Roundtable Interview with Asst Prof Asli Bilgic, Prof Dedee Murrell, Prof Marie-Aleth Richard and Assoc Prof Myrto Trakatelli
Asst Prof Asli Bilgic | Communications Committee; Akdeniz University, Antalya, Turkey
Prof Dedee Murrell | Communication Committee and International Board Member; The George Institute for Global Health, Sydney and St George Hospital, University of University of New South Wales, Sydney, Australia
Prof Marie-Aleth Richard | Chair of EADV Communication Committee; French Member of the Board, Timone Hospitals, Marseille, France
Assoc Prof Myrto Trakatelli | Chair of EADV School; Papageorgiou Hospital, Aristotle University Thessaloniki, Thessaloniki, Greece
What fascinates you the most about dermatology, and why did you decide to pursue a career in this field?
Prof Trakatelli: The skin is visible, accessible to touch, and enables us to discover conditions by examining it. There are so many illnesses one can detect through the skin: the specialty is vast, spanning different facets of medicine from skin cancers, tumours and conditions that can be treated through intervention to inflammatory, autoimmune and systemic diseases, paediatric dermatology, allergology disorders, and infectious and venereal ailments that can be treated medically. This certainly is not an exhaustive list! It comprises so many, and diverse, scenarios that it can appeal to all with a taste for problem-solving. Whether you are a blade or medication fan, whether you are an action taker or an enigma solver, you will definitely find the facet that will engage your interest, or dare I say, steal your heart?
When I was in Kindergarten I had quite a serious condition: I had a Steven–Johnson-like reaction to sulfonamides. I had to stay confined in the house for days with pain, oozing, and crusting in all my mucous membranes. My eyes were stuck shut each morning until the lids were prised open by using a form of glass stick. It was horrible. I can still ‘feel’ the pain I suffered! This disease marked me (luckily, not externally or functionally) and as a teenage I became quite obsessed with the wellbeing of my own skin, taking extreme care of it and slathering it with creams constantly. My friends used to chide me gently: How come you wear all those sticky, disgusting creams? Are you going to be a dermatologist? Classic teenager attitude!
I started medical school wanting to become a biochemist or molecular biologist and solve things with my trusty microscope; but, going through clinical training and later entering the lab for my biochemistry PhD made me realise that I loved working with patients and I that I missed seeing them. My passion for skin and its health had never abandoned me so it was a clear choice for me to become a dermatologist. And as I like working both with my hands and my brain, I became specialised in skin cancer and dermatologic surgery.
Prof Murrell: What drew me into dermatology was the puzzle of the picture: you have something visual on the outside of the body which is caused by, or related to, something that has ‘gone wrong’ inside the body (including the immune system, genetics, infection, or hormonal), or induced by something on the outside (including UV, allergens, infections). It is intellectually stimulating. Patients care a lot about how their skin is affected compared to internal diseases which don’t cause physical pain. They have emotional pain. Dermatologists can make a big difference to patients of all ages, who are grateful because they can see the difference you make to them.
Prof Richard: The skin is the showcase of the body and internal organs and is often affected in cases of serious illness. It is a varied and rich specialty with over 3,000 different skin diseases that affect the youngest to the very old. It is a specialty based on the examination of lesions and patients which requires you to be a real doctor, have knowledge in semiology, and in histology. We can perform many technical procedures and laser surgery, and we also have access to the most innovative molecules. Dermatology offers so many perspectives to treat our patients that my passion is endless.
Dr Bilgic: I love dermatology because it is mostly a visual science section. There are more than 3,000 dermatological conditions, always forcing you to read and research. There are many dermatological signs of systemic diseases, systemic cancers and genetic problems for example, which we can help to diagnose early. Furthermore, there are many different sections of dermatology and venereology that you can choose to master in, including autoimmune bullous diseases, paediatric dermatology, cosmetic dermatology, and more. I am just fascinated by the opportunities of dermatology as a career.
Could you tell us about your most recently published paper, and the impact that you hope the conclusions to have on the dermatology community?
Prof Richard: One of my most recent publications is about ‘out-of-pocket expenditures’ for the management of adult patients with psoriasis in France. The article illustrates some of the uncovered needs for patient management and the economic burden associated with skin diseases.
Prof Murrell: A recent study1 I did investigated why patients with psoriasis might be more susceptible to the coronavirus disease (COVID-19), triggered by noticing that a 14-year-old male in Portugal, who seemed very fit and was a soccer player, died suddenly of COVID-19. In the paper he looked slim and well, but the article said he had psoriasis. It was most likely not that severe as it was not visible. I started investigating whether angiotensin-converting enzyme 2 (ACE2) was increased in psoriasis as this is the receptor for COVID-19 and is connected with hypertension, something that patients with psoriasis develop quite often. There was nothing published about it. I contacted Prof Jim Krueger, whose lab I had worked in as a postdoc years ago, to suggest that we investigate if ACE2 was increased in lesional psoriasis or not. He had collected skin samples of patients with psoriasis before and after sekukinumab treatment. These samples were then tested for ACE2 and it was found to be increased in lesional and nonlesional skin of patients with psoriasis compared to normal skin. After treatment with sekukinumab, the levels returned to normal. We proposed that the biologic helped to make the patients less susceptible to a large dose of COVID-19 and the statistics so far show that these patients on biologics do not have an increased mortality from COVID-19 despite being relatively immunosuppressed.
Dr Bilgic: My most recently published paper2 was about plasma-rich platelet (PRP) injections for the treatment of male androgenetic alopecia (AGA). PRP treatment for various dermatological diseases has been investigated as an emerging therapeutic option, yet there remains a dearth of data on the effectiveness of this approach. Thus, we investigated the efficacy and safety of physically activated PRP injections versus placebo in the treatment of male AGA. Our study provided data supporting the positive effects of PRP treatment on AGA in males.
Prof Trakatelli: When COVID-19 hit, we started thinking about how to deal with our patients with skin cancers that had to undergo surgery. I was in touch with my ‘sisters of the blade’, Dr Elena Rossi and Prof Christina Magnoni, in the eye of the storm and we thought it would help our colleagues in Europe if we could come up with a plan and draft a paper on how to deal with this group of patients. I hope the paper will help colleagues managing patients that present with skin cancers needing excision.3
What does your role on the EADV Committee entail, and what have you achieved so far in this position?
Dr Bilgic: Primarily, EADV is a community composed of dedicated researchers and clinicians to work on improving quality of patient care and research, education, and training in the field of dermatology and venereology. We share an ambition to improve and maintain high standards in the dermatology and venereology profession and dermatology public health services.
As a Communication Committee member, I echo EADV’s voice through social media platforms and work as an ambassador to enhance awareness of EADV and its activities. Our main aims are to enhance internal and external communications at EADV, to play a consultative role drawing upon members’ expertise/experience as medics, to bring a communications lens into early internal discussions on projects, and help shape external perception of EADV.
We were responsible for the creation and/or collection of material for publication on the EADV Virtual COVID-19 resource centre. We created an anonymous questionnaire investigating the impact of COVID-19 on European dermatologists. The survey included 30 questions in three main areas: participants’ profile, impact of COVID-19 on professional activity, and on personal life. The survey results were presented at the EADV 29th Virtual Congress.
We reviewed and approved the shortlist of abstracts and presentations that are being recommended as the key drivers for the EADV media activity. We worked as EADV ambassadors and influencers during the EADV virtual congress to drive awareness among followers on social media through highlighting the benefits of attending and specific presentations that we were looking forward to attending. We also worked as official EADV spokespeople and attended media interviews.
Prof Richard: I have two positions in the EADV. I am the French Representative Board Member of the EADV and the Chair of the Communication Committee. The Communication Committee requires a lot of investment and work to improve the promotion and recognition of dermatologists, patients, and skin diseases throughout the academy. Very important surveys are now ongoing to promote patients’ needs and the role of dermatologists throughout Europe, and to advocate the position of dermatologists in health.
Prof Trakatelli: I am the Chair of the Education Committee for EADV (EADV School); I organise and oversee all educational activities of the academy outside of our congresses. For many years we held ‘fostering courses’ in classroom for residents and specialists but more recently, since I became the chair, we started developing virtual learning in the form of webinars and e-Learning courses.
In 2020, having to manage the cancellation or postponement of all of our face-to-face courses, we had to rapidly refocus and produce a series of ‘long-distance learning’ activities and I am proud to say that the Education Committee (Drs Daiva Jasaitiene, Paola Pasquali, Rossi, Catherine (Bibi) Van Monfrans, Sarah Walsh, and junior resident member Stella Siskou) managed to deliver many educational activities to our members and dermatologists all over the world. We created a special COVID-19 series that informed and supported colleagues on different aspects of the coronavirus impacting our specialty. We transformed our Nails Masterclass to a webinar series, which was adeptly chaired by Prof Bertrand Richert, and was shared during the first wave of quarantine (now a Continuing Medical Education [CME]-accredited e-Learning course). We developed a new e-Learning course initiating knowledge in dermatopathology, artfully chaired and organised by Prof Maite Teresa Fernández Figueras (also CME-accredited). We also liaised with Goleman EI and its CEO Ms Michele Nevarez to produce three special webinars on emotional intelligence and healthcare to help strengthen the positive outlook and resilience of health providers all over the world; the father of Goleman EI, Daniel Goleman himself, featured on the first webinar. Finally, we continue to provide monthly webinars on interesting topics in dermatology featuring top experts in their field. Our endeavours are accessible on our e-Learning platform.
We are hoping to do more and develop an optimised learning ecosystem for the future to offer our members excellent scientific knowledge in an accessible and simple manner.
Prof Murrell: I have two positions within the EADV board. The first is as an International Board Member representing the one-third of members who are outside the European Union (EU). I am also on the Communication Committee. My roles include promoting the activities of the EADV on social media; we have many followers on LinkedIn, our open Twitter page, private Instagram, and Facebook including friends and colleagues. As a journal editor, member of editorial boards, and author, my work involves submitting articles, citing the literature of the EADV, and the EADV Task Forces, for which I am a member of Autoimmune Blistering Diseases. As a member of many other dermatology societies and a lecturer at many international congresses I work to promote the EADV and I have received media training over the past 15 years and so I am interviewed about dermatology or career topics.
The decision was made to move the EADV 2020 Congress to a virtual meeting this year. What do you believe to be the advantages of an online congress?
Prof Murrell: The online platform enables more people who cannot afford to travel because of cost, family, or work commitments to learn, usually in the evenings or on weekend, which is when the on-demand lectures are useful. Although costs are reduced there are many disadvantages. For example, people are likely to listen to far fewer lectures than when they have the dedicated time off to be at a congress and to be able to arrange collaborations with others.
Dr Bilgic: The EADV congress was of equal quality as the previous EADV congresses but even better as the virtual congress provided us an exceptional opportunity to involve more colleagues around the world from their homes. EADV Virtual offered, as always, a programme that consisted of outstanding educational and brainstorming sessions; however, this time it was easier to attend our favourite sessions via the online platform, and better still, we can watch the sessions we missed as they are offered on demand until 31st January 2021.
Prof Trakatelli: It is accessible to all who are interested, including those that wouldn’t have the chance to travel to a regular face-to-face meeting, providing top scientific lectures from the comfort and security of your own home.
Prof Richard: The greatest benefit is to allow us dermatologists to continue to communicate and exchange with each other and to share the latest data and advances in dermatology.
‘New Frontiers in Dermatology and Venereology’ was the overarching theme of the EADV 2020 Virtual Congress. How have recent advancements in technology helped research and patient care?
Dr Bilgic: With COVID-19 challenging all our understanding of life and daily routines, EADV Virtual committed its focus to improve our understanding of the unmet needs of dermatological care.
At the virtual congress, the first clinical evidence of an oral microbial therapy was shared for modulation of systemic inflammation in psoriasis. This would offer us a therapy without immunosuppressive properties which is an important issue during pandemics. Furthermore, huge therapeutic advances in the field of hand eczema and alopecia areata were shared at EADV Virtual which could end the therapeutic drought in these frequently seen dermatological diseases.
Moreover, the innovations in artificial intelligence shared during the congress will help us as powerful monitoring and triage enablers; ground-breaking new therapies in immunotherapy and targeted therapy in cutaneous oncology and autoimmune diseases offer patients and clinicians life-extending treatment options.
Prof Trakatelli: We have wonderful new drugs for psoriasis that achieve skin clearance for a lot of patients, advances in promising therapies for metastatic skin cancers, and novel insight to mechanisms of disease. Furthermore, the use of teledermatology has helped provide medical care in times of social distancing!
Prof Richard: Artificial intelligence, teledermatology and new ways of communication, were, and are still are in my opinion, crucial during the current health crisis to protect patient care and safeguard ongoing research.
Prof Murrell: The new biologic revolution in dermatology has, for the first time, made psoriasis invisible. It’s still lurking under the surface like other diseases are if you stop treatment, but at last the patients don’t have to be stigmatised.
The mission of the EADV is to improve the quality of patient treatment, and the EADV frequently run campaigns on skincare education. As we head into winter, could you give our readers some expert dermatological advice on how best to protect our skin? What are the main threats to our skin’s health?
Prof Trakatelli: Winter dries skin out. People should hydrate the skin regularly applying nourishing emollients and avoid as much exposure to extreme temperature differences. For example, try to take short showers that are not too warm or too cold. Eat well, with seasonal fruits and vegetables and drink plenty of water daily!
Dr Bilgic: Hand hygiene is crucial in the prevention of viral transmission during the pandemic and beyond. The first and foremost important action is to wash our hands frequently. However, this comes with its risk regarding eczema exacerbation. To prevent eczema, I suggest using fragrance-free, perfume-free, and dye-free creams and ointments immediately after you wash your hands.
In the bath, use warm water and keep it to 5–10 minutes. Hot water could remove your skin’s natural oils and long showers could dry out your skin. Cleanse you skin gently with mild, fragrance-free cleansers and avoid rubbing your skin. After your bath, use a soft towel gently pat your skin dry and apply moisturisers immediately to allow your skin to lock in moisture. Use a sunscreen with broad spectrum sun protection factor (SPF) 30+ to protect your skin, even in winter. If you apply makeup, use it after your moisturiser and sunscreen.
Eat a healthy well-balanced diet to provide necessary ingredients for your skin. Get a good night’s sleep to build up your immune system. Dress in loose-fitting natural clothing like cotton or silk.
Prof Murrell: The skin is a major part of the body’s immune defence system which is why vaccination works so well when delivered via the skin. In heated indoor winter conditions the skin barrier dehydrates, so it is important to hydrate the skin daily, soaking in the bath or shower, and applying a moisturiser which replaces the skin’s ceramides and doesn’t introduce potential allergens (such as plants, perfumes, and many preservatives).
Prof Richard: The main threats are excessive drying from the cold; heating or excessive washing of the skin with detergents and other products should be avoided.
The EADV produced Task Force Recommendations for clinicians, to help provide expert care for patients during the COVID-19 pandemic. Could you summarise the key recommendations?
Prof Richard: Patients should wear masks, use hydroalcoholic solutions as often as possible, and must respect social distancing. Most dermatological treatments can and must be maintained during the pandemic.
Prof Murrell: Protect your airways from inhaling the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) by wearing a mask when outside your home, wash your hands frequently and apply moisturiser each time, limit any unnecessary travel and gatherings, do not cease your regular medication without consulting first with your doctor.
Dr Bilgic: General suggestions are to practise sensible social distancing, to wash hands frequently, to use skin care lotions and creams between hand hygiene procedures, to wear a mask as advised by national or local authorities. Always wear a mask if you are taking immunosuppressive drugs to treat, for example, autoimmune blistering diseases, psoriasis, hidradenitis suppurativa, atopic dermatitis, and melanoma, especially when outside and if you are unwell and coughing and sneezing. People must undertake or complete vaccination protection according to their national guidelines, at present with priority against influenza and pneumococcus if not already done and should avoid busy public transport and closed areas.
Immunosuppressive drugs are frequently used medications for many dermatological diseases and there are immunosuppressives that could increase the risk of more severe COVID-19. The Task Force on Autoimmune Blistering Diseases suggested patients should not stop or modify their treatment without discussing with their dermatologist as a relapse of autoimmune blistering disease could be more severe than an infection with COVID-19. In case of COVID-19 infection, modification of the treatment could be an option within close collaboration between the dermatologist managing the autoimmune blistering disease and the physician treating COVID-19.
The EADV Psoriasis Task Force, The EADV Vasculitis and Vasculopathy Task Force, and the EADV Acne, Rosacea, Hidradenitis Suppurativa (HS) Task Force, and the European Hidradenitis Suppurativa Foundation suggested that immunosuppressed patients are not at increased risk for severe manifestations and complications of COVID-19 compared to the general population based on available data on past and present outbreaks of coronavirus infections. Patients with cutaneous immune-mediated diseases, including psoriasis, hidradenitis suppurativa, vasculitis, and atopic dermatitis, are suggested to continue their treatment during the COVID-19 outbreak unless suggested otherwise by their dermatologists. This would prevent disease flares that can contribute to increasing patient burden, disability, poor quality of life, and healthcare overuse.
Of course, immunosuppressive or biologic treatments in patients with active COVID-19 infection or with any other active infection is contraindicated. It is also advised to pause such treatments if patients develop symptoms consistent with COVID-19 infection. Furthermore, if patients live in areas with a high incidence of COVID-19 infection, or are close contacts of confirmed cases, individual consideration of immunosuppressive therapy temporary discontinuation is suggested, considering factors such as age or comorbidities. Caution is suggested for individuals generally at risk of developing a more serious course of COVID-19 disease. The EADV STI Task Force suggested that some individuals should have access to sexual healthcare services during the pandemic.
Prof Trakatelli: Wear a mask, keep a safe 1.5 m distance, wash hands regularly and protect them with hydrating creams, don’t stop taking a prescription drug unless consulting with your doctor, and if you have something that is highly suspicious or that is worrying you on your skin try to consult a dermatologist; if possible, virtually by teleconsultation otherwise by face-to-face consultation. Skin cancers continue to appear, and some must be dealt with urgently even during a pandemic!
What have been your personal clinical experiences during the COVID-19 pandemic, and what lasting impacts do you anticipate the pandemic will have on dermatological care?
Dr Bilgic: COVID-19 has first and foremost created a fear in my heart for my loved ones. As working at the hospital created a huge risk, I tried to protect my family and so was all alone at home communicating via calls. Following this fear, I tried to shape my life and work according to our new routines. I had time both for research and dermatological projects, as well as having some extra time to watch films and television series because of working in shifts during the first peak of COVID-19.
In terms of lasting impacts of COVID-19, I believe we will see increasing tendencies to have virtual meetings and an increasing demand for virtual health services. It is important to be a part of this process to have the contribution and authority on new virtual healthcare policies.
Prof Richard: It is important to protect the management of all skin diseases to avoid missing opportunities to treat skin conditions early.
Prof Murrell: Patients were initially scared to come in for face-to-face consultations. Skin cancer checks are very difficult to conduct by telehealth; however, existing chronic skin problems which have been diagnosed can be managed via telehealth. Biologics do not appear to be increasing the incidence of COVID-19 as originally feared.
Prof Trakatelli: I discovered that I could find strength and be flexible in situations that challenged my comfort zone. I think that this adverse era will help bring in new ways of working such as the use of teledermatology, virtual patient management, and virtual learning, which will further advance dermatology!