Imaging of fibrosis of the oral mucosa by 20 MHz sonography

OBJECTIVES

To compare the ultrasonographic (US) appearances of the oral mucosa in health with patients with systemic sclerosis (SSc).

METHODS

An innovative 20 MHz US scanner was used to examine the lips, cheeks and oral vestibule of ten healthy persons and ten patients with SSc. The clinical, US and histopathological features of one patient with a fibro-epithelial polyp of the buccal mucosa are reported in detail.

RESULTS

Two patients with SSc displayed increased echogenicity due to fibrotic deposits. A similar echo pattern was seen in the case of the histopathologically verified fibro-epithelial polyp of the buccal mucosa.

CONCLUSION

20 MHz sonography may be suitable as a non-invasive tool for evaluation of fibrosis of the oral mucosa.

[Bleomycin-induced PSS-like pseudoscleroderma. Case report and review of the literature]

Although the association between administration of the antitumor agent bleomycin and the development of cutaneous fibrosis is established, there are only a small number of cases of bleomycin-induced scleroderma described in the literature. We report the development of generalised scleroderma with wide spread hyperpigmentation in a 52-year-old male patient, who received a total dose of 360 mg bleomycin in combination with cisplatin and etoposid for therapy of a malignant testicular seminoma. The clinical cutaneous alterations as well as the histological findings were indistinguishable from those encountered in progressive systemic sclerosis (PSS). In contrast to PSS however, Raynaud's phenomenon, cutaneous calcinosis, teleangiectasia, arthritis and involvement of additional organs were all absent. PSS-typical auto-antibodies were negative. Even 18 months after discontinuation of the drug and treatment with UVA1 phototherapy (3-4 times per week with 20 J/cm2) as well as physiotherapy, the skin changes had still not resolved. Based on our case and a detailed review of the literature, we discuss characteristics of bleomycin-induced scleroderma including pathogenesis, treatment modalities and course.

Low-dose UVA phototherapy for treatment of localized scleroderma

BACKGROUND

For treatment of localized scleroderma numerous treatments, including ones with potentially hazardous side effects, are currently used with only limited success.

OBJECTIVE

We attempted to determine the efficacy of low-dose UVA1 irradiation in patients with severe localized scleroderma.

METHODS

Patients were irradiated with 20 J/cm2 UVA1 for 12 weeks (total number of treatments: 30; cumulative UVA1 dose: 600 J/cm2).

RESULTS

Low-dose UVA1 irradiation induced significant clinical improvement (clearance of > 80% of lesions) in 18 of 20 patients. Clearance was documented by clinical score as well as by 20 MHz ultrasound and histopathologic analysis.

CONCLUSION

Low-dose UVA1 phototherapy can be highly effective for sclerotic plaques, even in patients with advanced localized scleroderma and with lesions rapidly evolving despite conventional therapy.

[The successful monotherapy of hypereosinophilic dermatitis with PUVA-bath photochemotherapy]

A 70-year-old woman with long-standing hypereosinophilic dermatitis improved strikingly with PUVA-bath photochemotherapy. The single UVA doses ranged from 0.3 to 3.3 J/cm2. After 19 treatment sessions pruritus disappeared, and after 32 treatments the erythematous maculae completely cleared. Under continuous treatment three times a week, no relapse has occurred to date. PUVA-bath photochemotherapy seems to be a promising new treatment modality without systemic side effects for patients with hypereosinophilic dermatitis.

Non-invasive assessment of the antipsoriatic activity of fumaric acid derivatives

BACKGROUND/AIMS

Noninvasive methods are introduced for the monitoring of healing of psoriasis. Fumaris acid derivatives (FAD) were used in the treatment of psoriasis vulgaris for more than 30 years, but the effectiveness of these drugs has remained controversial. The object was to study the efficacy of FAD in a prospective study including noninvasive techniques, which may allow more accurate assessment in a smaller patient group.

METHODS

High-frequency ultrasound including image analysis, and colorimetry was employed. 14 patients were treated for 20 weeks.

RESULTS

In the ultrasound image, acanthosis and inflammatory infiltrate of active psoriasis cause an echopoor area under the entry echo. Under theray, this echo area diminishes while its density increases. During healing, the decrease in redness could be quantified.

CONCLUSIONS

Monitoring of the healing of psoriasis is possible with ultrasonography and colorimetry. Fumaric acid was found efficient and safe in the treatment of psoriasis.

20 MHz sonography, colorimetry and image analysis in the evaluation of psoriasis vulgaris

For objective evaluation of the treatment of psoriasis vulgaris standard techniques are desirable. They should be reproducible, sensitive and non-invasive. In this study non-invasive bioengineering techniques, especially high frequency/high resolution ultrasound for measurement of the healing of psoriasis vulgaris were evaluated. Fifty patients with chronic stationary plaque type psoriasis participated in a prospective study; in each patient two psoriatic plaques were examined by means of sonography, colorimetry and image analysis during treatment until complete resolution had occurred. Skin thickness and density could be quantified by means of high frequency ultrasound. In active psoriatic lesions, an echopoor area underneath the entry echo in the ultrasound image caused by acanthosis and inflammatory infiltrate is typical. Under therapy the thickness of this echopoor area diminishes while its density increases. Intensity of the erythema especially the decrease of erythema through healing could not exactly be quantified with the colorimeter because the 'Lab'-CIE-colour representation system cannot distinguish well enough between the colours red and brown. Image analysis allowed to measure the sizes of the psoriatic plaques and to quantify their resolution under therapy. The measuring of plaque size by the aid of computer based image analysis is possible and useful.

Contact allergy to 8-methoxypsoralen

A 36-year-old female patient was treated with PUVA for dyshidrotic eczema that had not shown sufficient response to topical therapy over the previous months. PUVA therapy caused acute aggravation of the eczema. Patch testing demonstrated Type IV sensitization to 8-methoxypsoralen in Meladinine solution.

Evaluation of the efficacy of H1 blockers by noninvasive measurement techniques

BACKGROUND

Evaluation techniques for determining the strength of action and the onset of activity of H1 receptor blockers have not yet been sufficiently standardized.

OBJECTIVE

The clinical efficacy of the H1 receptor blocker loratadine was to be measured upon a wheal response subsequent to an intracutaneous injection of 0.1 ml histamine (0.1%).

METHODS

In a pilot study, 10 patients were treated with the H1 receptor blocker loratadine for a period of 7 days. Various noninvasive measurement techniques, i.e. 20-MHz sonography, laser-Doppler flowmetry, chromatometry using the Lab* system and computer-assisted planimetry, were applied to provide a quantitative evaluation of the wheal and the marginal erythema. Using these quantification methods, the development of the urticarial reaction 20 min after injection and its decline were evaluated.

RESULTS

The urticarial reaction was reduced substantially under treatment with 10 mg loratadine over a period of 7 days. The methods we used could accurately quantify different aspects of the urticarial reaction noninvasively.

CONCLUSIONS

All of the chosen measurement techniques are widely recognized. For objective assessment of the urticarial reaction with high-frequency ultrasound, we recommend the measurement of the distance between skin entrance echo and fascia since the demarcation of the wheal is often impossible by ultrasound. In order to improve comparison of results of various workgroups in the future, we therefore suggest the use of the selected combination of noninvasive procedures as a standard for evaluating the efficacy of H1 receptor blockers.

Sonographic quantification of the type IV reaction after intradermal application of recall antigens

20-MHz B-scan high-resolution sonography permits non-invasive, two-dimensional visualisation of micromorphological structures in vivo, and allows precise measurement of the depth and extent of inflammatory skin lesions. In 50 patients, the reactions following intradermal application of 8 recall antigens to the volar forearm were evaluated clinically and sonographically at various times (0, 24, 48, 72 h). In 30 patients, one of the inflammatory papules was excised after 48 h for complete histological work-up (serial sections) and subsequent comparison with the sonographic image. Infiltrates were characterised in the ultrasound scans by the almost regular occurrence of convexity of the skin surface, by a loosened structure (loss of echogenicity) of the corium and by protrusion of the corium into the subcutaneous fatty tissue. It was also possible to follow the dynamics of the type IV reaction with the measurement of echogenicity (densitometry). High-frequency ultrasound is an objective, exact and very sensitive tool for the measurement of type IV reactions after intradermal application of recall antigens and therefore superior to clinical evaluation. The B-scan was superior to the A-scan. However, for routine evaluation of tuberculin-like reactions, sonography is too time-consuming. Our results suggest that densitometry provides no additional or necessary information compared to sonometry.

A local education campaign on early diagnosis of malignant melanoma

The growing incidence of all kinds of skin cancer is a worldwide phenomenon observed in the last decades. Malignant melanoma is of special concern because of its high death rate when in an advanced stage, poor therapeutic response and fast growing incidence. Malignant melanoma is primarily located on the skin and therefore well suited for early cancer detection. The "Deutsche Dermatologische Gesellschaft" carried out a highly successful information campaign in Germany. Under this roof we organised different campaigns. Following considerable success in a campaign in 1989, a total of 1467 patients were examined and advised in the course of a local initiative (Education Campaign "Black cancer") in the city of Bochum (approximately 400,000 inhabitants) in the summer of 1991. In addition to full body examinations, important data were collected concerning the degree of knowledge about skin cancer, epidemiology, and the risk of skin cancer in general. As a result of the clinical examinations, 73 patients with strongly suspected skin cancer have been treated. Within this group, 14 malignant melanomas (1.0%) as well as 34 basal cell carcinomas (1.9%) were diagnosed. These numbers highly exceed the assumed risk incidence of skin cancer in Germany. Even on the assumption that the population was selective it is to be feared that a high number of individuals with skin cancer remain undetected and untreated. The majority of persons seeking advice had been motivated by the local media. The response and results of this local campaign indicate that further preventive measures for the general population in Europe are conceivable, meaningful and urgently needed.