Sept. 23, 2023

Exploring Dermatology with A/Prof Alvin Chong from Spot Diagnosis podcast: From Skin Cancer to Sun Protection

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Ever wonder what goes on in the world of dermatology? Buckle up as Dr Gavin Nimon (Adelaide Orthopaedic Surgeon) interviews none other than Associate Professor Alvin Chong, a seasoned dermatologist from Melbourne who has a wealth of knowledge to share. He hosts a podcast Spot Diagnosis Podcast, a treasure trove of information introducing more dermatology topics to medical students, GPs, trainees and nurses. Today, he lets us in on the most common conditions he encounters in his practice, which range from skin cancer to various inflammatory skin diseases.

Get ready to delve into the latest breakthroughs in skin cancer diagnosis and treatment. Professor Chong astutely guides us through the advancements made in melanoma treatment, with a special focus on the fascinating role of checkpoint inhibitors. But that’s not all, we also turn our attention to the sun and its effects on our skin. Learn about UV treatments, their risks, and how to use sunscreen correctly. With the rise of skin cancer among younger populations, Professor Chong stresses the importance of sun protection and applauds public health campaigns' efforts in combating this issue. If you're keen to expand your knowledge on dermatology, this episode is definitely for you!

Aussie Med Ed is sponsored by -HealthShare is a digital health company, that provides solutions for patients, General Practitioners and Specialists across Australia.

Aussie Med Ed is sponsored by Avant Medical Indemnity: They state that they offer holistic support to help the doctor practice safely and believe they have extensive cover that's continually evolving to meet your needs in the ever changing regulatory environment.

Chapters

00:00 - Podcast Interview

13:22 - Skin Cancer Diagnosis and Treatment Advances

28:17 - Ultraviolet Treatment and Sun Protection

Transcript

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Did you realise that 16 percent of what general practitioners see each day relates to the skin conditions or dermatology?

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And that 85 percent of Australians will suffer from acne at one stage in their life?

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70% of Australians by the age of 70 will have developed a skin cancer and one in 17 patients would've developed by the age of 85.

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A melanoma it's my pleasure to interview associate professor Alvin Chong, a dermatologist from Melbourne who also runs his own podcast series called Spot Diagnosis.

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I'm going to speak to him about common dermatological conditions.

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G'day and welcome to Aussie Med Ed, the Australian medical education podcast, designed with a pragmatic approach to medical conditions by interviewing specialists in the medical field.

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I'm Gavin Nimon an orthopaedic surgeon, and I'm based in Adelaide, and I'm broadcasting from Kaurna land I'd like to remind you that if you enjoy this podcast, please subscribe

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It is my pleasure now to introduce Associate Professor Alvin Chong, a specialist dermatologist in Melbourne, in Victoria.

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He has an appointment as a VMO at St Vincent's Hospital in Melbourne and at the Skin Health Institute.

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He is also an Adjunct Associate Professor at the University of Melbourne.

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Alvin is the creator and co host of Spot Diagnosis Podcast.

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Welcome Alvin.

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Thank you very much for joining us on Aussie Med Ed.

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It's a pleasure to be here, Gavin.

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So it's nice to be on somebody else's podcast for once.

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Yes, exactly.

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Being a co producer of another podcast, it's great to have you combining together to actually introduce different topics.

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I started Aussie Med Ed three years ago as a way of introducing medical topics to medical students and to also GPs.

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I believe you undertook the same sort of philosophy, but with the idea of having predominantly a dermatology focus.

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Can you tell us a little bit about spot

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diagnosis, please?

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Yeah, sure.

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So spot diagnosis podcast.

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We actually started recording it in 2019 and the reason why we recorded it and we started this podcast series was due primarily to the lack of, um, education on skin diseases.

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That's almost endemic in medical schools.

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I said, I'm an academic at university of Melbourne and we, for a long time, all we had to teach in dermatology with three one hour call lectures in four years of medical school.

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Of something that is 16 percent of the work of a GP.

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That is clearly inadequate.

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And we decided, okay, why don't we create our own podcast series at the Skin Health Institute.

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And the aim is really to introduce more dermatology topics to these poor medical students.

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Because you can imagine if you go to med school and you come out after three lectures given in second year, you're going to have virtually no working knowledge on skin.

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And that's basically a lot of what we see.

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But as it stands, we recorded the whole season 2019.

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And we launched it in March, 2020, which as all of us know, that's when the pandemic was declared.

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It was just timing.

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We thought we got to launch it and we did, but it was quite interesting because the entire world of medical education pivoted towards online education.

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And suddenly we had a lot of listeners and now we're on a fourth season.

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The reason why we have a podcast like this is every month we talk about a different topic in skin disease, for example.

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eczema or psoriasis and we invite a local specialist dermatologist with a particular interest and we will present very good quality evidence based information in a format that is accessible to all health professionals.

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So it's not only to medical students but also to GP trainees, GPs and nurses.

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And we're in our fourth season, we've had 42 episodes and it's going very well.

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We've just cracked 50, 000 downloads.

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Which for a niche, uh, uh, podcast and demonstrator is not too bad.

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It's excellent.

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It's fantastic news.

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And I've actually listened to the fair few episodes and I'm really enjoying it.

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It really expands upon the area we're working on and trying to provide a general area.

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You're going down a specific pathway.

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And it is really important because when I went through medical school, I figured that a lot of skin conditions could only be treated in one or two ways.

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I believe it's actually progressed a lot over the years, and we'll go into that in a little while.

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What are the more common types of conditions that you would see or the things that are important to mention today?

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So, I guess.

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We're very bound by geography and so if you're working in the tropics, for example, you'll be seeing a lot more tropical skin infections.

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Australia is fairly unique.

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We have, uh, unfortunately, the dubious distinction of having the highest skin cancer rates in the world.

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And it's partly because we're a country that's bathed in high UV with a largely susceptible Caucasian population.

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In Victoria, most, but probably about 40 to 50 percent of the work that I do is related to skin cancer.

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So diagnosing skin cancers, whether they're keratinocyte cancers or melanomas.

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And then the other 50, 50 to 60 percent is related to inflammatory skin diseases, eczema and psoriasis.

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We see acne a lot, and then there are all kinds of disorders which involve skin and integument like hair diseases.

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And after you deal with the common things, which make up 80%, then the other 20 percent can be almost anything, for example, planus, lupus, so the full spectrum of weird and wonderful things in, as well as common things.

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And of the skin cancers, you say, what are the ones that we need to really worry about?

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Yeah,

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sure, sure.

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Traditionally, we divide skin cancers into non melanoma skin cancers.

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And it's got a new name now is keratinocyte cancers.

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And there are things like basal cell cancer, which is by far the most common type of skin cancer that you're going to get out there, followed by squamous cell cancer.

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So these are the two main keratinocyte cancers.

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And then you have melanoma.

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Melanoma stands separately by itself.

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The good thing about keratinocyte cancers are, even though they're common, they don't result in a lot of death.

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Okay.

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So basal cell carcinomas, for example, will occur.

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In about 70 percent of the population once they reach the age, uh, 70, so it's really common.

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They occur in, uh, sun exposed parts of the skin, like the head and neck.

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They're kind of pearly, growing, ulcerated, um, nodule on the nose or the ears or the, or the forehead, usually asymptomatic.

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The good news is they don't metastasize.

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Once they're diagnosed and, and excised, then they're cured.

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squamous cell cancers are, um, the next one along.

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They They occur probably about a third as commonly as basal cell cancers.

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The ones that are on the head and neck can be nasty, so if they're on high risk sites like the scalp, the nose, the ears, the lip, they can metastasize.

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So head and neck squamous cell cancers are a little bit more concerning, but usually they are low risk sites like on the forearms, on the back of hands, and they're not that dangerous.

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Melanoma is, uh, a completely different beast.

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Fortunately, they're not quite as common as caries from the side cancers, but they're still common enough.

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So they're going to be about 17, 000 diagnoses of melanoma per year.

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And they're going to affect about 1 in 17 Australians by the time they reach 85.

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And the death rate from melanoma is still reasonably high.

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So I think the latest, uh, data shows that about 1, 200 to 1, 400 people die of melanoma per year.

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So that's.

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As many as in car accidents.

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Okay, this is considered the third most common cancer after prostate and breast.

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And it's still a killer.

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The good news is that you can actually diagnose it early.

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And it's largely preventable using sun protection.

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And I believe there's been some new developments in the diagnosis over the last 20 years or so with dermoscopy and other techniques.

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Perhaps you can outline a bit about that,

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please.

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Yeah, melanomas used to be, certainly when I was in medical school, we learned about the A, B, C, D, E, right?

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A for asymmetry, B for border irregularity, C for color variation, D for diameter, and E for elevation or evolution.

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And that's still very useful because it's like the, if you don't have a dermatoscope and you're looking at a dark lesion, a pigmented lesion, you use all those criteria to inform you as to whether something is worrying or not.

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Of the A, B, C, D, E, it's the E, evolution is the main concern.

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If it's something that's changing, it's a concern.

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But over the last 20 years, the use of the moscopy, so the microscope is really, it's like a glorified microscope, times 10 magnification, uses LED light, and you place it on the skin with a liquid medium to reduce refraction.

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And that allows you to look at lesions a lot more closely and also can peer through the top layer of the epidermis into superficial dermis.

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So you can have an appreciation of color and structure.

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And there's a way to learn the moscopy and that in itself has resulted in earlier diagnosis of melanoma and also better differentiation.

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So you're not cutting out pigmented separate keratosis, which are harmless, but we can differentiate them from suspicious pigmented lesions.

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So it really improves the benign malignant ratio.

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And I think the moscopy training is now done by a lot of GPs.

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Uh, certainly it's a very important part of being a dermatologist.

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But it's still not very well taught outside general practice and dermatology, for example, in medical schools.

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Certainly in Melbourne, it's not taught

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there.

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Do you think this would also be supplemented by artificial intelligence and the use of computers to help diagnose it as well?

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The first thing is, I think there needs to be more teaching in Demoscopy.

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Per se, across the board, because it's like listening to a stethoscope.

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All medical students learn how to use a stethoscope to listen to heart sounds.

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I think medical students should learn how to use a stethoscope because But it's not so easy to teach, you need expert demoscopists to teach.

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And I think it depends on the medical school if the resources are limited.

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And they say, Oh, you can only have a very limited amount of time learning dermatology.

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Then they try to teach everything rather than just go into great detail in one topic.

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So it's not so easy.

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Now artificial intelligence is very different.

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Anything that is visual and that can be analyzed, uh, pattern analysis.

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Okay.

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Anything that's that uses pattern analysis, artificial intelligence can do faster and more accurately than we can.

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Okay.

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That's actually been proven.

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There are now studies to show that an AI program can diagnose a melanoma.

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As accurately as a practicing expert dermatologist and much faster.

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Okay.

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So, so we are heading down the path of hopefully using AI as an adjunct to the way we diagnose things.

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The kind of naysayers would say that we're heading on a path of extinction.

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It's going to take over.

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I don't think that's going to happen.

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I think the, fortunately there are legal structures and medicine is a very conservative way of organizing thought.

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And so we're still largely protected by legal structures, by responsibility.

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You can't really hold AI responsible.

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If it makes a mistake, you can hold a doctor responsible.

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We make a mistake.

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But there's a lot of research now where they use AI to look at pigmented lesions.

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Yeah, I reckon

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the AI is interesting because I think it's going to be an extra tool to supplement your clinical acumen.

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One question though that comes to mind when you're talking about the stethoscope and also other cardiology devices is that over the years, the stethoscopes now become noise cancelling electronics.

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The other cardiology things like blood pressure machines you buy at the chemist shop to do your own home monitoring.

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Do you think it will come a day where you can buy your own dermatoscope with an AI?

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So at least you can monitor it and then.

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When you're worried, go to the dermatologist, get advice from there.

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Yeah, so, yeah, good question, isn't it?

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There are now AI linked apps, okay, and they're not widely used.

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I have seen apps where you can take a picture of a pigmented lesion and send it to an AI space, and then it's diagnosed, and then, uh, the recommendation, this is worrying, you need to see a dermatologist.

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This is benign, you can leave it alone.

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Okay, with all the disclaimers, whether we like it or not, it's actually being used already.

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It's being used right now.

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And they're pretty good, they're pretty good.

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I had a patient who, who came in and the app had picked one lesion which they were worried about and two lesions that they said were harmless.

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So I said, let me have a look at all of them and it was accurate.

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The lesions that they said were harmless was actually quite sophisticated.

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You need a bit of knowledge to actually say that it's harmless.

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And the one that they said was a malignant was clearly malignant.

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So they're really intelligent.

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Obviously at this

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stage, so anyone listening is to recommend you to see a dermatologist rather

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than this.

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Correct.

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Correct.

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What was interesting was this person had used an app and the recommendation was go and see a dermatologist and get it treated or go and see a doctor to get it treated.

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So that's probably the way triaging things.

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I think AI can be used to triage things.

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Excellent.

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I believe

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there's been some further advances, not only in the diagnosis, but in the treatment of these skin cancers, particularly melanoma.

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Yeah.

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So the main advance is actually in the treatment of melanoma.

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So it wasn't that long ago when, if you get diagnosed as having metastatic melanoma, it's over.

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Like chemotherapy doesn't work.

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The median survival is something like six months, so it is just a lethal disease.

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But everything changed with a type of treatment called checkpoint inhibitors.

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Okay, so checkpoint inhibitors are incredible drugs that actually allow the body's immune system to recognize the melanoma and to kill it.

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Okay.

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There is one called Pembrolizumab, which has been used now at least over the last 10 years and it is life changing.

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It can actually produce.

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Complete metabolic response in patients with widespread melanoma.

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And it is almost like science fiction.

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A magic bullet.

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Like a magic bullet.

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You got a f l in, in, in Adelaide, of course, by afl, right?

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It's a highly of afl.

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Oh, okay.

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All right.

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Let's, we can argue about that.

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And Victoria, the team Hawthorne had a, a really, a well-known play and he had, this is really clearly documented in the public sphere.

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He had a melanoma on his lip.

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Okay.

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And that was excised.

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And then he developed a metastatic melanoma in his lungs.

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So now, usually you get a diagnosis of metastatic melanoma in your lung.

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It is game over.

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He was actually given checkpoint inhibitors and they produced a complete metabolic response so well that he could actually go back and play for Hawthorn and captain Hawthorn.

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This is literally the science stuff of science fiction.

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So.

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Not everyone who gets treated with checkpoint inhibitors will respond that well, but you have great hope and previously there was none.

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Okay, so these checkpoint inhibitors are now being used in all kinds of cancers, but melanoma is one where it has created a huge inroad.

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Excellent.

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So has it improved the prognosis significantly across the board?

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So it's mainly a

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metastatic melanoma.

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Okay.

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Brilliant.

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So, of course, the first diagnosis when you start off with a melanoma is initial excision.

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What's the role of the punch biopsies versus excisional

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biopsies?

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Okay, so that's a very good point, right?

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So, we actually recommend that if someone has a pigmented lesion that is suspicious for a melanoma, that the initial biopsy be an excisional biopsy if at all possible, rather than a punch biopsy.

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And the reason for that is, um, false negatives.

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So a melanoma is not uniformly malignant.

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Okay.

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So you have a pigmented lesion and some of it may actually be benign, whilst other parts of it may actually show the invasion.

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And if you actually punch biopsy the wrong bit and you get a diagnosis, say, oh, this is just a benign nevus, it's a disastrous false negative, and it can lead to delays in treatments.

00:16:14.028 --> 00:16:15.028
And this has happened.

00:16:15.438 --> 00:16:19.038
Pigmented lesion, punch biopsy, it was called benign on the punch.

00:16:19.438 --> 00:16:25.188
But it actually because missed the malignant bit and the patient presents like a year later with metastatic melanoma.

00:16:25.778 --> 00:16:30.538
So excisional biopsy for suspicious pigmented lesions, if at all possible.

00:16:31.328 --> 00:16:34.428
So there's not a concern that it might spread the melanoma by doing a punch?

00:16:34.578 --> 00:16:34.899
No.

00:16:35.479 --> 00:16:37.489
So you don't spread melanomas by punch.

00:16:37.839 --> 00:16:39.349
It's been untruly proven.

00:16:39.408 --> 00:16:40.249
That doesn't happen.

00:16:40.289 --> 00:16:41.499
It's a misdiagnosis.

00:16:42.168 --> 00:16:42.729
Okay.

00:16:43.219 --> 00:16:43.788
Excellent.

00:16:44.139 --> 00:16:47.109
And the other cancers themselves, they're fairly straightforward.

00:16:47.109 --> 00:16:47.499
So

00:16:47.539 --> 00:16:53.899
if we talk about basal cell cancers, the majority of basal cell cancers are treated by excisions with clear margins.

00:16:54.349 --> 00:16:57.759
Superficial basal cell carcinomas can be treated reasonably well.

00:16:58.119 --> 00:16:59.889
with a medication called Imiqumod.

00:16:59.889 --> 00:17:01.129
This is a topical treatment.

00:17:01.619 --> 00:17:03.948
You apply it for a six week period.

00:17:03.969 --> 00:17:06.259
It causes quite a lot of inflammation.

00:17:06.638 --> 00:17:12.618
And, uh, essentially, Imiquumod stimulates the body's immune system to kill the basal cells and to clear them.

00:17:12.638 --> 00:17:14.608
So, the clearance rate is about 80%.

00:17:15.148 --> 00:17:16.588
It's pretty good, okay?

00:17:16.588 --> 00:17:20.598
Particularly in, in areas where surgery is considered difficult.

00:17:20.838 --> 00:17:22.740
For example, the lower limbs.

00:17:22.779 --> 00:17:26.289
But we use them primarily in low risk lesions in low risk areas.

00:17:26.874 --> 00:17:31.003
So, on the trunk, on the limbs, imicumot will work quite well.

00:17:32.034 --> 00:17:36.334
And it has to be superficial basal cell, so not an invasive nodular basal cell carcinomas.

00:17:37.044 --> 00:17:37.434
And what about

00:17:37.454 --> 00:17:39.574
SCCs for cryotherapy, is

00:17:40.003 --> 00:17:40.744
that even used?

00:17:40.884 --> 00:17:49.984
Okay, so if we talk about squamous cell cancers, invasive SCCs, there's only one treatment that I, I would recommend if at all possible, and that's actually surgical excision.

00:17:50.644 --> 00:17:53.824
Because the risk of metastatic diseases is present.

00:17:54.544 --> 00:18:00.183
So, if you got an invasive SCC in the head and neck area, it needs surgical excision with a good margin.

00:18:00.263 --> 00:18:02.463
That's the, the only thing that I would recommend.

00:18:03.074 --> 00:18:12.384
If you have lower risk SCCs, for example, multiple small SCCs on arms and lower limbs, potentially they can be curated off.

00:18:12.933 --> 00:18:15.944
You can try cryotherapy, but it's a higher risk situation.

00:18:15.954 --> 00:18:16.954
They tend to recur.

00:18:17.364 --> 00:18:19.174
And if they recur, you'd have to excise them.

00:18:19.744 --> 00:18:24.364
And unfortunately, not a lot else has been described for SCCs there.

00:18:24.729 --> 00:18:27.038
It's still the night, primarily the night.

00:18:28.048 --> 00:18:28.349
Obviously,

00:18:28.349 --> 00:18:33.949
there's a lot more to skin cancer than just this little bit, but so we'd refer you to Spot Diagnosis for more information.

00:18:33.949 --> 00:18:34.388
Yeah,

00:18:34.638 --> 00:18:35.259
absolutely.

00:18:35.999 --> 00:18:37.509
Next, we can talk about the other condition,

00:18:38.249 --> 00:18:40.239
the other one that you might see commonly is acne.

00:18:40.239 --> 00:18:41.499
Do you see a lot of that as well?

00:18:42.429 --> 00:18:42.699
Yeah, I

00:18:42.699 --> 00:18:43.848
see a lot of acne.

00:18:43.849 --> 00:18:44.179
Yeah, absolutely.

00:18:44.179 --> 00:18:56.894
So, Acne, it's, it's considered the most common skin disease because the epidemiology is like about 80 to 85 percent of young people from 12 to 25 will have some degree of acne.

00:18:56.984 --> 00:18:58.835
So it's really almost universal.

00:18:59.604 --> 00:19:01.564
Now again, it's a spectrum, right?

00:19:01.574 --> 00:19:11.964
So if you take a hundred kids, probably about 80 of the hundred kids will have mild acne, maybe which can be treated reasonably well with over the counter treatments like benzoyl peroxide.

00:19:13.298 --> 00:19:25.769
In amongst the spectrum, you're going to have the extreme ones, so about 10 percent have increasingly severe acne, nodular cystic acne, with a lot of scarring, and those ones are going to need further treatment apart from over the counter drugs.

00:19:25.778 --> 00:19:34.979
So the options would include oral antibiotics, topical retinoids, um, if you're female, contraceptive pills and anti androgens.

00:19:35.429 --> 00:19:37.429
And then the most commonly used.

00:19:37.794 --> 00:19:44.054
medication that is effective in severe acne is isotretinoin, also known as orotane or roacutane.

00:19:45.273 --> 00:19:54.394
So the roacutane obviously has a sort of a stigma about it of having some side effects, but I believe that it's not quite as common these side effects as what people think they are.

00:19:54.394 --> 00:19:55.453
Yeah, yeah.

00:19:55.693 --> 00:19:55.894
Look,

00:19:55.943 --> 00:20:02.023
it was very interesting when early on when I had a chat with you over the phone, I said, Oh, we use quite a lot of roacutane.

00:20:03.068 --> 00:20:07.038
I think you said, Oh, isn't that associated with depression and yeah, correct.

00:20:07.098 --> 00:20:12.019
And this is one of those kind of myths about, uh, raocutane.

00:20:12.500 --> 00:20:22.630
Um, it, it, the reality is that racutane is actually less likely to cause depression than severe acne.

00:20:22.750 --> 00:20:23.059
Okay.

00:20:23.108 --> 00:20:31.970
I think I, I sent you some information about a study where they looked, this is a, a huge study where they looked at a couple of thousand kids in Norway.

00:20:31.970 --> 00:20:32.210
Yeah.

00:20:32.279 --> 00:20:33.269
And they found that.

00:20:33.805 --> 00:20:42.664
These are about 4, 718 to 19 year olds and they looked at kids with substantial acne versus kids with minimal acne.

00:20:42.694 --> 00:20:46.503
So substantial acne, about 15 percent of those kids had substantial acne.

00:20:47.023 --> 00:20:50.814
And they found that the risk of suicidal ideation has increased 1.

00:20:50.815 --> 00:20:52.575
8 times, mental health problems increased like 2.

00:20:53.565 --> 00:20:55.515
25 times, low attachment 1.

00:20:55.515 --> 00:20:56.375
5 times.

00:20:56.414 --> 00:21:21.058
So severe acne itself can cause a lot of mental health issues as well as social issues and isotretinoin or roaccutane is the best treatment for this type of acne and there have been multiple meta analyses done which show that roaccutane does not actually increase the risk of depression per se.

00:21:21.669 --> 00:21:24.529
In this group of patients you really have a slightly more high risk.

00:21:25.564 --> 00:21:35.534
Now you can have very rarely someone takes racutane and they develop some mental health issues, but that is actually fairly uncommon.

00:21:35.534 --> 00:21:40.773
I've only had to stop a handful of patients in 20 years of dermatology practice.

00:21:41.324 --> 00:21:45.193
Usually, they would use a low dose, we guide them through.

00:21:45.544 --> 00:21:50.954
If a patient has pre existing depression, we often co manage them with a mental health professional.

00:21:51.523 --> 00:21:57.244
And once the acne clears, you can see them change, their outlook on life changes, often just blossom.

00:21:57.763 --> 00:21:59.144
It's quite a remarkable drug.

00:21:59.904 --> 00:22:00.324
So with

00:22:00.334 --> 00:22:06.503
this algorithm of treatments options, the old scarred acne, does that still occur or is it less commonly now?

00:22:07.364 --> 00:22:09.273
Yeah, I think it's a lot less common.

00:22:09.304 --> 00:22:23.263
All of us remember when we were growing up, looking at patients with terrible acne and almost no treatment, and they end up with their face full of scars or back full of scars, I think the good thing nowadays is that.

00:22:24.463 --> 00:22:33.903
The medical community is a lot, uh, more cognizant of treatments and they're less likely to allow it to get to that stage.

00:22:34.273 --> 00:22:43.934
And the other thing is also parents, parents now far more likely to seek help early on in a patient's acne journey rather than waiting for the scars to develop.

00:22:44.824 --> 00:22:45.523
That's brilliant.

00:22:45.703 --> 00:22:46.124
Sorry.

00:22:46.523 --> 00:22:48.244
Certainly there's options available.

00:22:49.148 --> 00:22:51.439
What other conditions do you treat that's worth

00:22:51.439 --> 00:22:52.199
mentioning today?

00:22:52.269 --> 00:23:06.469
The kind of conditions that I see a lot of, because they are quite common, the kind of inflammatory skin diseases and the way that psoriasis, for example, has been treated over the last 10 years is nothing short of miraculous.

00:23:07.239 --> 00:23:09.579
We know what psoriasis is, I'll just run it through with you.

00:23:09.579 --> 00:23:16.398
This is a inflammatory disease, yeah, where you get red plaques, often quite itchy on extensive surfaces.

00:23:16.798 --> 00:23:19.569
So they cover your arms, your legs, your back.

00:23:20.493 --> 00:23:27.453
Their scalp, it's always there, it's itchy, it's scaly, it's flaky and it affects 5 percent of the population.

00:23:27.463 --> 00:23:39.943
So quite a lot of people and, and like in any disease, if it's mild, it's not too bad, but we see quite severe psoriasis where patients are covered with this red rash and it stigmatizes them.

00:23:39.964 --> 00:23:41.084
They can't go anywhere.

00:23:41.084 --> 00:23:42.324
They can't wear t shirts.

00:23:42.324 --> 00:23:43.164
They can't wear shorts.

00:23:43.584 --> 00:23:46.584
If it's on the scalp, they, they shed dandruff everywhere.

00:23:47.144 --> 00:23:53.673
And I've got patients who have spent 20 years of their lives, not knowing what their normal skin looks like.

00:23:53.845 --> 00:23:54.164
Okay.

00:23:54.284 --> 00:23:57.794
So it is absolutely horrendous, itchy all the time.

00:23:57.824 --> 00:24:06.314
Every time I take their clothes off, there's a pile of scale, and I know their partners often have to go around with a vacuum cleaner just chasing after them.

00:24:06.743 --> 00:24:10.694
It is stigmatizing and absolutely debilitating.

00:24:11.348 --> 00:24:17.169
So, about 15 years ago, the first biologic treatment for psoriasis was found, okay?

00:24:17.169 --> 00:24:19.638
And this was a TNF alpha inhibitor.

00:24:20.348 --> 00:24:30.459
So with this new treatment, it's given us an infusion, and within weeks, the patient is completely clear of psoriasis, and it's a miraculous drug.

00:24:31.059 --> 00:24:35.179
And we're currently in a golden era of these biologic treatments.

00:24:35.179 --> 00:24:35.579
And so...

00:24:36.028 --> 00:24:47.939
We now can use these injectable drugs and they not only block TNF alpha, they also block interleukin 17, interleukin 23, and they're all given subcutaneously in different intervals.

00:24:47.989 --> 00:24:52.078
One of these medications, risincuzumab, is given one injection every three months.

00:24:52.689 --> 00:24:56.308
And they have been nothing short of astonishing, astonishing.

00:24:56.308 --> 00:24:59.189
So imagine if you're completely covered with psoriasis.

00:24:59.674 --> 00:25:04.224
You come and you get given one of these medications and it clears you.

00:25:04.275 --> 00:25:08.204
And as long as you're on it, like one injection every three months, you remain clear.

00:25:09.074 --> 00:25:09.354
Okay.

00:25:09.355 --> 00:25:13.295
So that's the type of response we're getting as close to a cure as you can get.

00:25:14.065 --> 00:25:16.994
And it is, it's revolutionized the way we treat psoriasis.

00:25:18.845 --> 00:25:26.025
Is it because psoriasis is an autoimmune disorder that this is an anti immune reaction or a immune suppressive type effect?

00:25:26.035 --> 00:25:28.815
So psoriasis is very polygenic and.

00:25:29.354 --> 00:25:32.163
And the way psoriasis works is there's two parts to it, okay?

00:25:32.163 --> 00:25:35.923
There's a lot of inflammation and there's a lot of proliferation of skin.

00:25:36.454 --> 00:25:38.464
And they have these pathways.

00:25:38.824 --> 00:25:42.534
So the psoriasis pathway, they found these cytokines, okay?

00:25:42.534 --> 00:25:46.864
So the interleukins, which are a part of the whole psoriasis cascade.

00:25:47.525 --> 00:26:10.663
And what the investigators have found is that if you actually block one of these interleukins, for example, interleukin 17 or interleukin 23, You basically just stop the whole process dead, but because it is so specific, you're only blocking a very small part of the immune pathway, the, you don't get the kind of massive immunosuppression like you get with, let's say, methotrexate or cyclosporine.

00:26:11.234 --> 00:26:11.484
Okay.

00:26:11.484 --> 00:26:16.364
So it's very targeted immunotherapy and it is incredibly effective.

00:26:17.183 --> 00:26:17.624
Wow.

00:26:18.443 --> 00:26:18.564
It's

00:26:18.564 --> 00:26:19.364
pretty amazing.

00:26:19.784 --> 00:26:20.483
It is amazing.

00:26:21.663 --> 00:26:24.874
So, what about the role of the ultraviolet treatment in

00:26:25.003 --> 00:26:25.983
treatment of psoriasis?

00:26:26.003 --> 00:26:32.334
While I've been raving about these biologic treatments, there is a catch, okay, and there's always a catch.

00:26:32.364 --> 00:26:33.693
They are really expensive.

00:26:33.794 --> 00:26:44.023
So, if I put a young man on a medication like risincuzumab, it will cost the government approximately 20, 000 Australian per year for the rest of his life, okay?

00:26:44.489 --> 00:26:49.259
So, there are certain types of limitations and cost is one of them.

00:26:49.279 --> 00:26:55.609
We still have to show that the patients have, number one, severe enough psoriasis and they fail conventional treatments.

00:26:55.609 --> 00:27:02.578
So conventional treatments would include things like ultraviolet light treatment or methotrexate or acetretin or cyclosporine.

00:27:03.019 --> 00:27:09.538
If we fail two out of the available treatments, then we can then apply for a biologic treatment.

00:27:10.459 --> 00:27:12.509
So we still use the ultraviolet light treatments.

00:27:12.983 --> 00:27:15.413
as a form of first and second line treatment.

00:27:15.864 --> 00:27:21.374
And if someone's psoriasis clears an ultralight treatment, we don't have to put them on lifelong injections.

00:27:23.069 --> 00:27:24.128
But if they don't, we can.

00:27:25.450 --> 00:27:29.888
And for the medical student, the ultraviolet treatment doesn't involve just going out in the sun and sunbaking.

00:27:29.888 --> 00:27:31.119
It's a little bit more to it than that.

00:27:31.599 --> 00:27:32.189
Can you perhaps

00:27:32.189 --> 00:27:33.409
outline about what that involves?

00:27:33.659 --> 00:27:34.239
Yeah, sure.

00:27:34.318 --> 00:27:37.999
Ultraviolet light is basically a component of sunlight.

00:27:38.019 --> 00:27:42.329
Okay, so you have UVA and UVB and UVC.

00:27:42.398 --> 00:27:46.089
Okay, so UVC, it's deadly and filtered out by the atmosphere.

00:27:46.564 --> 00:27:49.284
So we usually have UVB and UVA.

00:27:50.064 --> 00:27:54.964
In the past, we used to do something called PUVA and PUVA.

00:27:55.273 --> 00:28:07.064
So the P stands for Psoralen, where you take a tablet called a Psoralen and that actually makes you more sensitive to sunlight and then you stand in a, in a UVA booth and you get a wavelength UVA.

00:28:07.808 --> 00:28:08.769
To clear the skin.

00:28:09.038 --> 00:28:19.219
So what the U V A does is actually produces a local immunosuppression of the skin where it's shown, and that's very effective against psoriasis, eczema, things like cutaneous T-cell lymphoma.

00:28:20.259 --> 00:28:33.249
But it's very tricky because once you take a sorein, it's gonna be in your system for 12 to 24 hours, and everywhere you go, you need to be sun protection, you need to wear sunglasses because you can take a soul and walk under the sun and you get a bad burn.

00:28:33.929 --> 00:28:37.828
So it's been superseded by something called U V B treatment.

00:28:38.253 --> 00:28:45.943
UVB is a wavelength where, which can actually cause skin cancer, but it also causes an immune system to calm down.

00:28:46.523 --> 00:28:52.064
And there is a wavelength which we particularly like, the 319 nanometers, treatment.

00:28:52.554 --> 00:28:53.933
That is a lot less of a hassle.

00:28:54.193 --> 00:28:59.294
You go three times a week, we start low and we gradually increase the dosage.

00:28:59.669 --> 00:29:03.729
And what it does is it helps to clear, dampen the immune system locally.

00:29:03.789 --> 00:29:05.099
So you clear the cirrhosis.

00:29:05.378 --> 00:29:15.459
The problem, if you have a lot of UV treatments, and if you have susceptible skin, Caucasian skin that burns easily, you're going to open yourself up potentially to risk of skin cancer.

00:29:15.479 --> 00:29:20.999
So it's always a bit of a, that's a risk benefit ratio, catch 22, you know.

00:29:21.028 --> 00:29:22.409
So we still use that, by the way.

00:29:23.179 --> 00:29:24.009
So the ultraviolet

00:29:24.019 --> 00:29:25.759

A/Prof Alvin Chong

A/Prof Alvin Chong Dermatologist

Assoc. Prof. Alvin Chong is a Specialist Dermatologist in Melbourne, Victoria. He has appointments as VMO at St Vincent's Hospital Melbourne and Skin Health Institute. He is also Adjunct Associate Professor at the University of Melbourne Alvin is the creator and co-host of Spot Diagnosis Podcast spotdiagnosis.org.au

Exploring Dermatology with A/Prof Alvin Chong from Spot Diagnosis podcast: From Skin Cancer to Sun Protection

A/Prof Alvin Chong

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