Looking at the skin in the digital age

Scientific program

Dr Luc Thomas, France
Dermoscopy and digital dermoscopy in early detection of skin cancer: advantages and limits
Luc Thomas, MD, PhD, was board certified in dermatology in 1989 at Lyon 1 University. He was trained as a post-doctoral fellow at Harvard Medical School in 1990 and 1991, and obtained his PhD degree at Lyon 1 University in 1993. He became full professor of dermatology in 1996, first class professor in dermatology in 2009, and chairman of the department of dermatology of Lyon 1 University - Centre Hospitalier Lyon Sud in 2003. He obtained his board certification in clinical oncology in 2013. His main research fields include skin oncology, early diagnosis of melanoma, dermoscopy, skin surgery and nail diseases. He has published more than 400 peer-reviewed scientific articles in international journals, is the co-editor of four books published in several languages and co-author of more than 25 books. He has lectured at many international meetings, is an associate editor of Dermatology, a member of the board of the International Dermoscopy Society, a past member of the board and treasurer of the French Society of Dermatology from 2000 to 2003, and treasurer of the World Congress of Dermatology in Paris in 2002.
Dermoscopy is a non invasive skin examination technique nowadays widely accepted and used in the early detection of skin cancer including melanoma. Its very simple principles are based on the magnification and the suppression of the examination artifacts due to the reflective stratum corneum of the epidermis. Several studies and metaanalyses have shown the statistically significant improvement of diagnosis performances when compared to naked eye examination. Digital dermoscopy consists in the comparative sequential examination of dermoscopic images of the same lesion over either short (2-3 months) or long (6 to 12 months) time period. It permits earlier diagnosis in featureless yet changing lesions also demonstrated by several concordant studies and one metaanalysis. Dermoscopu and digital dermoscopy can be used in the setting of telemedicine consultations. Yet certainly efficient in trained examiners, these techniques might have a limited public health impacts since many patients escape from early detection for different reasons some being related to the natural history of some skin cancers.
Dr Susana Puig, Spain
Diagnostic tools in the follow-up of high risk skin cancer patients
Susana Puig is the Chief of the Dermatology Department of the Hospital Clinic and professor at the University of Barcelona. She is the director of the research program "Melanoma: Imaging, genetic and immunology" at the Biomedical Research Institute August Pi I Sunyer (IDIBAPS). Special research areas are melanoma and skin cancer focusing in different aspects and their clinical applications including imaging techniques for the in vivo non-invasive diagnosis (dermoscopy, confocal microscopy, etc), skin cancer susceptibility, carcinogenesis, genetics of melanoma, melanoma immunology and therapy. She is devoted to teach all over the world to translate to patient’s care innovation performed in melanoma and skin cancer research. She has published more than 240 indexed papers, editor of several books and contributed with more than 30 book chapters. She is active member of international consortiums as GenoMel, BioGenomel, M-skip and MelaNostrum dealing with melanomas genetics. She is Board member of the International Dermoscopy Society, the Confocal Working Group and the International Teledermatology Society dedicated to imaging innovation and she is also member of the steering committee of the EORTC Melanoma group.
Melanoma is the most deadly of the common skin cancers and its incidence is rapidly increasing. Approximately 10% of cases occur in a familial context. To date CDKN2A, identified as the first melanoma susceptibility gene more than 20 years ago, is the main high-risk gene for melanoma. Few years latter CDK4 was also identified as a melanoma susceptibility gene. The technologic advances have allowed the identification of new genes involved in melanoma susceptibility: BAP1, CXC genes, TERT, POT1, ACD and TERF2IP, being the last four involved in telomere maintenance. Furthermore variants in MC1R and MITF give a moderate increased risk to develop melanoma. Melanoma genetic counselling is offered to families in order to better understand the disease and the genetic susceptibility to develop it. Genetic testing for melanoma predisposition mutations can be used in clinical practice under adequate selection criteria and giving a valid test interpretation and genetic counselling to the individual. Early detection of melanoma is essential to improve melanoma survival. Those individuals at risk may benefit from specific surveillance programmes. In 2011, Salerni et al demonstrated once more that the inclusion of high risk patients in such a programme allows early detection of melanoma, even in clinically banal lesions. Total body photography detects 40% of melanomas during follow up while the remaining 60% were detected thanks to digital dermoscopy. In a mean follow up of 8 years in a region with low-moderate incidence of melanoma like Barcelona, new melanomas were detected in 12% of the patients inclided while in a high incidence oof melanoma region, as Sydney, the same percentage of patients develop melanoma in less than 3 years. The benefits of this protocol also include the avoidance of unnecessary excisions with a lower number needed to treat. Finally, the programme should be maintain because a new melanoma can appear at any time.
Dr Josep Malvehy, Spain
Monitoring for actinic keratosis /// Diagnostic in Non-Melanoma Skin Cancer
Dr Josep Malvehy graduated in 1992 at the Medicine University of Barcelona in Spain and obtained his diploma in Dermatology and Venereology in 1996 and the doctoral degree of the University of Barcelona in genetics and diagnostics of skin cancer in 2006. He is a consultant dermatologist at the Dermatology Department and director of the Melanoma Unit at the Hospital Clinic of Barcelona since 2003. He is consultant of the Memorial Sloan Kettering Cancer Centre in New York (US) since 2013 and the leader of the “Technology group” of the International Skin Imaging Collaboration Group. The main field of expertise is skin tumours with main interest in diagnosis and treatment of malignant neoplasms of the skin, non-invasive techniques of skin cancer diagnosis (dermoscopy, digital follow-up, confocal Microscopy, OCT, HD-OCT, impedanciometry, spectroscopy), genetics of melanoma, skin cancer susceptibility, skin carcinogenesis and teledermatology. He is author of more than 250 scientific publications in international journals, main editor of 3 books in diagnostics of skin cancer and author of more than 30 book chapters. Dr Josep Malvehy is or has been the main investigator of competitive research projects and principal investigator of several medical trials in diagnostics and treatment of skin cancer. He is elected member of the Royal Academy of Doctors (RAD) and board member of the World Melanoma Society, European Association of Dermato Oncology (EADO), International Dermoscopy Society (IDS), International Group of Confocal Microscopy (IGCM) and the International Teledermatology Society (ITS).
Non-melanoma skin cancer is the most frequent type of cancer among Caucasian population. In the era of non-invasive diagnosis challenging to manage skin cancers can be solved with the aid of new imaging technologies. In patients with field cancerisation techniques including dermoscopy, multimodal UV fluorescence, OCT or confocal microscopy are useful to improve the detection of the malignant tumours, recognise the subtype of the tumour and identify the margins. With this information in real time the clinician may guide biopsies and treat the patient with the best option in every clinical situation. The dermatologist may consider surgical versus non-surgical treatments with medical modalities or ablative treatments such as laser or cryotherapy. In addition to this application imaging technologies allow the detection of recurrences or persistence of the skin cancer when the tumour is not clinically evident. These non-invasive technologies are also of great value in the research studies of new drugs for skin cancer treatment. They allow a direct observation of the effect of the treatment in the live tissue of the patient and also the monitoring of the response that is not possible with biopsies. Finally in complex cancers of the skin tumour margin assessment is crucial to avoid recurrences. In this field new modalities of biophotonics have high accuracy in the detection of tumour during surgery. These new methods such as ex-vivo confocal microscopy (with or without fluorescence) or RAMAN spectroscopy are a revolution in the fast diagnosis at the surgical room.
Dr David Moreno-Ramírez, Spain
Teledermatology for skin cancer patients’ management
David Moreno-Ramírez, PhD, is the present Head of the Medical-Surgical Dermatology and Venereology Unit at the Hospital Universitario Virgen Macarena (Seville-Spain). The main clinical and research topics since his dermatology certification in 2003 have been the application of communication technologies to dermatologic care delivery, oncologic surgery of malignant melanoma, dermoscopy, epidemiology of skin cancer, and psoriasis. Telemedicine projects conducted have been supported by official competitive grants and public-health care institutional programs. These projects have given rise to an outstanding scientific output, and even the intellectual property registry has been achieved for some of the technologies developed. In the field of melanoma Dr Moreno-Ramírez heads a referential unit on the medical-&-surgical treatment of advanced malignant melanoma, and he has also coordinated studies on epidemiology of malignant melanoma and non-melanoma skin cancer. The interest in public health and health management led him to be appointed as Medical Director and Deputy Managing Director of the Hospital Universitario Virgen Macarena between 2011-2015. Dr Moreno-Ramírez is a board member of the European Association of Dermato Oncology, and the International Society of Teledermatology. Since 2014 is the editor of the medical education program Actas Dermosifiliograficas, the official scientific journal of the Spanish Academy of Dermatology and Venereology.
A decade after its implementation on routine practice Teledermatology-based (TD) screening of skin cancer has shown to improve the early detection of skin cancer essentially by enhancing the access to the Skin Cancer Clinic. A striking shortening in waiting times, as well as a better allocation of skin cancer patients (to in-person clinics, to presurgical management in the case of handicapped and elderly patients, to remote management of actinic keratosis, etc.) are readily guaranteed by using TD. Populations served by TD receives a faster expert advice without leaving their community settings. Teledermatology has made possible immediate and comprehensive screening of skin cancer. This is of interest from a public health perspective, enabling the achievement of a goal that conventional care delivery was not able to reach. Imaging and communication technologies now may transport dermatological care wherever and whenever such knowledge and expertise are needed. Moreover, TD has become an educational tool for primary care physicians. As a consequence, an increasing number of patients with skin cancer and premalignant lesions are diagnosed and treated even at earlier stages. It is likely that many of these patients may never have sought dermatological care because of a more limited access to the dermatologist. Teledermatology uses and methodologies, the results achieved and even how TD has changed the present management of skin lesions are to be explained. Lastly, TD is not only a matter of waiting lists. Communication technologies provide an opportunity to improve the quality of care and the health status of the populations served. It may be said that the classical aphorism of “doing different things to achieve different results” comes true with TD.
Antoine Bohuon, France
Digital transformation in dermatology
Antoine Bohuon, Co-founder & CEO @ Epiderm.co, Rennes, France Antoine is a self-taught entrepreneur who has worked in several areas before turning to the digital transformation in healthcare. Antoine created Epiderm with Dr Elisabeth Berrissoul, dermatologist to improve access to cares in dermatology. Already 11 Dermatologists around the world are working on Epiderm and more than 8,500 patient are using the service. Antoine is actually focused on « User Experience » improvement on the product. His mindset while creating new services « Move forward, make mistakes, learn, change and then repeat ».
We will explore digital disruption in Healthcare and specially in dermatology. • We will try to identify what is exactly a startup. What’s the startup mindset ? • Who’s working on it ? Panorama of startups improving dermatology worldwide • Watson ? AI ? Text mining ? What healthcare disruption really means
Dr Giovanni Pellacani, Italy
Clinical applications of Confocal Microscopy
He graduated in Medicine at the University of Modena and Reggio Emilia in July 1995, magna cum laude. He completed School of Specialization in Dermatology in November 1999. Since 1995 he practice research mainly in the field of cutaneous physiopathology, skin bio-engineering, non invasive diagnosis in dermato-oncology, paying particular attention at the study of melanoma and pigmented skin lesions, their early identification by means of dermoscopy in combination with system for image analysis and automated diagnosis, and in vivo reflectance-mode confocal scanning laser microscopy for the study of cytological and architectural aspects of skin tumours, in correlation with dermoscopy and histopathology. So far, Giovanni Pellacani published over 200 papers, including over 180 articles present in the “Science Citation Index” with an overall Impact Factor of over 500 points (H-index=41), 20 book chapters and over 200 abstracts in national and international congresses and conferences.
Reflectance confocal microscopy represents a useful tool for the study of the skin at cellular level resolution. The possibility to observe in vivo images of the skin almost like histopathology is offering ad adjunct to the diagnosis in several diseases. This technology has been maid applied for skin cancer detection showing a high diagnostic performance when placed in a workflow after dermoscopy for discriminating benign from malignant lesions in a subgroup of difficult to diagnose cases. In details, confocal microscopy today play a relevant role in diagnosis of small lesions, especially in patients with multiple and atypical nevi, in lesions on the face and in pink lesions, known to be diagnostic challenging in dermoscopy. One of teh main outcome derived by the use of confocal microscopy in a clinical setting for skin cancer diagnosis is given by the significant reduction of number needed to escise, thus saving numerous unnecessary excisions of benign lesions compared with dermoscopy alone. It can also be successfully applied for tumor superficial margin definition for basal cell carcinoma and lentigo maligna when these tumors are located in cosmetic sensitive areas. New developments are leading to conofcal devices suited for imaging freshly excisied tissue (ex vivo confocal microscopy) which offer the possibility to obtain histopathologic section of almost any human tissue. It’s application in basal cell carcinoma Mohs’ surgery already showed its applicability dramatically reducing the time of operation, but several application oin other skin and non-cutaneous conditions are well foreseen in the future.
Dr Eric Tkaczyk, USA
Innovations and Developments in Noninvasive Optical Imaging
Dr Tkaczyk is a physician-scientist with research interests in biophotonics for diagnosis and treatment of skin diseases. He graduated summa cum laude with degrees in mathematics and electrical engineering from Purdue University, where he was a Beering Presidential Scholar. He then completed a Ph.D. in electrical engineering at the University of Michigan Center for Ultrafast Optical Science under the mentorship of Director Ted Norris, winning several research awards including the best paper award from the International Biomedical Optics Society at Photonics West and also first prize at the IEEE International Summer School and Symposium on Medical Devices and Biosensors. He subsequently earned an M.D. with honors from the University of Michigan Medical School and went on to do medical device design post-doctoral work in the European Union at the University of Tartu, Estonia, supported by Fulbright and Whitaker awards. This work culminated with a prize awarded by both the US Ambassador to Estonia and the Estonian Speaker of Parliament at the Estonian-American Innovation Award ceremony. He joined the faculty of the University of Tartu Medical School, where he developed a course in biomedical optics, and spearheaded an international regenerative medicine collaboration. He subsequently completed dermatology residency training at Vanderbilt University Medical Center, where he is Assistant Professor of Dermatology and Director of the Cutaneous Imaging Clinic.
Optical engineering has seen revolutionary developments during past decades, as evidenced by recent Nobel Prizes focused on light science and technology. These technologies are contributing extensively to major advances in modern medicine, and dermatology is poised to be at the forefront of this revolution. Accordingly, a large number of optical diagnostic products have emerged with great potential to assist dermatologists in medical decision-making. Leading dermatology journals often feature studies in confocal microscopy. Many dermatologists also are aware of optical coherence tomography (OCT), which is essentially the light analog of ultrasound. This talk will focus on the application of even newer imaging techniques that are emerging within dermatology to provide information as follows: • Raman – relying on vibrational spectroscopy, reveals distribution of almost any molecule in the skin • Multiphoton microscopy – relying on ultrashort laser pulses, provides ultra high resolution, label-free images of many intrinsic skin compounds • Photoacoustic tomography – relying on sonic shock waves created by the absorption of light, enables optical imaging with depth advantages of ultrasound I will address considerations for selecting the most appropriate technique for different clinical dermatology scenarios. This will include comparisons of key results, future potential, advantages, and current limitations. In general, noninvasive optical diagnostic techniques have the potential to equip dermatologists with unparalleled insights and understanding. However, it is very important to select the appropriate modality for the clinical questions asked.
Dr Ana Beatris Rossi, France
Non-invasive imaging evaluation of dermo-cosmetics
Dr Ana Beatris Rossi is a French /Brazilian dermatologist with 27 years of experience practicing dermatology and 17 years’ experience performing clinical studies to evaluate efficacy and safety of drugs, cosmetics & medical devices. She has been working as dermatology expert for several pharmaceutical and cosmetics companies, including Unilever, Johnson & Johnson, Galderma, Novartis and Pierre Fabre. Currently, she is the head of the Pierre Fabre Clinical Skin Research Center in Toulouse, and leads a pluri disciplinary team of 80 scientists that design, perform and coordinate more than 900 clinical studies /year. The activities of this team support the development of products safe and efficacious for the patients-consumers, in the respect of pharmaceutical values and ethics. The daily work of this group of scientists allows a better understanding of the skin and pathophysiology of common dermatological and scalp conditions. This team also develops new noninvasive or minimally invasive methods of skin and hair evaluation, with several publications in peer reviewed dermatology journals.
Noninvasive or minimally invasive methods including imaging techniques are a major tool in the evaluation of dermocosmetics. The aim of these methods is to be able to detect changes in the skin in a reproductive and robust way, together with offering scientific support for product’s claims. A multitude of methods are proposed in cosmetics evaluation and will be discussed during the presentation. Standard high quality photography allow the before and after blinded comparison and objective measurement of changes. Depending on the filters used, photos can highlight UV damage, skin surface morphological changes and sub-epidermal erythema. 3-D photos allow the evaluation of surface changes and are commonly used in the evaluation of anti-aging and cellulite products. Confocal cellular imaging is used to assess pigmentation and skin lightening effect of sunscreens and skin lightening products, characterize skin aging, measure epidermal thickness, assess sun damage and determine the penetration of a formulation. Fluorescence microscopy can provide a clear 2-D or 3-D view of human skin structure and cell interactions, and detect the changes after stimuli and /or product application. Keratinocytes, melanocytes and Langerhans cells can be clearly identified and quantified. The Biophysics and Imaging team in Pierre Fabre has a key role for offering innovating and robust spectroscopic and imaging techniques for skin research and Pierre Fabre’s product’s evaluation. The dedicated approach goes all along from the device development, with academic or industrial partners, up to application in clinical studies. Some of these innovative methods and latest findings will be presented.
Dr Giuseppe Argenziano, Italy
Mobile apps in the field of dermatology
Giuseppe Argenziano is Associate Professor and Head of the Dermatology Unit at the Second University of Naples, Italy, and Coordinator of the Skin Cancer Unit at the Research Hospital “Arcispedale Santa Maria Nuova IRCCS” in Reggio Emilia, Italy. His main research field is dermato-oncology, being author of numerous scientific articles and books concerning dermoscopy, a new technique improving the cliniciansdetection of benign and malignant skin tumors. As coordinator of a Skin Cancer Unit, he has established a successful tertiary, multidisciplinary, referral center particularly devoted to the diagnosis and management of patients with skin tumors. Over the past 20 years he has supervised over 100 foreign students and 40 residents in Dermatology, established scientific collaborations with more than 200 colleagues from more than 30 Nations, and organized more than 50 national and international scientific activities, courses and conferences (such as the Consensus Net Meeting on Dermoscopy and the First Congress of the International Dermoscopy Society). He is co-founder and past president of the International Dermoscopy Society; project leader for the development of a high diagnostic technology oncologic center at the Arcispedale Santa Maria Nuova IRCCS in Reggio Emilia; faculty member of the Master of Science in Dermoscopy and Preventive Dermato-oncology, and the Short Course in Dermoscopy, two e-learning courses by the Medical University of Graz and by the Cardiff University, respectively; and member of the Editorial Board of the Journal of the American Academy of Dermatology. Professor Argenziano has authored more than 400 full scientific articles and produced landmark primary publications and books in in the field of dermoscopy. Over the past 20 years he has been invited as speaker and/or chairman in more than 500 national and international conferences in the field of dermatology. His combined publications have received a sum total of 7198 citations with an h-index value of 44 (Scopus 01/2016).
The development of new generation smartphones represented a big change in many areas, including imaging in dermatology. Fast internet connections and high image quality of smartphone cameras made it extremely easy to share dermatologic images among doctors and patients. During this presentation a few applications in the field of dermatology will be discussed, including the YouDermoscopy App and WhatsApp. The first is a new teaching application devoted to dermoscopy, whereas the second is the famous application for instant messages and sharing images. The YouDermoscopy App has the aim to teach dermoscopy to doctors interested in this field using a gaming approach that, in our estimation, could improve the learning experience of the participant. WhatsApp is a leading application that is increasingly used by doctors and patients to share images of dermatologic conditions. If we like it or not, this tool is here and will be increasingly used by patients to communicate with their doctors. We only have to understand how to interact with these new technologies in order to simplify our daily job!