Comparative investigation of human stratum corneum ceramides

The stratum corneum (SC) requires ceramides, cholesterol, and fatty acids to provide the cutaneous permeability barrier. SC lipids can be analyzed by normal-phase high-performance thin-layer chromatography (HPTLC). However, without further analysis, some uncertainty remains about the molecular composition of lipids represented by every TLC band of an unknown sample. We therefore analyzed each ceramide band further by subjecting the isolated lipids to a direct coupling of reversed-phase high-performance liquid chromatography and electrospray ionization-mass spectrometry (HPLC/ESI-MS, or LC/MS). LC/MS analysis and ESI-MS/MS negative ion and collision-induced dissociation experiments revealed that ceramide band 4 contained not only N-(omega-OH-acyl)acyl-6-OH-sphingosine, Cer(EOH), but also N-(alpha-OH-acyl)-sphingosine. Band 5 exclusively contained N-acyl-6-OH-sphingosine. Our results demonstrate the benefit of LC/MS analysis for selective identification of human SC ceramides. Moreover, the combination of HPTLC for pre-separation and LC/MS for identification of lipids is an even more powerful tool for detailed ceramide analysis.

Cutaneous peculiarities in blepharophimosis-ptosis-epicanthus inversus syndrome: report of a case

Blepharophimosis-ptosis-epicanthus inversus syndrome (BPES) is a rare inherited disorder with characteristic oculofacial affection of the eyelid region. Recent results of genetic analysis of the causative gene, as well as a hitherto unknown association with hormone-dependent endometrial carcinoma, motivated us to review this syndrome.

Analysis of histidine and urocanic acid isomers by reversed-phase high-performance liquid chromatography

The qualitative separation performance of a C18, C8 and C4 reversed-phase column was investigated for the separation of histidine and its metabolites histamine, 1-methyihistamine and trans- and cis-urocanic acid. Trans- and cis-urocanic acid were baseline separated from their precursor histidine on all three columns using isocratic elution with a mobile phase composed of 0.01 M aqueous TEAP pH 3.0 and acetonitrile at a ratio of 98:2 (v/v). However, histidine was not separated from histamine and 1-methyihistamine. Selecting the C8 column and introducing 0.005 M of the ion pairing reagent 1-octanesulfonic acid sodium salt into the aqueous solution and acetonitrile at a ratio of 90:10 (v/v), significantly improved the separation. The separation was also followed by a change in the retention times and the order of elution. The sequence of elution was histidine, cis-urocanic acid, trans-urocanic acid, histamine and 1-methylhistamine with retention times of 5.58 +/- 0.07, 7.03 +/- 0.15, 7.92 +/- 0.18, 18.77 +/- 0.24 and 20.79 +/- 0.21 min (mean +/- SD; n=5). The separation on the C8 column in the presence of the ion-pairing reagent was further improved with gradient elution that resulted in a reduction in the retention times and elution volumes of histamine and 1-methylhistamine. The detection limits of histidine and trans-urocanic acid at a wavelength of 210 nm and an injection volume of 0.05 ml were 5 x 10(-8) mol l(-1) (n=3). The kinetic of the in-vitro conversion of trans- into the cis-isomer after UV irradiation was depending on the time of exposure and the energy of the light source. UVB light induced a significantly faster conversion than UVA light. TUCA and cUCA samples kept at -25 degrees C were stable for up to 50 weeks. Samples, eluted from human skin showed various concentrations of histidine and trans- and cis-urocanic acid with an average of 1.69 +/- 0.33 x 10(-5) mol l(-1), 1.17 +/- 0.43 x 10(-5) mol l(-1) and 1.67 +/- 0.33 x 10(-5) mol l(-1), respectively (n=8).

Determination of histidine and urocanic acid isomers in the human skin by high-performance capillary electrophoresis

Histidine was baseline separated from histamine, 1-methylhistamine and cis- and trans-urocanic acid using high-performance capillary electrophoresis (HPCE) on a fused-silica column (50 cm x 75 microm) with 0.05 M NaH2PO4 buffer, pH 5.0, and 12 kV. The detection limit of histidine, trans- and cis-urocanic acid was 10(-6) M at a wavelength of 214 nm. The detection limit of the urocanic acid isomers was slightly enhanced to 5 x 10(-7) M at 267 nm. The transformation of the trans-urocanic acid standard in vitro into the cis-isomer was dependent on the time of exposure and the energy of the light source. UVB light induced a significantly faster conversion than UVA light. The HPCE method was used for the characterization and measurement of histidine and urocanic acid in human skin eluates. The concentrations of histidine, trans- or cis-urocanic acid in ethanol washes from the skin of healthy, non-allergic volunteers were 2.22+/-0.40 x 10(-5) 0.96+/-0.26 x 10(-5) and 1.04+/-0.30 x 10(-5) M, respectively, (mean+/-SEM, n=8). The results obtained by HPCE correlated well with data obtained by HPLC. Correlation coefficients of r2=0.981, r2=0.814 and r2=0.956 were found for histidine, trans- and cis-urocanic acid, respectively.

The excess of atopic eczema in East Germany is related to the intrinsic type

BACKGROUND

Prevalence data for atopic eczema based on a dermatological examination have not so far been available for East and West Germany. Possible differences in the proportions of extrinsic and intrinsic types of eczema, and how far these could explain differences in the prevalence of eczema, need to be clarified.

OBJECTIVES

To compare the prevalence of atopic eczema in pre-school children between different locations in East and West Germany, and over a period of 7 years, at three time points. Additionally, to determine the proportions of intrinsic and extrinsic types of eczema by taking skin prick test reactivity into account.

METHODS

Repeated cross-sectional studies in 1991, 1994 and 1997 in 5-6-year-old pre-school children at five different locations in West Germany (n = 2075) and six in East Germany (n = 1926) were carried out. Individuals with eczema were identified by an examination performed by physicians of the Department of Dermatology. In addition, a skin prick test and a standardized questionnaire were used.

RESULTS

The overall prevalence of atopic eczema in these children was 10.4%. At all three times of investigation (1991, 17.5% vs. 11.2%; 1994, 12.6% vs. 8.7%; 1997, 11.2% vs. 4.5%) and in the total group (12.9% vs. 8.2%), the prevalence was significantly higher in East than in West Germany. After controlling for influences of sex, parental history of atopic diseases, observer and socio-economic status in multiple logistic regression analyses, these differences remained significant for 1991, 1994 and for the overall group (odds ratio, OR 1.78, 95% confidence interval, CI 1. 43-2.21). Girls (OR 1.56, 95% CI 1.27-1.92) and children whose parents had a higher level of school education (OR 1.17, 95% CI 1. 00-1.37) were affected more frequently. Of all children, 26.6%, and of those with eczema, 41.9% exhibited at least one reaction in the prick test (OR 2.21, 95% CI 1.75-2.80; sensitization in eczema vs. no eczema). Whereas 50.4% of the children with eczema in West Germany were sensitized, only 36.5% of the diseased children in East Germany reacted positively in the prick test (OR 1.77, 95% CI 1.12-2. 79).

CONCLUSIONS

These results are in accordance with findings regarding allergic sensitization and hay fever and might indicate that factors other than allergy are responsible for the higher prevalence of atopic eczema in East Germany.

Optimizing the therapeutic approach in tinea capitis of childhood with itraconazole

BACKGROUND

Tinea capitis is the most common dermatophytosis of childhood with increasing incidence. Whereas griseofulvin is considered by many as the mainstay of treatment, newer oral antifungal agents, including fluconazole, itraconazole and terbinafine have demonstrated higher efficacy, resulting in shorter treatment durations.

OBJECTIVES

We aimed to determine the optimum regimen for the treatment of childhood tinea capitis with itraconazole.

METHODS

A mycological culture outcome-dependent combination of a 28-day continuous and facultative additional 14-day courses with itraconazole was used in 42 children (20 girls; 22 boys) aged 12-140 months (mean 66) with tinea capitis due to Microsporum canis (n = 26) and Trichophyton violaceum (n = 16). The drug was given orally according to the patients' body weight (50 mg daily for < 20 kg; 100 mg daily for > or = 20 kg) over 4 weeks. Direct microscopy and fungal culture as a parameter for efficacy were repeated 2 weeks after termination of treatment. Assessment of efficacy was based on the evaluation of results from light microscopy and culture at 8 weeks after initiation of treatment, and in the case of a further positive mycological culture at 14 and 20 weeks, respectively. A positive fungal culture at these times resulted in an additional course for 2 weeks with the initially chosen itraconazole dosage.

RESULTS

In 34 of 42 patients a single 4-week course of itraconazole resulted in a complete mycological cure of lesions as demonstrated by light microscopy and mycological culture. Four of 42 patients had to be treated by a second itraconazole course for 2 weeks, and four children received a third course of itraconazole for 2 weeks until all lesions showed negative direct microscopy and mycological culture. No abnormal haematological or biochemical results occurred. Apart from transient, completely reversible indigestion in two children, no side-effects were observed.

CONCLUSIONS

A culture-based 28-day continuous therapeutic regimen plus facultative cultural outcome-dependent additional 14-day courses of a body weight-adapted dosage of itraconazole in tinea capitis due to M. canis and T. violaceum is discussed; this offers the advantage of an effective therapy with complete negative direct microscopy as well as negative cultural results, within a shorter active treatment period (cf. previous studies with continuous administration of itraconazole).

[Contagious impetigo--pathogen spectrum and therapeutic consequences]

OBJECTIVE

The aim of this prospective study was to compare the clinical picture of contagious impetigo (C.I.) with the causative organism and to generate data of the susceptibility of bacteria as the basis for adequate therapy.

PATIENTS AND METHODS

In 126 patients with C.I. (86 children, 66 of them younger than 10 years) bacterial swabs were taken and antibiotic sensitivity testing for isolated organisms was tested.

RESULTS

In all cases in which contents of vesicles or pustules were analysed, Staphylococcus aureus was the only pathogen isolated. In non-bullous variants of C.I. Staphylococcus aureus was the most often isolated organism as well. Both staphylococci and streptococci were isolated in 12 cases, whereas in just 9 cases streptococci were the only pathogen detected. All Staphylococcus aureus isolates were sensitive to flucloxacillin and cefotaxime. Erythromycin-resistance amounted to more than 20 percent. The percentage of resistant staphylococci against the predominantly topically applied antibiotics fusidinic acid and mupirocin was 2 and 0 per cent, respectively.

CONCLUSION

For all manifestations of C.I. Staphylococcus aureus is at present the leading organism which has to be taken into consideration for treatment. If oral antibiotic therapy is indicated, penicillinase-stable penicillins or cephalosporins, preferably of the cefalexin-type, are the drugs of choice. Macrolides are no longer recommended for initiating of C.I. treatment.

Photoallergic contact dermatitis due to combined UVB (4-methylbenzylidene camphor/octyl methoxycinnamate) and UVA (benzophenone-3/butyl methoxydibenzoylmethane) absorber sensitization

In a 71-year-old male Caucasian patient with persistent eczema on light-exposed skin, photocontact allergy was demonstrated to the UV filter substances 4-methylbenzylidene camphor (UVB), octyl methoxycinnamate (UVB), benzophenone-3 (UVA) and butyl methoxydibenzoylmethane (UVA) present in sunscreen products used by the patient over several years. A significantly reduced UVB sensitivity of 25 mJ/cm2 in this patient (normal minimal erythema dose in our laboratory = 70-130 mJ/cm2) was considered an early indication of a persistent light reaction. Topical anti-inflammatory treatment over 2 weeks together with consequent application of a sunscreen containing Mexoryl SX/titanium dioxide led to complete remission. Taking into account the widespread use of the above UV filter substances not only in sun protection products, but also in cosmetics such as antiaging lotions and day care products, the possible risk of allergy to these chemicals has to be taken seriously. The substitution of known photocontact sensitizers in UV filters by photostable compounds and detailed product information are the basis of preventive strategies.

[Intralesional methotrexate injection: an effective time and cost saving therapy alternative in keratoacanthomas that are difficult to treat surgically]

A 53 year old female patient developed a keratoacanthoma, present on the left side of her nose for two months. After repeated unsuccessful trials with cryotherapy, she was treated with intralesional injection of methotrexate performed twice with a weekly internal. This led to complete resolution within 5 weeks. Although controlled studies on the effect of methotrexate in keratoacanthoma are not available, the rapid regression and the good cosmetic result suggest that this therapy may play a beneficial role in treating these lesions especially in problem locations.

Persistent annular erythema of infancy associated with intestinal Candida colonization

We report a case of persistent annular erythema of infancy in a 4-month-old boy. Physical and laboratory parameters showed no sign of internal disease or specific infection except a massive Candida albicans colonization (> 103 organisms/mm3) of the lower gastrointestinal tract. Oral treatment with amphotericin B for 2 weeks resulted in a complete remission of the skin lesions indicating Candida colonization as a trigger.

Parental sun protection management in preschool children

A total of 287 children (5 to 8 years old) were investigated for parental sun protection management techniques in a questionnaire-based survey. We evaluated the parents' knowledge about the risk of melanoma, their level of education, their nationality and the child's skin type with the children's use of sunscreen, clothes and shade. In general, the parents' knowledge about the correlation of skin cancer with extensive sun exposure in childhood was good. There was no correlation between the level of parental education and the frequency of sun protection measures. Children of non-German parents had significantly less sun protection. Our results indicate the need for special teaching programs for children in Germany to achieve a more responsible sun protection management.

[Current status of the interdisciplinary model project "Neurodermatitis Education for Children and Adolescents"]

With the help of the German Ministry of Health and the health insurance companies a national interdisciplinary project for children and adolescents with atopic eczema will be developed. The aim of the project is to generate standardized teaching concepts for parents and children covering medical, psychological and social aspect of the disease. 800 children and adolescents of different age groups will be enrolled in this project. Furthermore, during the three years of the study the efficacy of the teaching concept will be evaluated.

Skin surface pH, stratum corneum hydration, trans-epidermal water loss and skin roughness related to atopic eczema and skin dryness in a population of primary school children

Non-invasive investigations of skin morphology and function are standard tools to study the pathophysiology of several cutaneous disorders, yet they have not been used in population-based epidemiological studies. Here we examined skin surface pH, stratum corneum hydration, trans-epidermal water loss (TEWL) and skin roughness by profilometry in a study population comprising 377 primary school children (8-9 years old) as part of a multicentre survey on risk factors for allergic diseases in school children. Skin surface pH showed significant higher values (p=0.029) in the group with atopic eczema (n=45) compared with the group without atopic eczema; all other parameters did not differ significantly between children with and without atopic eczema. With increasing skin dryness there was a significant increase in pH values (p=0.004). Stratum corneum hydration showed a significant decrease with increasing dryness (p<0.001). Measurement of skin roughness also revealed a significant linear relationship with skin dryness (p=0.02). It is concluded that measurement of skin surface pH, corneometry and profilometry are useful non-invasive techniques to objectively assess skin dryness in epidemiological studies regarding atopic skin disease.

[Sjögren-Larsson syndrome]

This rare, ubiquitous neurocutaneous disorder is inherited in an autosomal recessive fashion. Its primary clinical manifestations are congenital ichthyosis, spastic diplegia or tetraplegia, and mental retardation. The causative biochemical defect has been identified as a deficiency of the enzyme fatty aldehyde dehydrogenase, a component of fatty alcohol:NAD+ oxidoreductase. We present a case report of an affected 3.5 year old white girl to give an overview of the pre- and postnatal diagnostic procedures as well as of therapeutic options.

Systemic vitamin C and vitamin E do not prevent photoprovocation test reactions in polymorphous light eruption

The possible influence of oxidative stress is discussed in the pathogenesis of polymorphous light eruption (PLE). A double-blind, placebo-controlled study of prophylactic treatment with systemic administration of vitamin C (3 g/d) and E (1500 IU/d) for 8 days was undertaken in 9 patients with PLE (verum, n=4; placebo, n=5). Evaluation of the maximal effects after photoprovocation before and after intake of the antioxidants revealed a reduction of most skin reactions (overall skin reaction, papules/vesicles) in both groups with marked differences in the placebo group. The antioxidants in the doses given and over the time period used did not influence the development of PLE, but might interfere with immunosuppressive effects of repeated photoprovocation tests.

[Eosinophilic cellulitis (Wells syndrome)]

Eosinophilic cellulitis (Wells' syndrome) is a rare disorder characterized clinically by recurrent erythematous plaques resembling cellulitis and histologically by a dermal infiltrate of lymphocytes, eosinophils and eosinophil debris between collagen bundles, forming flame figures in typical cases. A 71-year-old woman with Wells' syndrome with blood and bone marrow eosinophilia showed a good response to dapsone. The level of eosinophil cationic protein (ECP) in serum was elevated. Immunophenotyping of peripheral T cells revealed an increased proportion of CD3+CD4+T cells. The patients' cultured peripheral lymphocytes spontaneously released significant amounts of interleukin 5 (IL-5), but not interleukin 4 (IL-4) or interferon gamma (IFN gamma). These findings suggest that activated T cells may be involved in the pathogenesis of blood and tissue eosinophilia in this patient.

Changes in collagen I and collagen III metabolism in patients with generalized atopic eczema undergoing medium-dose ultraviolet A1 phototherapy

Fourteen patients suffering from acute, exacerbated atopic eczema were screened for changes in collagen I and collagen III metabolism in serum (n = 11), urine (n = 11) and skin biopsies (n = 9) before and after medium-dose ultraviolet (UV) A1 phototherapy (15 exposures of 50 J/cm2 over a 3-week period, total dose 750 J/cm2). Mature collagen I and, to a lesser extent, mature collagen III were found to be decreased after the therapy in skin samples from the irradiated patients. As markers of collagen I degradation, the cross-links pyridoline and deoxypyridoline were analysed in urine using high-performance liquid chromatography. Both cross-links were found to be mildly increased after UVA1 phototherapy, without reaching statistical significance. As markers of de novo collagen synthesis we screened for the procollagen I-carboxyterminal peptide (PICP) and procollagen III-aminoterminal peptide (PIIINP) levels in serum and skin. The ratio of PICP to PIIINP in serum dropped significantly after the UVA1 phototherapy, suggesting a different impact of UVA1 on the two collagens. These findings were paralleled by a diminished ratio of PICP to PIIINP in tissue samples. Staining for matrix metalloproteinase 1 (MMP-1) and its specific counterpart, tissue inhibitor of MMP-1 (TIMP-1), showed slight increases for both proteins by therapeutic UVA1; this was also seen in serum for TIMP-1 but not MMP-1. In our study, high-energy UVA1 doses induced changes of the skin collagens in patients with atopic eczema which are measurable by their metabolites in serum and urine.