Skin – a reflection of the internal organs and other diseases

The skin separates the human body from harmful environmental factors and can also reflect processes occurring within the body. Changes in skin condition are therefore closely linked to internal medicine. As environmental factors continue to change, the prevalence of chronic inflammatory skin diseases is increasing. These conditions reduce quality of life because patients experience significant emotional distress and social difficulties, while treatment is not always successful.

We discussed the main challenges faced by dermatologists, the possibilities offered by the most advanced methods of treating skin diseases and introducing them into clinical practice, and other relevant issues in dermatology and venereology with Prof. Skaidra Valiukevičienė, Head of the Department of Skin and Venereal Diseases at the Medical Academy of the Lithuanian University of Health Sciences.

You Continue Your Work Without Breaking Tradition: As Every Autumn, This Year You Have Invited Colleagues in Dermatovenereology and Other Specialists to an Interdisciplinary Conference Taking Place in Kaunas on October 24. What Is the Main Goal of This Event, and Which Current Issues Will Receive the Most Attention?

Indeed, we are continuing the tradition. Every autumn, we invite colleagues in dermatology and other specialists to an interdisciplinary conference. The event is organized by the Lithuanian University of Health Sciences, Vilnius University, the Lithuanian Dermatovenereology Society, and the Lithuanian Psoriasis Association.

The main goal of the national conference “Current Issues in Dermatology and Venereology,” taking place in Kaunas on October 24, is to commemorate World Psoriasis Day, which was first observed in Lithuania in 2004. The commemoration of World Psoriasis Day was initiated and continues to be supported by the International Federation of Psoriasis Associations. Its aim is to draw attention to the high prevalence of this chronic, incurable disease and to the need for medical specialists, policymakers, and the public to address the social exclusion experienced by people with psoriasis.

The first part of the conference will review experience and innovations in traditional systemic therapy and biological treatment for psoriasis, as well as the importance of biological markers in the course of the disease. Members of the Lithuanian Psoriasis Association are invited to participate actively and will hold a meeting of association members before the conference.

The second part of the event will present the epidemiological situation of acne among young people and adult women, discuss aspects of its pathogenesis and treatment, and share experience from rare clinical cases.

A satellite interdisciplinary seminar will also present the results of the European Union Seventh Framework Programme scientific project “SkinDetector.” The project is being carried out by the Department of Skin and Venereal Diseases, the Institute of Endocrinology, and the Department of Neurology at the Lithuanian University of Health Sciences, in cooperation with physicists from the K. Baršauskas Ultrasound Research Institute at Kaunas University of Technology, endocrinologists from the University of Dresden, and equipment manufacturers from small companies in England, Spain, Finland, Greece, and Ireland.

The project aims to develop and apply equipment for monitoring the biophysical parameters of the skin in patients with diabetes. Clinical studies show that the combined assessment of skin thickness and temperature in three-dimensional space may be useful in clinical practice for monitoring diabetic foot complications.

It Is Always Interesting to Hear Presentations From Colleagues and Internationally Recognized Specialists. What New Information Do You Expect From Them? How Important Is It in Shaping New Trends in the Diagnosis and Treatment of Skin Diseases in Lithuania?

Our lecturers provide a great deal of new information, but it is always interesting to learn what is happening farther away, in other countries.

For many years, we have had the ambition to develop and strengthen the field of trichology, the science of hair, in Lithuania. Although hair is part of the skin, it has been undeservedly neglected. Trichology research and clinical practice are developing rapidly in Europe, and many technologies are being introduced for the diagnosis and treatment of hair disorders.

During the conference, the renowned trichology specialist Prof. Dr. Ulrike Blume-Peytavi, Head of the Hair and Cosmetic Dermatology Institute at Charité University in Berlin, will provide an extensive overview of current issues in the diagnosis and treatment of androgenetic alopecia.

Androgenetic alopecia is a form of hair loss caused by an abnormal response of the hair follicles to circulating male sex hormones, or androgens. These hormones cause the hair follicles from which hair grows to shrink, and new hair no longer grows from them. An increased number of androgen receptors and greater activity of the enzyme 5α-reductase have been found in the hair follicles. Patients complain of thinning hair and slower hair growth on the scalp. Androgenetic alopecia can occur in both men and women.

Another colleague with whom we have collaborated for five years is Prof. Dr. Wolfgang Uter, Head of the European Surveillance System on Contact Allergies project at the University of Erlangen-Nuremberg in Germany. He will present the results of European contact dermatitis surveillance, including prevalence and sensitization to various allergens, and will share perspectives on the treatment of this disease.

It will be useful to hear new information about the prevalence of contact dermatitis in European countries, including Lithuania, and about the challenges of controlling occupational contact dermatitis.

I Would Like to Discuss Psoriasis Separately, an Incurable but Manageable Condition, Often With Very Good Results. What Positive Changes Can You Identify for Patients?

Psoriasis is a classic dermatological problem that receives particular attention for several reasons. First, it is an incurable disease affecting approximately 2% of the population. It is also distinctive because it can cause disabling arthritis.

Psoriatic arthritis affects approximately 25% of patients with psoriasis involving the skin and joints. Psoriasis has been identified as a hereditary autoimmune disease that can be controlled by blocking chronic inflammation with biological medications, including tumor necrosis factor-alpha inhibitors and interleukin-22, interleukin-23, and interleukin-17 inhibitors.

It has been found that psoriasis beginning before the age of 40, particularly in patients with a family history of the disease, is more likely to lead to arthritis. The course of psoriasis is difficult to predict. It reduces quality of life and may cause disability.

Studies show that psoriasis, regardless of its severity, has a negative effect on patients’ quality of life comparable to that of chronic heart disease, diabetes, and malignant tumors. The skin lesions are visible to others, so patients ask us to emphasize that psoriasis is not contagious. The public needs to know this.

People with psoriasis sometimes face unjustified restrictions in the service sector or the workplace. Children may also exclude peers with psoriasis. As a result, the condition can cause significant social isolation.

A major change in the management of psoriasis in Lithuania occurred in 2011, when a budget was approved for centrally funded biological medications for the treatment of severe psoriasis. It is encouraging that opportunities to treat severe psoriasis with biological medications are gradually increasing in Lithuania. At present, 89 patients are receiving these medications, which have been purchased for them.

Biological medications for severe psoriasis are prescribed when traditional systemic treatment is ineffective. Decisions on prescribing biological therapy are made by councils of dermatologists at the university hospitals in Kaunas and Vilnius.

Treatment with these medications is long-term and continuous. Therefore, patients recommended for biological therapy must be selected very carefully after all traditional treatment methods have been tried.

Many topical medications for psoriasis are available in Lithuania, including newer-generation preparations such as glucocorticoids and vitamin D analogues, and 80% of their cost is reimbursed. When traditional medications and phototherapy, or treatment with ultraviolet radiation, fail to control the disease and maintain a good quality of life, the immediate possibility of prescribing biological therapy should be considered.

Timely intervention is essential in psoriasis treatment. Tumor necrosis factor has been shown to play an important role in the development of both psoriasis and ischemic diseases. It is also produced by adipose tissue. Therefore, people with severe psoriasis are more likely than control participants to experience myocardial infarction and hypertension, and psoriasis is more difficult to control in patients who are overweight.

Two-thirds of psoriasis cases are mild to moderate, and family physicians can provide substantial support to these patients. Family support is also important, as is sharing experiences with other people living with the same condition.

What Other Diseases Receive Increased Attention From Dermatologists in the Autumn? After All, the Season Has a Significant Influence on Skin Diseases, Doesn't It?

Many skin diseases exhibit a clear seasonal pattern. During the autumn, when there are fewer sunny days, chronic inflammatory skin diseases—particularly psoriasis—often worsen, and the number of more complex cases increases.

There is also a noticeable rise in the number of patients seeking medical attention for atopic dermatitis, a genetically determined inflammatory skin disease. The development of atopic dermatitis is influenced by the complex interaction of several factors, including alterations in cellular and humoral immune responses, changes in the skin microbiome—particularly overgrowth of Staphylococcus aureus on damaged skin—and exposure to food, environmental, airborne, and contact allergens.

An interesting finding is that atopic dermatitis is associated with mutations in filaggrin, a structural protein of the epidermis. Numerous studies have shown that filaggrin mutations are particularly common among fair-skinned populations. Consequently, severe atopic dermatitis occurs much less frequently in people with darker skin than in those with fair skin.

Lithuanians are no exception, particularly because environmental factors have a considerable influence on both individuals and their skin. At present, this situation remains unchanged.

Autumn exacerbations of psoriasis and atopic dermatitis require targeted treatment. Restoring the skin barrier with emollients, using topical immunomodulatory agents—which are suitable for long-term use and may also be used in children with atopic dermatitis—and combining vitamin D analogues with topical glucocorticoids for psoriasis, together with phototherapy, can effectively control these chronic inflammatory skin diseases.

It is also important not to overlook other skin disorders that commonly worsen during autumn, including acne, herpes simplex infections (cold sores), chronic hand eczema, and others.

Sexually Transmitted Infections Are Another Important Area of Dermatovenereology. How Do You Assess the Current Epidemiological Situation? What Concerns Specialists, and What Do You Expect for the Future?

Sexually transmitted infections (STIs) represent the historical foundation of dermatovenereology. These diseases were initially recognized through characteristic skin manifestations in infected individuals and their transmission through sexual contact.

Today, STIs remain a major public health concern. Population mobility, socioeconomic factors, and changing sexual behaviors all contribute to their continued spread. Surveillance is further complicated because different infections may be transmitted through sexual contact, blood exposure, household contact, pregnancy, or childbirth.

Any STI also facilitates transmission of human immunodeficiency virus (HIV).

The epidemiological situation of STIs in Lithuania has not improved. HIV infection has even been diagnosed in minors. At Kaunas Clinics, we treat approximately five patients with neurosyphilis each year, and isolated cases of congenital syphilis still occur.

For this reason, we traditionally dedicate part of our conference program to venereology.

Interestingly, Sweden reports approximately twice as many newly diagnosed STIs as Lithuania. We believe this reflects several factors.

In Lithuania, STI statistics likely underestimate the true burden because epidemiological surveillance remains incomplete, and access to modern diagnostic testing for high-risk groups—including young people, victims of sexual violence, and individuals already diagnosed with one STI who require screening for others—is still insufficient. The cost of STI testing substantially exceeds the reimbursement for a tertiary-level dermatovenereology consultation.

In Sweden, STI testing is readily accessible, particularly for young people, resulting in higher detection rates.

According to the Lithuanian Centre for Communicable Diseases and AIDS, Lithuania recorded 190 cases of gonorrhea in 2013 (219 in 2012), 306 cases of chlamydia (265 in 2012), 269 cases of syphilis (227 in 2012), and 177 newly diagnosed HIV infections (160 in 2012).

Economic challenges continue to hinder the development of healthcare in Lithuania. Nevertheless, given the growing concerns surrounding infertility and HIV infection among young people, improving STI control should remain a priority.

Undiagnosed and untreated chlamydial infection can lead to chronic pelvic inflammatory disease and ultimately infertility.

We believe that improving access to STI testing within healthcare institutions, together with strengthening sexual education among young people, represents the most appropriate secondary prevention strategy.

We hope to receive continued support from the Ministry of Health, the National Health Insurance Fund, and the Health Affairs Committee of the Lithuanian Parliament in achieving these goals.

Biological Therapy Has Revolutionized the Treatment of Skin Diseases. Is This Innovative Treatment Already Producing Tangible Results? Can You Give Examples From Clinical Practice? Is Access to Biological Therapy Improving?

Biological therapy represents one of the most advanced treatment approaches available—not only for psoriasis but also for controlling advanced melanoma and basal cell carcinoma.

Clinical trials are currently investigating whether biological therapies may also be effective in treating severe atopic dermatitis.

In Lithuania, 89 patients with psoriasis are currently being successfully treated with biological medications.

It is encouraging that access to biological therapy for psoriasis continues to improve each year, and the number of patients eligible for treatment is gradually increasing.

Unfortunately, the same cannot yet be said for biological treatment of advanced melanoma and basal cell carcinoma, where access remains more limited.

Dermatologists Continue to Work Closely With Physicians From Other Specialties in the Management of Complex Chronic Diseases. How Do You Coordinate This Collaboration? What Advice Would You Give to Family Physicians?

Interdisciplinary collaboration is essential in the management of many chronic inflammatory skin diseases and skin cancers.

Dermatovenereology is recognized as both a medical and surgical specialty. Patients with complex diseases often require multidisciplinary decision-making.

For example, dermatologists collaborate closely with rheumatologists when managing psoriasis and also share dermatological knowledge with family physicians.

During continuing medical education projects, family physicians themselves have reported that they would like more education on skin diseases and sexually transmitted infections. These conditions are common, making this knowledge highly relevant to primary care practice.

Dermatologists also work closely with allergists in the management of chronic allergic inflammatory skin diseases and collaborate with endocrinologists when treating acne, vitiligo, and alopecia areata.

Careful assessment of changes in the skin often allows clinicians to recognize underlying internal diseases at an early stage.

I believe that family physicians should diagnose skin diseases within the scope of their professional competencies. However, we should always remember the Hippocratic Oath. If a physician feels that their knowledge or clinical experience is insufficient, it is better not to speculate but to refer the patient promptly to a dermatologist or another appropriate specialist in the patient's best interest.

Finally, I would be pleased to see more family physicians and specialists from other disciplines attending dermatology and venereology conferences. Likewise, dermatologists themselves should actively participate in scientific meetings organized by other medical specialties throughout Lithuania.

Interview by R. Pečeliūnienė

Lithuanian Doctor’s Journal, No. 8