location. Unsurprisingly, acne severity scores do not correlate with quality-of-life scores in patients with acne.”