Progress in Dermatology and Venereology in 2023 as reflected in the Journal of the European Academy of Dermatology and Venereology

It has become a tradition at the beginning of a new year to look back at some highlights of last year as they appeared in our Journal. Let me guide you through some articles published in the past year that I found especially interesting. Anti-cancer immunotherapy has reached the stage of adjuvant melanoma treatment. In a multicentric study in 39 skin cancer centres in Austria, Germany and Switzerland, 1194 patients with stage III/IV melanoma received adjuvant Nivolumab, Pembrolizumab and Dabrafenib/Trametinib, respectively, and in a real-world setting. The recurrence-free survival after 12 months was 78.1% with anti-PD-1 antibodies and 86.5% with BRAF/MEK inhibitors.1 Among other influencing factors, total lymph node dissection was studied and found not to be superior to sentinel lymph node dissection. They further found that patients suffering from immune-related adverse events show lower recurrence rates than patients without (HR 0.5 with CI 0.4–0.7). A Dutch group studied the results of Mohs Micrographic Surgery (MMS) for basal cell carcinoma in the face of older adult patients. Apart from surgical modality and tumour characteristics, they focused on general morbidity as measured by the age-adjusted Charlson Comorbidity Index (aCCI) in 207 patients older than 75 years undergoing MMS for facial BCC. They found a significantly higher mortality in patients with a higher aCCI namely 3.6 years survival in patients with multiple comorbidities compared to 11.6 years survival in the group with a lower aCCI. They conclude that it is not so much the modality of surgery, nor the number of MMS rounds, nor the type of reconstruction that influences the overall survival. Dermatologists should take into account the general morbidity in selecting their treatment.2 Line-field confocal optical coherence tomography can provide practical hints for the diagnoses of vascular lesions as studied in cherry hemangiomas, angiokeratomas, thrombosed haemangiomas and Kaposi sarcomas.3 A topical mTOR inhibitor (rapamycin) has shown marked effects in the treatment of facial angiofibromas with 90% improvement in 39 reports about a total of 483 patients.4 For the first time, worldwide expert recommendations for the diagnosis and management of vitiligo have been given as a Position Statement from the international vitiligo task force concentrating first on classification and diagnosis and secondly on new specific treatment recommendations also including new options with, for instance, JAK inhibitors.5, 6 For decades, Kligman's trio combining hydroquinone, retinoic acid and corticosteroid is considered the gold standard in treating melasma. With the new substance isobutylamido-thiazolyl-resorcinol (Thiamidol), a new trio has been created and compared with the classical preparation: There was a significant effect in both treatment groups, the quality of life score for melasma (MelasQOL) showing even higher improvement with the new trio compared to the classic substances.7 The European guidelines for paraneoplastic pemphigus/paraneoplastic autoimmune multiorgan syndrome describe the clinical findings with severe chronic mucositis and polymorphic skin lesions and the diagnostic importance of anti-envoplakin antibodies or antibodies to rat bladder epithelium.8 From the international Degos Disease Registry, 96 patients with atrophic papulosis (Köhlmeier-Degos disease) were studied and differences between children and adults were investigated. In childhood, there were more male patients. Also, systemic involvement with gastrointestinal, CNS or cardiac complications was more common in children. The mortality was similar in both age groups with around 30%.9 In a systematic literature review, total costs (direct plus indirect) for moderate to severe atopic dermatitis were studied in Europe with 27 publications from 22 unique studies in the years 2010–2020. The total costs were €20,695 per-person-per-year (PPPY) whereby the direct medical costs range between €307 and €6993 PPPY. As expected, the costs increased with the severity of eczema.10 The role of topical emollient application in the primary prevention of allergy and/or atopic dermatitis is a matter of debate since early studies in 2014 found this effect, while later studies could not. In a systematic review and network meta-analysis, the effect of primary prevention with emollients was studied in 11 double-blind controlled randomized studies in a total of 3483 patients. Overall atopic dermatitis occurred less frequently when emollients were used for prevention (RR 0.64, CI 0.47–0.88; p < 0.001).11 Some patients with atopic dermatitis when treated with Dupilumab develop facial erythema. This phenomenon was studied in 162 patients with severe atopic dermatitis under Dupilumab treatment; 137 had facial erythema before Dupi treatment, 121 improved, seven got worse and six out of 25 patients developed new facial erythema under Dupilumab. In studying the medications, the authors conclude that the development of facial erythema may be a result of topical steroid withdrawal.12 New kinase inhibitors have shown tremendous effects in atopic dermatitis after oral application. A new substance already registered for vitiligo treatment namely ruxolitinib has been used topically in a double-blind placebo-controlled trial in atopic dermatitis. Significantly more patients achieved a reduction of itch by two or four points on a numerical rating scale compared to placebo (65% vs. 29%); the effects started already after 12 h.13 In a study of 52 patients with Drug Reaction with Eosinophilia and Systemic Symptoms reactivation of human herpes virus was studied and found to occur at least with one episode in 77% of the patients, 53% showed two episodes of viral reactivation. Most commonly human herpes virus 6 (HHV-6) was involved and detectable in skin biopsies using non-coding transcripts of HHV-6 miR-aU14.14 In a meta-analysis of the whole transcriptome alterations in barrier-related gene expression, such as keratin 1, filaggrin, involucrin, desmoglein 1 and kallikrein 5 and 7 were studied. When acne skin was compared with papulopustular rosacea, there were 58 genes overlapping in expression while 63 genes went in the opposite direction. Sebum lipids like stearic or palmitic acid (pro-inflammatory), oleic or linoleic acid (anti-inflammatory) and squalene (comedogenic) can alter protein expression of HaCaT cells in vitro for instance, for example induce a decrease in involucrin expression in acne.15 After it became clear that interleukin 36 appears to play a relevant role in the induction of pustular psoriasis, a new biologic spesolimab as anti-IL-36 R-antibody seems to be an effective treatment. In a placebo-controlled study, 53 patients with generalized pustular psoriasis were followed over 12 weeks. After a general flare, significant improvement in psoriasis skin symptoms, pain and quality of life was observed already after 1 week, and the effect lasted up to 12 weeks.16 The burden of alopecia areata is known to go along with a remarkable impairment in quality of life. In a systematic review, 40 studies were analysed focusing on quality of life, mental health and work productivity. The authors found a reduction in the quality of life in alopecia areata patients of about 75%. The specific dimensions of impairment were ‘embarrassment’, ‘social functioning’, ‘anxiety/depression’ but also the ‘financial burden’ and ‘influence on life decisions’.17 The European guideline for the management of balanoposthitis appeared this year with clear recommendations on the therapy of the various diseases underlying this condition. Apart from pharmacotherapeutic also general recommendations to management are given.18 In the Historical Perspectives series, among others, Annamari Ranki from Helsinki gave a very worthwhile reflection on modern dermatology and how to combine clinical work with research.19 Altogether, 2023 was a good year for JEADV. We received ca. 4000 new manuscript submissions and we have kept our impact factor stable with 9.2 and still rank as number 4 among 70 peer-reviewed international dermatology journals while many other competing journals went down. For the first time, we published three theme issues namely on melanoma, on hair and on vitiligo. These theme issues feature a number of special articles, original and review articles as well as short reports and letters to the Editor on a specific topic without preventing the normal flow of manuscripts as they come in on a daily basis. They are usually introduced by an editorial by a special expert or a JEADV section editor of the area. Of special interest are the European guidelines which appeared in the last 12 months (Table 1) some in cooperation with international societies. I hope this short selection has stimulated our readers to continue enjoying our journal not only for education and to refresh knowledge but also to learn about activities in our field in different places of the world.