Long-term efficacy of medium-dose UVA1 phototherapy in atopic dermatitis

BACKGROUND

UVA1 (340-400 nm) therapy proved to be highly effective in patients with severe atopic dermatitis. The optimal dose regarding therapeutic efficacy and possible side effects is still to be evaluated. In vitro cell culture as well as in vivo animal studies recently indicated that a correlation between UVA irradiation and photoaging, skin carcinogenesis, or melanoma induction may exist. Therefore it seems appropriate to focus research activities on reducing the UVA1 dose applied during phototherapeutic regimens minimizing nonbeneficial side effects.

OBJECTIVE

The present study was performed to evaluate the therapeutic effectiveness and long-term efficacy of medium-dose UVA1 irradiation in patients treated for acute exacerbated atopic dermatitis.

METHODS

Thirty-two patients underwent a medium-dose UVA1 therapy consisting of 15 treatments applied from Monday to Friday for a period of 3 weeks. The applied dose per treatment was 50 J/cm(2) resulting in a cumulative dose of 750 J/cm(2). Clinical severity was assessed according to the SCORAD index before and after irradiation as well as in monthly intervals up to 3 months after cessation of phototherapy.

RESULTS

Medium-dose UVA1 phototherapy is effective for alleviating acute exacerbated atopic dermatitis as shown by a significant reduction of SCORAD ratings (P <.001) at the end of the active UV treatment period. A significant skin improvement was still present 1 month later (P <.001). However, at the end of the 3-month posttreatment observation period the skin condition had reached the pretreatment level.

CONCLUSION

According to our data, medium-dose UVA1 phototherapy is a highly effective, nonsteroidal, therapeutic alternative for treatment of acute exacerbated atopic dermatitis. However, effectiveness is merely short term, limited, and is followed by recurrence of symptoms within a 3-month observation interval.

[Dubowitz syndrome and atopic eczema. Case report of monozygotic twins]

Autosomal recessive inheritance, intrauterine growth retardation, short stature, microcephaly, distinct facial dysmorphism, psychomotoric retardation, and often uncharacterized eczematous skin lesions distinguish the rare Dubowitz syndrome. Here a pair of monozygotic twins with Dubowitz syndrome and clear-cut atopic eczema is presented.

[Perianal streptococcal dermatitis]

Two boys aged 6 and 9 years presented with persistent sharply circumscribed perianal erythema. One boy had no other skin findings; the other had additional lesions on the genitalia and extremities. The diagnosis of perianal streptococcal dermatitis was made after streptococci were cultured from skin swabs. This primarily childhood disease should be distinguished from candidiasis and perianal atopic dermatitis. As in our cases, topical therapy is usually ineffective and oral penicillin remains the treatment of choice.

Optimal management of atopic dermatitis

Optimal treatment of patients with atopic dermatitis requires the knowledge of its pathogenetic factors and the often time-consuming attention to the course of the disease in each individual patient. In the therapeutic attempt, altered skin barrier function, possible provocation factors and psychological matters have to be taken into account. Basic therapy should comprise optimal skin care and the strict avoidance of triggering factors if possible. During periods of acute exacerbation, topical glucocorticosteroids in combination with classic antihistamines with sedative effects are still the drugs of first choice and will result in the rapid relief of symptoms in most patients. UVA1 phototherapy has proven to be a glucocorticoid-equivalent alternative therapy for exacerbated atopic dermatitis. If superinfection with Staphylococcus aureus is evident, topical antiseptics are useful in treating localized lesions, while a general superinfected eczema should be treated with systemic staphylococcal-effective antibacterials. Cyclosporin or extracorporeal photochemotherapy are reserved for patients with very severe atopic dermatitis that is unresponsive to conventional treatment protocols. Promising future therapeutic approaches consist of an improvement in the antipruritic treatment options, the topical application of immunomodifying treatment modalities or phosphodiesterase inhibitors, and possibly Chinese herbal therapies and psychological intervention strategies.

Effect of gentian violet, corticosteroid and tar preparations in Staphylococcus-aureus-colonized atopic eczema

BACKGROUND

In atopic eczema (AE), skin colonization with Staphylococcus aureus plays a possible role in the pathophysiology of the disease.

METHODS

Thirty-eight patients with AE were screened for their cutaneous colonization with S. aureus. The antibacterial and clinical efficacy of topical therapy with the antiseptic dye gentian violet, a potent glucocorticosteroid or a tar solution (liquor carbonis detergens) was evaluated in vivo in 21 patients with a density of >10(4) CFU/cm(2) and in vitro. Skin sites were treated twice daily for 4 days with the active drug or a corresponding control. Quantification of S. aureus was done daily during therapy as well as 3 days thereafter. The severity of the lesions was rated by a regional SCORAD.

RESULTS

In gentian-violet-treated skin, bacterial density decreased significantly in lesional (p < 0.001) and unaffected skin (p < 0. 001). Bacterial densities did not decrease during therapy with glucocorticosteroid or liquor carbonis detergens but dropped afterwards. All therapeutics reduced the severity score, reduction being greatest for the glucocorticosteroid and lowest for liquor carbonis detergens. In vitro, a high antibactericidal efficacy was demonstrated only for gentian violet.

CONCLUSIONS

Antibacterial therapy with gentian violet not only reduces S. aureus dramatically, but also reduces the severity of the eczema. Reduction of S. aureus after therapy with glucocorticosteroids and LCD seems to be secondary to improvement of the skin condition.

Two ceramide subfractions detectable in Cer(AS) position by HPTLC in skin surface lipids of non-lesional skin of atopic eczema

The non-involved skin of atopic eczema (NEAE) is characterized by severe dryness and an impaired barrier function of the stratum corneum as indicated by an increased transepidermal water loss. Previous studies have demonstrated that this barrier impairment coincides with marked alterations in the amount and composition of stratum corneum ceramides. The aim of this study was to identify specific alterations in NEAE that may be used in the diagnosis of the atopic eczema. Using a classical procedure for high performance thin layer chromatography we could confirm earlier results: apart from Cer(EOH), which contains omega-hydroxy fatty acid (O) ester-linked to linoleic acid (E) and amide-linked to 6-hydroxy-4-sphingenine (H), the quantities of all ceramide fractions were significantly decreased. Furthermore, Cer(EOH)/Certotal was significantly increased, whereas the percentage of Cer(EOS), which contains sphingosine (S), and Cer(NP), which contains non-hydroxy fatty acid (N) amide-linked to phytosphingosine (P), were significantly decreased. Using a modified procedure for high performance thin layer chromatography we could demonstrate the formation of a double peak in the position of Cer(AS), which contains alpha-hydroxy fatty acid (A), in lipids of NEAE. The subfractions of the double peak comprised 15% and 12% of Certotal. MALDITOF mass spectrometry suggested that the double peak was formed by a homologous series of mono-hydroxylated and mono-unsaturated ceramides of different chain length, e.g., Cer(AS) subfractions containing either (C16,18) or (C22,24,26) alpha-hydroxy fatty acids. In contrast, in normal skin a single peak in Cer(AS) position, which comprised 22% of Certotal, was mainly formed by the long chain subfraction. In some cases this single peak displayed a small shoulder at its right flank, but never showed a clear peak separation when developed with NEAE samples. Furthermore, even in senile xerosis, or in either non-involved skin of psoriasis or seborrhoic eczema, only a single peak occurred in Cer(AS) position. Accordingly, the double peak might be specific for NEAE and turn out to be a marker for atopic eczema.

[Henoch-Schönlein purpura: successful treatment with Dapsone]

A 26-year old patient who suffered from purpura for four years evolved into the complete clinical picture of Henoch-Schönlein-purpura in the past two years. A causative agent was never found. Multiple therapeutic approaches including systemic steroids, azathioprine as well as pentoxyfylline failed to control the arthralgias, intestinal symptoms and skin lesions. Therefore dapsone therapy was initiated at a dosage of 100 mg daily after checking the glucose-6-phosphate-dehydrogenase and with regular control of the blood methemoglobin level. Within two weeks, the patient's symptoms completely cleared, he has now been in remission for the past six months. As noted elsewhere, dapsone is an effective therapy for severe cases of Henoch-Schönlein- purpura.

Effect of penicillin G on corium thickness in linear morphea of childhood: An analysis using ultrasound technique

Linear morphea is the most common form of localized scleroderma in children. The pathogenesis of this disorder is unknown. We report a child with a 6-year history of linear morphea in whom intravenous administration of 5 MU aqueous penicillin G three times a day for 10 consecutive days caused reduction in the thickness of the corium as demonstrated by ultrasound measurements.

[Treatment of acute exacerbated atopic eczema with emollient-antiseptic preparations using the "wet wrap" ("wet pajama") technique]

Six patients (3 children and 3 adults) with acute exacerbated atopic eczema were treated with basic emollients in combination with chlorhexidine-soaked dressings over a period of three days using the "wet-pyjama" technique. Improvement of eczema was documented with the severity score "Scoring of Atopic Dermatitis" (SCORAD); most pronounced changes were found for the subjective parameters itch and sleep loss. Paralleling skin improvement a reduction of Staphylococcus aureus colonisation was noted. Improvement of skin changes lasted beyond the active treatment period. Wet-wrap dressings are an effective treatment modality for atopic eczema without use of corticosteroids and can be used easily on an outpatient basis when manufactured dressings are used.

The wide spectrum of clinical expression in Adams-Oliver syndrome: a report of two cases

Two children are described with the combination of aplasia cutis congenita (ACC) and transverse limb defects known as Adams-Oliver syndrome. Whereas in the first child the typical features of ACC, syndactyly and transverse nail dystrophy were only mildly expressed and associated defects of the central nervous system and cardiac malformations were absent, the second child suffered from a very severe expression of the syndrome, with a combination of ACC, syndactyly, cutis marmorata telangiectatica congenita and multiple cardiac and central nervous system malformations which resulted in fatal central respiratory insufficiency.

[Systemic therapy in the treatment concept of atopic eczema. Reliable treatment methods and experimental developments]

Our therapeutic approach to atopic eczema consists of a continuous topical dermatological basic therapy in combination with an antiinflammatory therapy in phases of exacerbations. In the treatment of exacerbated atopic eczema, systemic agents are added to achieve effective control more rapidly or to induce remissions in cases refractory to standard therapy. Antihistamines to control the pruritus, as well as antibiotics and acyclovir for antimicrobial superinfections are often used. In many patients exacerbations can be successfully controlled with phototherapy, especially with UVA1 light. The use of systemic immunosuppressants, like glucocorticosteroids, cyclosporine or azathioprine generally can be avoided and is a therapeutic alternative only in few selected cases. In the last years promising new experimental treatments have evolved, which could become therapeutic alternatives for the future.

Environmental risk factors for respiratory and skin atopy: results from epidemiological studies in former East and West Germany

The fall of the Berlin wall in 1989 offered the unique opportunity to compare populations of a similar genetic and geographic background which had been living under quite different environmental exposure conditions for over 40 years. Since 1990 comparative epidemiological studies were performed between various regions in former East and West Germany with yearly questionnaires and 3 years' physical, dermatological, allergological and exposure examination in a total of about 30,000 preschool children. There were striking differences between the various German regions with higher prevalence rates of respiratory atopy (hay fever, asthma) and atopic sensitization (prick test, RAST) in West Germany, while atopic eczema was significantly higher in East Germany (17.5 vs. 11.4% in West Germany). Total serum IgE levels were markedly higher in children in the east of Germany, similarly to the prevalence of parasitic infestation (questionnaire data as well as positive ascaris RAST). In multivariate logistic regression analysis the following factors were significantly associated with atopic eczema: animal contact (odds ratio, OR 2.9), animal furs in the bedroom (OR 2.2), use of gas without ventilation (OR 1.7) and living near road with heavy traffic (OR 1.7). Furthermore, socioeconomic factors measured as parental educational status (university vs. elementary school) were significantly associated (OR 2.3) with atopy. Respiratory tract infections and irritant responses decreased together with decreasing SO2 and suspended particulate air pollution in East Germany from 1991 to 1997. It is concluded that environmental factors from the physical, chemical, biological, and psychological environment (characteristic of a 'modern' or 'western' society) do influence the development of atopic sensitization and disease.

[Unilateral latero-thoracic exanthema in childhood. Clinical characteristics and diagnostic criteria in 5 patients]

Unilateral laterothoracic exanthem a (ULE) is a self-limited, probably infectious-allergic skin disease predominantly affecting small children. We describe five such cases. The typical unilaterally located or at least unilaterally dominant exanthem usually starts in the axillary region and is characterized by red, partly confluent papules and fine scales. Two of the children presented with atypical manifestations of ULE. Due to its asymptomatic course, therapy is not necessary in the majority of cases.

Safety and efficacy of intermittent therapy with itraconazole in finger- and toenail onychomycosis: a multicentre trial

The efficacy and safety of intermittent itraconazole therapy were investigated in patients with onychomycosis. Patients were divided into two groups according to site and extent of infection. Group A comprised 635 patients with toenail onychomycosis (at least one nail with > or = 20% involvement; n = 560) or fingernail onychomycosis (at least one nail with > 75% involvement; n = 63) or both (n = 12). These patients received itraconazole 400 mg day-1 for 1 week per month for 3 months. Group B comprised 48 patients with fingernail onychomycosis (at least one nail with > or = 20% involvement but no nail with > 75% involvement) who received itraconazole 400 mg day-1 for 1 week per month for 2 months. Patients were followed for a further 18 weeks without treatment, and received another treatment cycle if not cured or markedly improved 6 weeks after the end of the last cycle. An additional cycle was administered to 76 patients with fingernail onychomycosis (group A, n = 43; group B, n = 28) and to 316 patients with toenail onychomycosis. Clinical response rates and mycological cure rates at study end point were 89.0% and 68.4% respectively for toenails, 91.4% and 85.3% respectively for group A fingernails and 84.4% and 77.1% respectively for group B fingernails. Most adverse events occurred infrequently; major changes in liver function tests were not noted. In conclusion, intermittent itraconazole therapy is highly effective and safe in patients with onychomycosis.

[Cutaneous Staphylococcus aureus colonisation of atopic eczema. Mechanisms, pathophysiological importance and therapeutic consequences]

Mechanisms for the increased Staphylococcus aureus colonization in atopic eczema are only partially known. From the aspect of the bacterium, the presence of various extracellular matrix components seems important. In the host epidermal lipid deficencies disturbing barrier dysfunction are important. Staphylococcus aureus' immunological and inflammatory effects include the release of superantigens, additional exotoxins and exoenzymes and perhaps bacterial DNA-triggered mechanisms. Therapeutic possibilities include the use of systemic antibiotics in cases of generalized superinfected atopic eczema, the use of corticosteroids and specific antibiotic-antiseptic combinations in cases of localised superinfected atopic eczema and the wide-spread use of topical antiseptics in cases of microbial-laden atopic eczema.

Gianotti-Crosti syndrome: clinical, serologic, and therapeutic data from nine children

Gianotti-Crosti syndrome (GCS), a self-limiting papulovesicular acrodermatitis often associated with underlying viral infection, is mainly described in children. Nine children with GCS were evaluated with dermatologic examination and serologic tests for viral infections. Therapy was modified according to the subjective symptoms of patients, which included characteristic acrolocated papulovesicles, generalized skin eruption, and mild to severe pruritus. Results of serologic investigations revealed Epstein-Barr virus, Coxsackie A virus, parvovirus B19, and parainfluenza virus 1/2. In three children no underlying viral infection was found. Therapeutic interventions included topical clioquinol lotion 1 percent, topical application of corticosteroids, systemic antihistaminic therapy, and systemic methylprednisolone. Skin lesions resolved after 2 to 4 weeks in treated as well as in nontreated children. Although GCS in children often lacks close association with a causative viral infection, such severe infections as hepatitis B and human immunodeficiency virus must be considered. Whole-body involvement seems to correlate with severe pruritus and additional general symptoms requiring more intensive therapy.

Proteus syndrome with widespread portwine stain naevus

Proteus syndrome is a rare condition comprising asymmetrical overgrowth of different parts of the body in association with various cutaneous abnormalities. We describe a 3-year-old boy with Proteus syndrome, who presented with hemihypertrophy of the right leg, asymmetric macrodactyly, subcutaneous masses and a widespread portwine stain interspersed with angiokeratomas on the right leg, scrotum and on the middle and left side of the back. Doppler ultrasound of the right leg did not show hypercirculation, but did reveal the absence of the right superficial femoral vein.

Staphylococcus aureus colonization in atopic dermatitis and its therapeutic implications

Skin colonization with Staphylococcus aureus is a characteristic feature of atopic dermatitis with more than 90% of patients being colonized. Extracellular matrix proteins are important for the adherence of S. aureus to human keratinocytes. The bacterium interferes in the inflammatory process of atopic dermatitis in various ways, among which the ability to release superantigens in a high percentage of clinical isolates is of great importance. As the colonization correlates significantly with the severity of eczema, anti-staphylococcal treatment measurements are widely used. In cases of atopic dermatitis exacerbation with wide-spread weeping lesions, a systemic antibiotic treatment is warranted, with erythromycin no longer being recommended due to an increased resistance rate. In localized superinfected lesions the topical application of an antibiotic-glucocorticoid preparation may offer advantages to the mere steroid application. Based on efficacy and resistance data, fusidic acid is the antibiotic of choice. There is evidence that phototherapy in atopic dermatitis may be even more effective when combined with anti-staphylococcal measurements. In the future new therapeutical options may be available.

Isolation of cDNA clones coding for IgE autoantigens with serum IgE from atopic dermatitis patients

Recently we demonstrated that a high percentage of atopic dermatitis (AD) patients displayed specific immunoglobulin E reactivity to human proteins. Here we show that IgE autoreactivity is found predominantly in AD patients with severe skin manifestations and reveal the molecular nature of four IgE autoantigens. An expression cDNA library constructed from a human epithelial cell line (A 431) was screened with serum IgE from two AD patients. DNA sequence analysis of three IgE-reactive clones identified the alpha-chain of the nascent polypeptide-associated complex, cytokeratin type II, and the BCL7B oncogen as atopy-related IgE autoantigens (ara). The fourth cDNA coded for an IgE autoantigen containing a typical calcium binding motif that occurred in histogenetically different cells and tissues (keratinocytes, muscle, brain). Recombinant Escherichia coli-expressed IgE autoantigens bound IgE from AD but not from patients with other immunologically mediated disorders (graft vs. host disease, systemic lupus erythematosus) and elicited immediate type skin reactions in AD patients. In serum samples collected from an AD patient over a period of 5 years, IgE anti-ara NAC antibody levels peaked during disease exacerbation. Our finding that ara BCL7B was detected in serum bound to IgE antibodies suggests that intracellular IgE autoantigens can become released after tissue damage and may occur as IgE immune complexes. Via binding to antigen presenting cells as well as to effector cells, IgE autoantigen immune complexes may contribute to exacerbation and/or perpetuation of severe atopic diseases even in the absence of exogenous allergens.

Role of Staphylococcus aureus surface-associated proteins in the attachment to cultured HaCaT keratinocytes in a new adhesion assay

Colonization of human skin with Staphylococcus aureus is a common feature in a variety of dermatologic diseases. In order to reproducibly investigate the adherence of Staphylococcus aureus to human epidermal cells, an in vitro assay was established using the biotin/streptavidine labeling system and the HaCaT cell line. This assay was used to define the role of several Staphylococcus aureus surface proteins with regard to their function in the staphylococcal adhesion process. Our studies included the standard laboratory strain Newman as well as its genetically constructed mutants DU5873, DU5852, DU5854, and DU5886 generated by allele replacement or transposon mutagenesis, which are deficient in the elaboration of staphylococcal protein A (spa), clumping factor (clfA), coagulase (coa), and the fibronectin-binding proteins A and B (fnbA/B), respectively. In comparison with strain Newman all mutants showed remarkably reduced adherence to the HaCaT keratinocyte cell line in our assay, yielding only between 43% and 60% of the adherence capacity of strain Newman after 60 min. Bacterial adherence could be re-established by introducing the cloned wild-type genes for the surface proteins on shuttle plasmids into the chromosomally defective mutants, thus suggesting a pathogenetic role of these proteins in the attachment of Staphylococcus aureus to human keratinocytes. Bacterial adherence was additionally enhanced by alkaline pH-values that are characteristic for skin conditions with epidermal barrier dysfunction. The use of Staphylococcus aureus mutant strains, deficient in the elaboration of defined proteins, allows specific investigation of colonization and virulence factors of this dermatologic relevant microorganism.