[Atopic eczema. Spectrum of provocation factors and possibilities for their effective reduction and elimination]

Atopic eczema forms together with extrinsic bronchial asthma and allergic rhinoconjunctivitis the classical atopic triad. Genetic predisposition is the crucial pathogenetic factor. The combination of genetic disposition and provocation factors leads to the clinical appearance of skin disease. In addition to therapy adjusted to the stage of the disease, modern management should include a search for relevant trigger factors and then their avoidance to reduce or even prevent flares of the disease. The spectrum of provocation factors ranges from simple measures such as appropriate clothing up to specific measures such as indoor aeroallergen reduction measures.

[Tinea capitis et corporis due to Microsporum canis in an immunocompromised female adults patient]

Tinea capitis as well as tinea corporis in adults may occur under conditions of immunosuppression. If suspected clinically, direct microscopy and examination by culture is indispensable. Therapeutic intervention should start without delay. A proven fungal infection of scalp hairs warrants immediate initiation of systemic treatment. Hereby prevention of disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions as well as infection of other persons is possible.

Improved risk-benefit ratio for topical triamcinolone acetonide in TransfersomeR in comparison with equipotent cream and ointment: a randomized controlled trial

BACKGROUND

Transfersome is a drug delivery technology based on highly deformable, ultraflexible lipid vesicles which penetrate the skin when applied non-occlusively.

OBJECTIVES

To assess the advantages of this carrier-based formulation in humans, the efficacy and the atrophogenic potential of triamcinolone acetonide (TAC) in Transfersome was compared with commercially available TAC-containing cream and ointment.

METHODS

Healthy volunteers were enrolled in double-blind, placebo-controlled clinical trials with random study medication assignment to the test areas.

RESULTS

A 10-fold lower dose of TAC in Transfersome(R) (2.5 micro g cm-2) was bioequivalent to 25 micro g cm-2 TAC in conventional formulations as measured by erythema suppression (cream: P = 0.01, ointment: P < 0.001). A skin blanching assay revealed different kinetics of the formulations, with a delayed onset of action of the Transfersome and ointment preparations. Ultrasonic measurements revealed a significantly reduced atrophogenic potential. There was a 12.1% reduction in skin thickness given by TAC in Transfersome compared with a 21.1% reduction given by a bioequivalent dose in TAC cream after a 6-week treatment period (P = 0.007).

CONCLUSIONS

Transfersome may significantly improve the risk-benefit ratio of topically applied glucocorticosteroids.

High prevalence of superantigens associated with the egc locus in Staphylococcus aureus isolates from patients with atopic eczema

The present study was aimed at identifying a possible correlation between disease severity and colonization with superantigen-producing Staphylococcus aureus strains in patients with atopic eczema. To this end, Staphylococcus aureus strains from 91 patients with atopic eczema were screened for various staphylococcal superantigens such as SEA, SEB, SEC, SED, TSST1, the recently described enterotoxin gene cluster egc (which encodes the enterotoxins SEG, SEI, SEK, SEM, and SEO), and the see, seh, and sej loci. Swabs were taken from seven different sites in each patient. The rate of colonization with Staphylococcus aureus was 87.9%. Of those patients colonized, 35% were colonized with more than one different strain. Of the 120 genetically different strains investigated, the egc locus was found in 48.3% and the sej locus in 7.5%. The see and seh loci were not found in any strain. The presence of the classical superantigens SEA-SED or TSST1 was found in 38.3%. Overall, 71.3% of the Staphylococcus aureus-positive patients harbored at least one superantigen-producing strain on their skin. There was no difference in the prevalence of superantigens between atopic eczema patients and healthy volunteers. Moreover, there was no difference in the extent of disease expression between patients colonized by superantigen-positive Staphylococcus aureus strains and those with superantigen-negative strains as measured by the SCORAD system. However, patients colonized with Staphylococcus aureus had a significantly higher SCORAD score than those not colonized.

[Palmoplantar vesicular lesions in childhood]

BACKGROUND AND OBJECTIVE

Palmoplantar vesicles in children have various underlying causes, requiring different therapies. We evaluated the most common underlying diseases and determined simple criteria for differentiation.

PATIENTS/METHODS

Within a two years period all children up to 14 years of age who presented with acral vesicles were included in this study.

RESULTS

The most common causes of acral vesicles in a group of 32 patients, were dyshidrotic eczema with (n=11) or without atopic diathesis (n=11) and scabies (n=7). Rarely, the cause of vesicular lesion was tinea (n=2) or infantile acropustulosis (n=1). While dyshidrotic eczema was a disease of late childhood, palmoplantar lesions caused by scabies developed in younger children up to the age of 4 years. Scabies in contrast to infantile acropustulosis tend to present with more generalized lesions, not being restricted to acral location. Dyshidrotic eczema revealed lesions bilaterally and in case of atopy, additional body areas were involved. Unilateral presentation was a clue for tinea.

CONCLUSIONS

Acral vesicles in childhood can be diagnostically discriminated by the age of the patient and the distribution of the lesions.

[Pediatric dermatotherapy]

Dermatological therapy of children differs considerably from treatment of adults and poses a special challenge. Dermatological diseases often form idiosyncratic entities with a prognosis different from adults and must be treated appropriately. Consideration should also be given to the fact that children occasionally experience adverse reactions to drugs, which are not observed in adults. A selection of dermatological diseases and typical drug reactions are presented to illustrate the special features and differences between pediatric dermatotherapy and treatment of adults.

[Tinea capitis. Therapeutic options in the post-griseofulvin era]

Tinea capitis is the most common dermatophyte infection during childhood. In Germany, only griseofulvin is approved for therapy by regulatory agencies. In recent years, several newer antifungal agents such as itraconazole, fluconazole and terbinafine have broadened the therapeutic armamentarium and are used for the treatment of childhood tinea capitis. Itraconazole and terbinafine seem to be equally or more effective in treatment of tinea capitis within a shorter period of time than griseofulvin. Fluconazole is probably also effective for this indication, although supporting data is limited. Encountered side effects as well as interactions with other drugs appear to be well within acceptable limits for all three drugs. In conclusion, systemic therapy of scalp ringworm with itraconazole and terbinafine, as well as perhaps fluconazole, seems to be an equivalent or a superior therapeutic approach as compared to the use of griseofulvin. For the future, regulatory approval for the use of these newer antifungal agents in tinea capitis of childhood is recommended.

UV-induced skin changes due to regular use of commercial sunbeds

BACKGROUND/AIM

Increased pigmentation and thickening of the epidermis are the most important photoprotective skin reactions induced by ultraviolet (UV) radiation. The present study was designed to find out what changes are induced by regular use of commercial sunbeds twice weekly over a period of 6 weeks.

METHODS

The parameters analysed were skin pigmentation measured by chromametry, minimal erythema dose (MED) as a parameter of light sensitivity, epidermal thickening as determined by histology, induction of keratinocyte apoptosis as determined by TUNEL staining and antioxidant metabolism as measured by changes of cis- and trans-urocanic acid (UCA) content of the skin.

RESULTS

As expected, chromametry confirmed the clinically obvious increased skin pigmentation. However, no increase in MED was observed. In addition, neither epidermal thickening nor sunburn cells were seen. Significant detectable changes in proportion of the UCA isomer content of the UV-exposed skin were seen. The total UCA and cis-UCA content increased significantly between nearly all points of measurement. The amount of trans-UCA first decreased, then increased significantly between the different time points.

CONCLUSION

Our data indicate that sunbed-induced tanning is non-protective, which has to be addressed for persons looking for this effect before planning a stay in a sunny climate. However, sunbed-induced tanning may influence immunological reactions.

[Keratosis lichenoides chronica. Bath PUVA therapy]

We describe the case of a 51-year-old male patient with characteristic lesions of keratosis lichenoides chronica confined to the back of his hands and feet. The lichenoid papules, linear hyperkeratotic ridges and erythematosquamous plaques appeared first in early childhood and recurred after a short episode of spontaneous remission. They didn't respond to various topical treatment modalities over the years. After a local PUVA therapy all lesions disappeared with no recurrence for over two years now. Our case report indicates a new promising indication for bath-PUVA-therapy.

Dihydroxyacetone in a new formulation--a powerful therapeutic option in vitiligo

BACKGROUND

Most treatment protocols for vitiligo require a long treatment duration and usually do not result in complete repigmentation. Therefore, cosmetically acceptable and easily to handle alternatives are warranted.

OBJECTIVE

To evaluate the properties of dihydroxyacetone (DHA) in a new formulation for the treatment of vitiligo on exposed areas.

METHODS

We treated 10 patients suffering from vitiligo affecting the face and/or hands with a newly introduced, commercially available self-bronzing cream containing DHA 5%. DHA was applied every second day.

RESULTS

The characteristic pigmentation showed very satisfactory cosmetic results in 8 out of 10 patients after 2 weeks of treatment.

CONCLUSION

The new DHA formulation is a practical and well-accepted treatment modality.

Invasion of human keratinocytes by Staphylococcus aureus and intracellular bacterial persistence represent haemolysin-independent virulence mechanisms that are followed by features of necrotic and apoptotic keratinocyte cell death

BACKGROUND

Colonization of human skin by Staphylococcus aureus is a characteristic feature of several inflammatory skin diseases, which is often followed by tissue invasion and severe cell damage. A crucial role has been attributed to staphylococcal haemolysins in the cytotoxicity to epidermal structures.

OBJECTIVES

To investigate haemolysin-independent virulence to human keratinocytes.

METHODS

The stable alpha-haemolysin, beta-haemolysin double-negative S. aureus mutant DU 5720 was compared with the fully virulent parent strain 8325-4 and with its isogenic fibronectin-binding protein A/B-negative variant DU 5883 in an invasion model.

RESULTS

This assay showed dose-dependent internalization of all the strains investigated by human HaCaT keratinocytes, with reduced internalization of DU 5883. Transmission electron microscopy revealed adhesion of staphylococci to cellular pilus-like extrusions, followed by the embedding of the bacteria in cellular grooves. Following attachment to the keratinocytes the staphylococci were engulfed into vesicles within the cytoplasm where some bacteria persisted for 24-48 h. Addition of cytochalasin D strongly reduced the bacterial uptake, suggesting an active keratinocyte process. Bacterial invasion was followed by severe keratinocyte cell damage showing the morphological changes of cytotoxic and, to a lesser extent, apoptotic cell death as determined by the trypan blue exclusion test and the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labelling assay. The highest levels of lethal cytotoxicity were observed in haemolysin-producing strains, whereas the induction of apoptosis seemed to depend on internalization.

CONCLUSIONS

Staphylococcal invasion of human keratinocytes represents a potent staphylococcal virulence factor, which, independently of alpha- and beta-haemolysins, leads to necrotic and apoptotic cell damage.

[Recurrent palmoplantar hidradenitis in childhood]

We describe five cases of recurrent palmoplantar hidradenitis in children. The pathogenesis of this highly characteristic disease presenting with painful erythematous papules and nodules involving palms of the hands, soles of the feet, or both is not clear at the moment. One possible mechanism is a temporal relationship between exposure to dampness and cold, which also applied in four of these children. The self-limited disease tends to reappear. After thoroughly informing the children and their parents on avoiding provoking factors, all children experienced freedom from the disease during a 12-month follow-up.

Internet advice in dermatology and allergy: 1 year analysis of telerequests and answers

The purpose of this study was to analyze the content and objectives of questions asked by internet users who accessed the homepage of the Department of Dermatology and Allergy Biederstein at the Technical University of Munich. Users were offered the opportunity to ask free questions on the Web site. The results of lay and medical individuals seeking advice were collected over a 12 month period and the answers given were reviewed. We received inquiries from 279 laypersons and 31 physicians. The majority of questions (53.8%) asked by non-medical users dealt with dermatology-related problems. Inquiries related to hair (13.3%) and acne or rosacea (11.3%) were most common. 46.2% of e-mail requests were allergy-related. Most of the interest focused on food allergy and adverse food reactions (22.5%) or hay fever and perennial rhinoconjunctivitis (19.4%). Previous consultation of a physician was reported in 40.9%. 13.6% had consulted an allergist or dermatologist. The majority of questions asked by physicians concerned allergy-related topics (64.6%). Most questions were answered by a short letter giving advice and encouraging the non-medical user to visit a dermatologist and/or allergist (72.4%). In 27.6% we felt that the inquiries were answered completely.

[Confluent and reticulate papillomatosis. Successful therapy with azithromycin]

Confluent and reticulated papillomatosis is a fairly rare dermatosis of still unknown origin affecting mostly female young adults. The lesions are mainly localized in the midline of the trunk. Systemic treatment is the treatment of choice because the disease is resistant to topical therapy and recurrences are often seen. In recent publications retinoids and minocycline have been reported as the favourite therapeutic approaches. We successfully treated a 19-year-old-girl with azithromycin resulting in a complete healing of all skin lesions. The patient has been free of disease for five months. Based on our own case and data in literature, azithromycin is an effective, reasonable and safe therapeutic alternative.

Transonychial water loss in healthy and diseased nails

The objective of this study was to determine the transonychial water loss (TOWL) in both healthy and affected nails in different diseases and to compare it with the transepidermal water loss (TEWL). TOWL was measured by a new evaporimetric method: Plasticine was used to fix the protection cover of the evaporimeter probe to the nails. The TOWL behaved contrary to the TEWL. Affected nails in patients with atopic eczema (p <0.01), psoriasis (p<0.05) and onychomycosis (p<0.001) showed a significantly lower TOWL than did nails of healthy test subjects. The decrease in TOWL in diseased nails in comparison to healthy nails could be due to the formation of a stratum granulosum in atopic, psoriatic or fungus-affected nails, as this layer is normally absent in healthy nails.

[What's new in diagnosis and therapy of dermatomycoses in childhood]

Mycotic infections in childhood are caused in the majority of cases by dermatophytes. If an oral treatment is indicated, itraconazole and terbinafine are superior to griseofulvin and are nowadays drugs of first choice although an official registration for treatment of children is missing in Germany. Yeasts in infections of childhood are the causative organisms in Pityrosporum-folliculitis and act as an important co-factor in diaper dermatitis.