Treatment of Old World cutaneous leishmaniasis with intralesionally injected meglumine antimoniate using a Dermojet device

Pentavalent antimonial compounds, the mainstay in the treatment of the various forms of leishmaniasis, have considerable toxicity, are difficult to administer and expensive. We describe a safe and efficient therapeutic modality using a spring-loaded and air-powered device for the intralesional injection of a high-velocity meglumine antimoniate microspray in a patient with cutaneous leishmaniasis.

Orofacial granulomatosis as the initial presentation of Crohn's disease in an adolescent

Orofacial granulomatosis (OFG) is a rare and heterogeneous clinical condition that presents with chronic swelling of the oral or facial tissues due to granulomatous inflammation. It is histologically characterized by noncaseating giant cell granulomata and epithelioid histiocytes. OFG includes the previously recognized clinical entities of Melkersson-Rosenthal syndrome and cheilitis granulomatosa (Miescher's cheilitis). A consistently effective medical treatment is not currently available. We describe an adolescent patient with a history of recurrent orofacial swelling preceding gastrointestinal symptoms by several years. He exhibited clinical and histological changes consistent with the diagnosis of OFG. It was resistant to standard therapies such as topical corticosteroids. Thorough history taking and clinical examination suggested Crohn's disease (CD), and further tests confirmed the diagnosis. The patient improved promptly after initiating oral treatment for CD with mesalazine and prednisolone. We conclude that OFG may be under- or misdiagnosed since the clinical manifestation may be misleading and its course is independent of or even preceding CD. Thus, patients with OFG should be asked about gastrointestinal symptoms consistent with CD. Those with suspicious symptoms should undergo a careful gastrointestinal evaluation, possibly including enteroclysis and complete gastrointestinal endoscopic examination, especially when the patient's history is conspicuous.

Molecular genetic analysis excludes implantation metastasis of basal cell carcinomas

Basal cell carcinoma (BCC) of the skin is the most common tumor in the white population. A 66-year-old man developed 2 BCCs at the left parietal region of the head and at the helix of the left ear. The 2 lesions matched exactly when pressing the ear against the head, suggesting an implantation metastasis mechanism. Molecular genetic techniques were used to confirm or exclude such a mechanism in this rare clinical constellation. Tumor tissues were precisely microdissected for DNA isolation. Exons 5-9 of the p53 tumor suppressor gene were directly sequenced. In addition, loss of heterozygosity analysis of chromosome 9q was performed using 5 polymorphic microsatellite markers. The BCC of the ear revealed a p53 mutation at codon 273, whereas the other one lacked this mutation. In addition, the smaller BCC of the ear showed loss of heterozygosity at 9q33.3, in contrast with the larger BCC. Interestingly, histologically normal skin of the ear distant from the small BCC had the same deletion, indicating a field defect of this skin patch at 9q33.3. Molecular genetic analysis clearly demonstrated different genetic alterations of the two BCCs and therefore most likely excludes a mechanism of implantation metastasis.

Branched filaments no fungus, ovoid bodies no bacteria: Two unusual cases of mycetoma

We describe a 58-year-old man presenting with necrotizing panniculitis of the lower right leg and a 64-year-old woman with a clinically similar lesion combined with pustular eruptions and subsequent ulceration on the forehead. In the first patient, Giemsa staining showed small ovoid bodies and Grocott staining revealed hyphae. Histology from the process on the forehead showed branched filaments in the periodic acid-Schiff (PAS) staining. In the first case, Madurella mycetomatis, a fungus, was the pathogenic agent, whereas in the other case white colonies of filamentous organisms resembling fungi could be cultivated that turned out to be the bacterium Nocardia brasiliensis. Since the initial clinical appearance of these two forms of mycetoma were almost identical and histopathologic findings were inconclusive, only sophisticated microbiologic work-up of material from lesional skin led to the correct diagnosis. In times of global tourism, these unusual cases impressively document the necessity to become more familiar with mycetoma to make accurate therapeutic decisions with effective results, possibly saving a limb.

Spindle cell hemangioma

BACKGROUND

Spindle cell hemangioma (SCH) is an uncommon benign vascular tumor.

OBJECTIVE

To report and discuss a case of SCH in an 11-year-old boy.

METHODS

A case report and discussion of the rare entity of SCH are given.

RESULTS

The excision of a vascular tumor showed a vascular connection to the great saphenous vein. Histologic examination was consistent with SCH.

CONCLUSION

The diagnosis of SCH is supported by typical histologic and immunohistochemical features and by the intraoperative finding of an association with a large vessel.

Long-term dermoscopic follow-up of melanocytic naevi: clinical outcome and patient compliance

BACKGROUND

Digital dermoscopy for the follow-up of melanocytic naevi (MN) is becoming more common in dermatological private practice.

OBJECTIVES

To evaluate the clinical outcome, including the patient's compliance, in a long-term follow-up of single MN.

METHODS

Criteria for the selection of MN for follow-up: clinically suspicious without dermoscopically atypical features, or typical for the patient. Clinical outcome measures: number of detected malignant melanomas (MM) and/or atypical MN; quantity, quality, and differences in morphological changes between 'low-risk' patients (no MM in history and < 50 MN) and 'high-risk' patients (MM in history and/or > 50 MN). Compliance: the number of patients who joined a recommended follow-up scheme.

RESULTS

No MM was found in 145 consecutive patients (mean age 28 years, 54% female) during a 4-year period (median follow-up per patient: 24 months; ranging 4-45; at least three visits). In five patients (3%), seven histologically proven atypical MN were shown on whole body examination at sites other than those documented. A total of 1968 images in 177 'low-risk' and 95 'high-risk' MN were analysed: 37% (n = 65) of 'low-risk' and 32% (n = 30) of 'high-risk' MN showed dermoscopic changes (difference not statistically significant), none were suspicious for MM. Compliance, evaluated within a separate database of 303 consecutive patients (mean age 32 years, 52% female) over a 6-month period, was only 46%, although recall letters were used.

CONCLUSIONS

(i) In our setting of daily routines in dermatological private practices long-term follow-up of a single MN seems not to be helpful for the detection of MM. (ii) A whole body examination must be done at each visit. (iii) The clinician's experience of the type and number of possible morphological changes in MN is crucial in order to avoid unnecessary excisions. (iv) The patient's compliance might be an important problem. (v) Cost-effectiveness has yet to be analysed.

[Actinic keratoses]

Actinic keratoses are defined as proliferation of cytologically atypical keratinocytes in the zone of epidermal-dermal junction in photodamaged skin. In the northern hemisphere the prevalence of actinic keratoses ranges depending on different epidemiological studies from 11% to 25% for people aged 40 or older. The main cause of actinic keratoses is exposure to UVB radiation in sunlight UVB radiation induces mutations in the telomerase gene and in the tumor suppressor gene P53, which can also be detected in invasive squamous cell carcinoma. The only histological parameter to distinguish between actinic keratoses and SCC is the level of invasiveness. The risk for actinic keratoses to develop into SCC is about 16% over lo years. For this reason and because of the high prevalence of actinic keratoses, it has been suggested to replace the term,, actinic keratosis K with intraepidermal squamous cell carcinoma' to better characterize the lesion. In the following review recent aspects of pathogenesis and therapy of actinic keratoses are discussed.

Willingness to pay and time trade-off: sensitive to changes of quality of life in psoriasis patients?

BACKGROUND

Willingness to pay (WTP) and time trade-off (TTO) have been used successfully as quality of life (QOL) measurements in dermatology. However, until now there have been no studies available individually comparing these measures pre- and post-treatment.

OBJECTIVES

To check sensitivity to changes for WTP and TTO (i). pre- to post-treatment, and (ii). to a 6-month follow-up period.

METHODS

We performed a prospective multicentre study in outpatients with psoriasis vulgaris treated with synchronous balneo-phototherapy (simultaneous application of narrowband ultraviolet B and bathing in 10% Dead Sea salt solution). Besides WTP and TTO, the Psoriasis Disability Index (PDI) and the Psoriasis Area and Severity Index (PASI) were monitored.

RESULTS

One hundred and ninety-four patients participated in the pretreatment survey, of whom 138 (71%; 84 men, 54 women; mean age 43.9 years) also returned the post-treatment questionnaire. WTP (percentage of monthly income) was shown to be independent of patients' income. During treatment, mean +/- SD WTP fell from 13.8 +/- 19.2% to 11.5 +/- 15.9% (relative improvement 16.7%; P < 0.05), TTO (h per day) from 2.7 +/- 3.8 to 2.3 +/- 3.6 (relative improvement 15%; P < 0.001), PDI improved from 29.8 +/- 18.6 to 23.5 +/- 18.9 (relative improvement 21.1%; P < 0.001) and PASI (available for 113 patients) from 14.9 +/- 7.7 to 5.6 +/- 5.0 (relative improvement 62.4%; P < 0.001). Changes in WTP, PDI and PASI were statistically significantly correlated. Ninety-one of 138 patients (66%) also completed a third survey after a follow-up period: no further changes in PDI, WTP and TTO were found, indicating a stable QOL post-treatment.

CONCLUSIONS

Correlation analysis indicated that WTP, assessed as percentage of monthly income, seems to be an appropriate way to measure QOL, unbiased by income of patients. WTP, TTO and PDI were correlated and were sensitive to changes during treatment. WTP and TTO therefore also seem to be appropriate tools for assessment of QOL in interventional studies, especially for pharmacoeconomic analyses.

Effects of light fractionation and different fluence rates on photodynamic therapy with 5-aminolaevulinic acid in vivo

To improve efficacy of photodynamic therapy (PDT) with intravenously administered 5-aminolaevulinic acid (ALA) fractionating the light dose or reducing the light intensity may be a possibility. Therefore, Syrian Golden hamsters were fitted with dorsal skinfold chambers containing an amelanotic melanoma (n=26). PDT was performed (100 mW cm(-2), 100 J cm(-2), continuously or fractionated, and 25 mW cm(-2), 100 J cm(-2); continuously or fractionated) using an incoherent light source following i.v. application of ALA. Following fractionated irradiation, the light was paused after 20 J cm(-2) for 15 min. Prior to and up to 24 h after PDT tissue, pO(2) was measured using luminescence lifetime imaging. The efficacy was evaluated by measuring the tumour volume of amelanotic melanoma cells grown subcutaneously in the back of Syrian Golden hamsters (n=36). Only high-dose PDT resulted in a significant decrease of pO(2). Irrespective of the mode of irradiation only high-dose PDT induced complete remission of all tumours (13 out of 13). It could be shown that low-dose PDT failed to induce a significant decrease of pO(2). No significant effect of fractionated irradiation was shown regarding the therapeutic efficacy 28 days after PDT. Thus performing a fractionated PDT with ALA or reducing the light intensity seems not to be successful in clinical PDT according to the present data.

Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet

BACKGROUND

There is a need for better standardization of the dermoscopic terminology in assessing pigmented skin lesions.

OBJECTIVE

The virtual Consensus Net Meeting on Dermoscopy was organized to investigate reproducibility and validity of the various features and diagnostic algorithms.

METHODS

Dermoscopic images of 108 lesions were evaluated via the Internet by 40 experienced dermoscopists using a 2-step diagnostic procedure. The first-step algorithm distinguished melanocytic versus nonmelanocytic lesions. The second step in the diagnostic procedure used 4 algorithms (pattern analysis, ABCD rule, Menzies method, and 7-point checklist) to distinguish melanoma versus benign melanocytic lesions. kappa Values, log odds ratios, sensitivity, specificity, and positive likelihood ratios were estimated for all diagnostic algorithms and dermoscopic features.

RESULTS

Interobserver agreement was fair to good for all diagnostic methods, but it was poor for the majority of dermoscopic criteria. Intraobserver agreement was good to excellent for all algorithms and features considered. Pattern analysis allowed the best diagnostic performance (positive likelihood ratio: 5.1), whereas alternative algorithms revealed comparable sensitivity but less specificity. Interobserver agreement on management decisions made by dermoscopy was fairly good (mean kappa value: 0.53).

CONCLUSION

The virtual Consensus Net Meeting on Dermoscopy represents a valid tool for better standardization of the dermoscopic terminology and, moreover, opens up a new territory for diagnosing and managing pigmented skin lesions.

Evaluation of the long pulsed high fluence alexandrite laser therapy of leg telangiectasia

BACKGROUND AND OBJECTIVES

The treatment of larger leg veins with laser or intense pulsed light often shows varying degrees of success and inconsistent clinical response rates. Aim of this study was to evaluate the effectiveness and safety of the 755 nm long pulsed high fluence alexandrite laser in the treatment of larger leg veins.

STUDY DESIGN/MATERIALS AND METHODS

Twenty female volunteers aged 25-51 years (mean 39) with 0.3-1.3 mm leg telangiectasias received laser treatment, 10 of them with an additional pass done right after the first pass. Their skin type ranged from 1 to 3 (five type 1, seven type 2, eight type 3). After test spots with increasing fluences (40-90 J/cm(2)) to determine the individual safe fluence, the maximum fluence of 90 J/cm(2) could be used in all 20 subjects. The spot size was 3 x 10 mm, a spray cooling system was used with 80 milliseconds spray and delay time, respectively. The number of pulses administered ranged from 30 to 467 per subject (mean 139). The treated area was controlled 1 day, 1 month, and 3 months post-treatment and the side effects were quantified. At each visit, the treatment area was photographed. The percent clearance in the treated areas was scored by two observers. Subject satisfaction was evaluated at the 3 months post-treatment visit.

RESULTS

After 3 months, in all 20 test subjects some clearance was visible. It ranged from low-grade to complete clearance. Most subjects (15 of 20) had a clearance between 26 and 75%. Hyperpigmentation was observed in 15 subjects. Hypopigmentation was seen in two subjects. No edema, no purpura, no erythema, no scarring, no blistering, and no crusts were observed. Mean subject satisfaction score was assessed and all volunteers reported to be "satisfied."

CONCLUSIONS

The long pulsed high fluence alexandrite laser is effective and safe in the treatment of leg veins 0.3-1.3 mm in diameter.

Benign Degos' disease developing during pregnancy and followed for 10 years

Degos' disease, or malignant atrophic papulosis, is a rare and often fatal multisystem vasculopathy of unknown etiology. The cutaneous manifestations comprise erythematous papules, which heal to leave scars with a pathognomonic central porcelain-white atrophic area and a peripheral telangiectatic rim. Involvement of the gastrointestinal tract is observed in 50% of cases, with intestinal perforation being the most common cause of death. Other organ systems can also be affected; 20% of cases involve the central nervous system. Systemic manifestations usually develop from weeks to years after onset of skin lesions or, in rare instances, may precede skin lesions. In the patient with Degos' disease reported in this article, the characteristic skin lesions developed during pregnancy, a precipitating event not previously reported. She has survived an unusually long time (10 years) without visceral or neurological involvement, despite florid cutaneous lesions. Moreover, we could detect the presence of antiphospholipid antibodies, the significance of which are currently unclear. These observations therefore confirm that there may be a strictly cutaneous form of Degos' disease with a favourable prognosis.

Heat shock protein 70 membrane expression and melanoma-associated marker phenotype in primary and metastatic melanoma

Cell membrane localization of the 72 kDa heat shock protein 70 (Hsp70) has been found on different tumour cell lines, on biopsy material from solid tumours and metastases and on leukaemic blasts from acute myelogenous leukaemia patients, but not on the corresponding normal tissues, as determined by flow cytometry using the Hsp70-specific monoclonal antibody C92F3B1. In the present study Hsp70 membrane expression was studied on primary malignant melanomas, melanoma metastases, melanocytes, human skin fibroblasts and peripheral blood lymphocytes, together with expression of the melanoma-associated markers Mel-1, Mel-2 and Mel-5, major histocompatibility complex class I and the fibroblast-specific marker ASO2. As previously shown, fibroblasts and peripheral blood lymphocytes from healthy human volunteers were found to be negative for Hsp70 and for the melanoma-associated markers Mel-1, Mel-2 and Mel-5. Human melanocytes from healthy human donors were also negative for Hsp70, but were positive for Mel-1 and Mel-5. Independent of the Clark's level, all the malignant melanomas (n = 9) and metastases (n = 11) exhibited were positive for both Mel-1 and Mel-2. The primary melanomas could be divided into two groups according to their Hsp70 and Mel-5 expression pattern: those with an Hsp70-negative and a Mel-5-positive phenotype (-/+) (five out of nine), and those with an Hsp70-positive and a Mel-5-negative phenotype (+/-) (four out of nine). All the melanoma metastases (n = 11) had an Hsp70-positive, Mel-5-negative phenotype (+/-). These data provide the first hint that the marker combination Hsp70 positive/Mel-5 negative might be useful in estimating the metastatic potential of a melanoma. Investigations on changes in the marker combination Hsp70/Mel-5 during onset of melanoma disease and progression will clarify its potential as a prognostic risk factor.

Histopathological diagnosis of onychomycosis by periodic acid-Schiff-stained nail clippings

BACKGROUND

The current laboratory methods for diagnosing fungal infections of the nails are the potassium hydroxide (KOH) scraping technique and fungal culture. However, due to the long incubation period required for fungal culture and the reported rate of approximately 30% false negative results observed when using these methods, a quick and highly specific screening test for diagnosing onychomycosis is urgently needed.

OBJECTIVES

In a prospective study, to compare the traditional mycological diagnostics using culture medium and KOH preparation with the histopathological diagnosis of onychomycosis by periodic acid-Schiff (PAS)-stained nail clippings.

METHODS

Material from 387 nails of 350 patients suspected of having onychomycosis was obtained and a KOH stain as well as two fungal cultures (Kimmig agar with and without cycloheximide) were prepared. In addition, the same specimen was histopathologically examined (PAS stain).

RESULTS

Culture medium and KOH preparation respectively revealed 100 and 156 cases of onychomycosis, as compared with 182 cases by histological examination. Histological examination gave a significantly higher rate of positive results (P < 0.05). Considering the total number of positive results given by at least one of the three methods (total = 438), histological evaluation was found to give the highest rate of successful recognition of mycotic infection (41.6%).

CONCLUSIONS

The histopathological evaluation of PAS-stained nail clippings is very quick and easy to perform, and will increase the frequency of diagnosing onychomycotic disease above that achieved by culture and KOH preparation alone. However, because information concerning the vitality of the fungi and accurate identification of the specific pathogen is not available through this investigation alone, mycological culture continues to remain the indisputable 'gold standard' of mycological diagnostics.

Discoid lupus erythematosus and lupus profundus in childhood: a report of two cases

Discoid lupus erythematosus (DLE) is a rare disorder in childhood, with 22 cases reported in the English-language literature. Less than 2% of patients with DLE have an onset before 10 years of age. We describe two children with DLE and lupus profundus with an onset of the disease at the ages of 11 and 15 years and focus on likely histopathologic differences between DLE in children and in adults. Histopathologic characteristics for childhood DLE might be an intense periadnexal and perivascular infiltrate extending into the interstitium and subcutaneous tissue consisting of lymphocytes, histiocytes, eosinophilic granulocytes, and plasma cells and lacking epidermal atrophy. The diagnosis of DLE in our two patients was established by clinicopathologic correlation based on clinical presentation, histologic and immunofluorescent findings in skin biopsy specimens, and the absence of clinical and laboratory evidence of systemic involvement. Therapy with antimalarials resulted in reduction of the skin lesions, but in one patient severe lipoatrophy occurred.

Influence of 5-aminolevulinic acid and red light on collagen metabolism of human dermal fibroblasts

Patients with localized scleroderma receiving topical photodynamic therapy with 5-aminolevulinic acid show a reduction in skin tightness, suggesting that this therapy reduces skin sclerosis. To investigate potential mechanisms, the effects of 5-aminolevulinic acid and light on collagen metabolism were studied in vitro. Normal and scleroderma fibroblasts were treated with sublethal doses of 5-aminolevulinic acid and red light and transferred to three-dimensional collagen lattices. Cell supernatants were taken 6-72 h after photodynamic therapy to determine protein levels of the matrix metalloproteinases 1, 2, and 3, and of their inhibitors, tissue inhibitor of metalloproteinase 1 and 2 by enzyme-linked immunosorbent assay. Cellular mRNA expression of these proteins and of collagen type I and III was measured by quantitative real-time polymerase chain reaction. A significant, time-dependent induction of matrix metalloproteinase 1 (up to 2.4-fold after 48 h) and matrix metalloproteinase 3 (up to 4.3-fold after 48 h) protein levels was seen after 5-aminolevulinic acid-photodynamic therapy. Irradiation with ultraviolet A light, used as a positive control, showed a similar induction of matrix metalloproteinase 1 (2.3-fold after 48 h). The mRNA levels of matrix metalloproteinase 1 and matrix metalloproteinase 3 were significantly increased 12 h after irradiation, whereas collagen type I mRNA was strongly decreased already 6 h following irradiation. Collagen type III, tissue inhibitor of metalloproteinase 1, and matrix metalloproteinase 2 did not change after photodynamic therapy. Addition of nontoxic concentrations of sodium azide, a singlet-oxygen quencher, significantly inhibited induction of matrix metalloproteinase 1 by 5-aminolevulinic acid and light. These data show that 5-aminolevulinic acid and light induce matrix metalloproteinase 1 and matrix metalloproteinase 3 expression in normal and scleroderma fibroblasts in a singlet oxygen-dependent way while reducing collagen type I mRNA expression. Induction of collagen-degrading enzymes together with reduction of collagen production might be responsible for the anti-sclerotic effects of 5-aminolevulinic acid-photodynamic therapy observed in vivo.

Treatment of atopic dermatitis and impact on quality of life: a review with emphasis on topical non-corticosteroids

Atopic dermatitis (AD) is a chronic skin disease with increasing prevalence and rising costs. Stigmatisation and pruritus are only some aspects of potential quality-of-life (QOL) impairments. AD is not curable and repeated treatments are often necessary. At present, treatment with topically-applied corticosteroids is state-of-the-art for mild to moderate flare-ups. However, many patients are worried about the use of corticosteroids due to the widespread fear of adverse effects. In this review the present literature is analysed concerning impact on quality of life for topically-applicable alternatives to the state-of-the-art treatment. For comparison reasons, data from other treatment modalities are additionally given. Characteristics of studies were analysed using 'general' (year and mode of publication, type and aim of study, number of patients, and clinical measurement) and 'QOL specific' criteria (type and number of QOL measurements including relevance for study aim and age group, validation in used language, sensitivity to change, and improvement at end of study). QOL data are published only in the minority of studies evaluating treatment efficacy and do not cover the variety of possible therapies. Data are available for tacrolimus, pimecrolimus, UVA/UVB combination and UVB narrowband (topical non-corticosteroidal treatments), as well as for topical corticosteroids, cyclosporin, and inpatient treatment. All studies provided a marked improvement in quality of life after therapy. One study assessed quality of life after a treatment-free follow-up period obtaining a clear increase in impact on quality of life. Since studies used different QOL measurements and vary in inclusion criteria, treatment schedules and presentation of results, a comparison of QOL improvement is not recommended. A single randomised study compared topically applied non-corticosteroidal treatment (UVA/UVB combination) with another treatment modality (cyclosporin) and found no difference in QOL improvement. At present, there is a clear lack of controlled randomised studies evaluating different active treatment modalities and their impact on quality of life. Consensus meetings are desirable to formulate guidelines for the selection and correct use of QOL measurements. Patients' fear of side effects (e.g. concerning corticosteroids) should be integrated in QOL questionnaires for evaluation of possible compliance problems and real costs. Since relapse after treatment is frequent in AD, QOL measurements should also be performed after a treatment-free follow-up period. At present, we can not answer the question 'which treatment best improves quality of life in AD?'.

Ekzem auf Naevus flammeus

Ein Naevus flammeus ist eine kongenitale Fehlbildung bestehend aus multiplen dilatierten Gefäßen des oberflächlichen Gefäßplexus in der Dermis. Es wird über vier Patienten mit Ekzemen im Bereich eines Naevus flammeus berichtet. Bei zwei von ihnen war das Feuermal am Hals lokalisiert, bei einem Patienten am Rücken und beim vierten an der Wange (bzw. präaurikulär) links. Die Patienten wurden mit dem Blitzlampen-gepumpten gepulsten Farbstofflaser behandelt. Alle Feuermale zeigten danach gute Aufhellung, zum Teil war eine deutliche Besserung bzw. Abheilung des Ekzems im Bereich des Naevus flammeus zu sehen.