Global Dermatology

Contributions from WCD2023 Ambassadors

Collection of articles about dermatology from all over the world. Dermatology beyond borders.

Prof. Jouni Uitto (1943-2022)
In Memoriam

By Prof. Chee Leok Goh, Honorary President 25th WCD

It is with deep sadness that we were informed that Prof JouniUitto passed away recently.  The dermatology fraternity has lost a great, a well-loved colleague and a good friend. Those of us who knew Prof Uitto will forever remember his contagious and pleasant disposition. He was always cheerful and was always encouraging fellow colleagues and juniors to do more and better by his own examples.  There was never a boring moment when we were in his company.  We would hear his voice in all the social and academic functions and gatherings.  Everybody would gravitate around him to join in conversation. He was frequently invited to share because of his intellectual prowess and his friendly predisposition.  He would put everyone at ease and accepted requests whenever he could. He was a person with a big heart and warm laughter.

The organizer of WCD is sad to hear of Prof Uitto’s passing.  He was WCD’s long-time supporter and a WCD ambassador.  He was a great teacher in clinical dermatology and molecular biology. WCD was looking forward to his promotion and contribution to the recent developments in molecular biology and some bullous disorders. I first met Prof Uitto when he visited the National Skin Centre (NSC), Singapore in early 1990.  I found out that Prof Uitto’s wife, Elaine, was a Singaporean Chinese and that she travelled to Singapore periodically.  They have three lovely children.  Subsequently we were fortunate to have him visit us as NSC to conduct teaching in dermatology periodically. He was invited to be NSC’s visiting expert and spent 3 weeks in August/September 1994. During his attachment he conducted a series of lectures and tutorials on molecular biology and gene therapy and taught us everything about basement membrane disease. We all became experts in type VII collagen. We learnt a lot from him. At the end of his attachment, he professed that he had never given so many lectures and seen so many patients during an attachment.  He continued to visit NSC and conducted clinical teaching whenever he visited his in-law’s family in Singapore.  Prof Uitto was a great teacher and mentor. His teaching and warmth were unparalleled and very much appreciated everywhere.

Prof Uitto received his medical degree from University of Helsinki Faculty of Medicine and later in 1986 became the Chairman of the Department of Dermatology of the renowned Jefferson Medical College, Philadelphia. He was also Professor of Biochemistry and Molecular Biology.  He held many other clinical, academic and research positions in his career and in so shaped modern dermatology. He was a well-liked and well-recognized expert on collagen biology and elastic tissue.  He pioneered the application of genetic techniques to treat skin disorders such as epidermolysis bullosa and other genodermatoses.

In addition to his scientific pursuits, Prof Uitto was a tremendous teacher and mentor to many young dermatologists and skin biologists. We will miss his knowledge, collegiality, and unmistakable laughter. He received many prestigious academic awards. He was internationally recognized for research on connective tissue biochemistry and molecular biology in skin diseases and skin aging.   He will be sorely missed in the dermatology world.  We offer our sincere condolences to Elaine and her family for the passing of their beloved Prof Uitto.

International collaborations disclose the mystery of the treeman syndrome

Most dermatologists are very familiar with cutaneous warts, common benign lesions caused by human papilloma virus (HPV) infections. Most HPV infections are self-limited, and mild symptomatic lesions spontaneously resolve over months after the initial, subclinical infection. Occasionally, however, some skin-tropic HPVs cause overt cutaneous epithelial hyperproliferation, known as common warts, and they can affect as many as 20 percent of individuals in the general population at any given point of their life. Common cutaneous warts usually resolve spontaneously, but some of these lesions, defined as recalcitrant warts (RW), persist despite repeated treatments. In some cases, there is a familial susceptibility to development of warts, as in epidermodysplasia verruciformis (EV), a genetic disorder characterized by the presence of numerous flat warts in generalized distribution. In exceptional cases, the warts can also transform into cutaneous giant horns resulting in a phenotype known as the tree-man syndrome (TMS). This very rare condition was initially characterized and dubbed as TMS in an Indonesian patient by Dr. Anthony Gaspari, then the Chair of the Department of Dermatology at the University of Maryland in Baltimore, MD and currently a faculty member of Thomas Jefferson University.

The persistence of HPV-related warts and horns in TMS suggests the presence of an underlying single gene disorder of impaired immunity to cutaneous HPVs. Thus, in sporadic and familial cases it was postulated that proliferation of a common pathogen, HPV, is not efficiently controlled by the patient’s aberrant immune system. In support of this notion, several inborn errors of immunity with cutaneous warts have been identified, highlighting the role of T lymphocytes in the cutaneous anti-HPV immune response. In addition, the genetic basis of EV has been recently demonstrated to involve a number of mutated genes encoding proteins critical for keratinocyte-intrinsic or T cell-based immunity to HPVs.

The genetic etiology of TMS has recently been described, and the scientists in the Department of Dermatology of Cutaneous Biology at Thomas Jefferson University in Philadelphia, in collaboration with a large international group of geneticists and physician-scientists representing 10 different countries, have contributed to identification of the molecular basis of TMS. The team, led by a world renown expert in primary immune deficiencies, Professor Jean-Laurent Casanova with laboratories at Rockefeller University in New York and in Imagine Institute of the University of Paris, studied a multiplex family from Iran with two members with extensive warts and a third family member with giant cutaneous horns. The latter patient was diagnosed as TMS apparently inherited in an autosomal recessive pattern. Extensive studies utilizing state-of-the-art approaches of the next-generation sequencing, combined with sophisticated immunological techniques, as detailed in the July 8, 2021, issue of the Cell (Beziat et al., 184: 3812-3828, 2021), revealed a discrete homozygous amino acid substitution mutation in the CD28 gene expressed in the T cells. The parents were heterozygous carriers of the mutation, confirming the autosomal recessive inheritance. The difference in the severity of the affected individuals may be explained by the types of HPVs associated with their lesions: The multiple, unusually severe warts in the two patient were associated by HPV4 infections, while the TMS patient’s lesions yielded HPV2. Interestingly, however, the three patients were otherwise healthy, and there was no evidence of generalized immune deficiency, suggesting that human CD28-dependent T cell responses are largely redundant for protective immunity, but selectively allow development of HPV-driven pathology in the form of multiple warts and giant cutaneous horns. Collectively, these observations attest to the phenotypic spectrum of cutaneous HPV infections at the intersection of mutant genomes and aberrant immunity. This international, multidisciplinary work continues to examine additional challenging cases in the spectrum of HPV-associated cutaneous infections, including TMS, and we look forward of having the opportunity to present our latest findings in the 25th World Congress of Dermatology 2023 in Singapore.

“The colour of beauty is the colour you own” – A step to combat colourism by the Sri Lanka College of Dermatologists

Since the European occupation, “fair skin” has been considered an ideal of beauty and supremacy in Sri Lanka. In the recent past, this sociocultural belief has been strengthened by advertisements of the skin fairness industry. This concept of colorism had led to discrimination, low self-esteem, and body shaming among young adults causing numerous psychosocial issues.

Most of the skin lightening agents are not stringently regulated or controlled by the authorities and widely marketed through social media. The harmful substances identified in these products are hydroquinone, steroids and heavy metals. Intravenous Glutathione is widely used for skin lightening purposes across the country, though it is not registered by the National Medicines Regulatory Authority for this purpose.

As dermatologists, we have noticed the adverse effects stemming from the use of skin lightening agents within the public. To combat this, the Cosmetic Dermatology subcommittee of Sri Lanka College of Dermatologists (SLCD) planned a public awareness campaign to promote natural skin colour & its benefits and to educate them on the harmful effects of skin lightening treatments. Our ultimate goal is to help people to be proud of their skin colour and to reduce the discrimination faced by dark-skinned individuals in society. The public awareness campaign themed “Colour of Beauty is the Colour You Own “was launched on the 22nd of January 2022, with the patronage of His Excellency the President of Sri Lanka, officials from the Ministry of Health, dermatologists, psychiatrists, oncologists, celebrities and other public figures. A social media campaign was started with attractive content in the form of animations, still images and videos disseminating the message to the target groups. Members of the Sri Lanka College of Dermatologists actively participated in discussions through electronic media and wrote articles in printed media on the above subject.

Our message will be disseminated in the form of posters and leaflets to the young women in the apparel industry since they were identified as one of the target groups. We extend our sincere gratitude to the ILDS for funding the poster campaign.

We have taken measures to spread the message among school children in liaison with the Ministry of Education, as secondary school students were identified as another core audience.  Sri Lanka Girls Guides association, Interact Club, and Sri Lanka National Youth Award Authority have already consented to support the initiation taken by SLCD. Island wide awareness among university students will be done through their social media platforms.

A special webinar will be arranged for beauticians to make them aware of the consequences of skin lightening agents.

For the sustainability of the project, SLCD is working in collaboration with the Health Promotion Beurre of the Ministry of Health Sri Lanka.  SLCD also plays a pivotal role in giving expert opinion on registration, and marketing of the skin lightening agents in National Medicines Regulatory Authority and Consumer Affairs Authority. We do believe that the regulatory process will become more stringent in the future, with pressure on the officials by the educated general public.

As the professional organization responsible for skin health, we believe SLCD has succeeded in imparting this message of the importance of appreciating one’s skin colour. It is heartening to see the positive comments by other medical professionals, social media influencers and the general public. We hope to continue our campaign with extra vigor, to convince the younger generation to be proud of their skin colour without resorting to superfluous use of skin lighting products.

Dr. Chandani Udagedara
President, Sri Lanka College of Dermatologist