Epidemiology, comorbidities, and healthcare utilization of patients with chronic urticaria in Germany

BACKGROUND

Comprehensive data on the epidemiology and comorbidities of chronic urticaria (CU) in Germany are either limited, or not contemporary.

OBJECTIVES

To investigate the epidemiology of CU, overall comorbidities and healthcare resource utilized by patients with CU in Germany, using an anonymized statutory health insurance (SHI) database.

METHODS

Anonymized SHI claims research database of the Institute for Applied Health Research, Berlin [InGef] (01 January 2015-30 September 2018) was used to analyse insured individuals with a confirmed diagnosis of CU (ICD-10-GM codes). Twelve-month diagnosed prevalence and incidence, comorbidities (vs. atopic dermatitis and psoriasis), and healthcare utilization by patients with CU were investigated.

RESULTS

Of 4 693 772 individuals of all ages listed in the database, 3 538 540 were observable during 2017. Overall, 17 524 patients (˜0.5%) were diagnosed with CU; chronic spontaneous urticaria (CSU: 71.2%), chronic inducible urticaria (CIndU: 19.7%), CSU+CIndU (9.1%). Females, vs. males, had higher diagnosed prevalence (0.62% vs. 0.37%) and diagnosed incidence (0.18% vs. 0.11%) of CU among all patients. Patients most frequently visited general practitioners (41.3% of total visits). Hypertensive diseases (43.5%), lipoprotein metabolism disorders (32.1%) and affective disorders (26.0%) were the most frequently reported comorbidities of special interest. Rates of most comorbidities of special interests were similar to atopic dermatitis and psoriasis patients, and all higher vs. overall population. More than half (54.1%) of all CU patients were not prescribed any treatment. Second-generation H₁ -antihistamines were the most commonly prescribed medication for adult (17.9%) and paediatric (27.9%) patients. Patients with CIndU (paediatric, 15.5%; adult, 7.8%) were more often hospitalized versus patients with CSU (paediatric, 9.9%; adult, 4.6%).

CONCLUSIONS

In Germany, prevalence of CU along with multiple comorbidities may pose increased burden on the healthcare system. Awareness of adhering to treatment guidelines, and aiming for complete control of urticaria, needs to be driven and may improve outcomes.

Tod durch Sepsis nach längerfristiger hochdosierter Glukokortikosteroid-Therapie einer Urtikaria

Ein 80-jähriger Patient mit der Einweisungsdiagnose einer unklaren schweren Urtikaria wurde stationär in einer Klinik für Dermatologie über mehr als 3 Wochen mit systemischen Antihistaminika und intravenös gegebenen Glukokortikosteroiden in höherer Dosis (über 100 mg Prednisolonäquivalenten/Tag) behandelt. Darunter kam es zu einer diabetischen Stoffwechsellage, einer Thrombozytopenie und einer intensivmedizinisch nicht beherrschbaren Staphylokokkensepsis, die schließlich zum Tode führte.

Die Schlichtungsstelle beurteilte die längerfristige hochdosierte systemische Glukokortikosteroid-Therapie der Urtikaria als vermeidbaren Behandlungsfehler, da aufgrund der von der Klinik gewählten hohen Glukokortikoid-Dosen und der Behandlungsdauer mit einer ausgeprägten Immunsuppression und entsprechend hoher Infektanfälligkeit zu rechnen war, die sich im konkreten Fall in tragischer Weise realisiert hat.

In der Therapie der akuten Urtikaria, aber auch der chronisch-spontanen Urtikaria kann bei Nichtansprechen auf die höherdosierten H1-Antihistaminika die Gabe von systemischen Glukokortikosteroiden notwendig werden; diese sind allerdings bei akuter Urtikaria nur kurzzeitig (für 3 – 4 Tage) mit 40 – 50 mg Predinisolonäquivalent pro Tag empfohlen. Nur wenn assoziierte schwere Angioödeme vorliegen, ergibt sich eine Indikation für eine höherdosierte intravenöse Prednisolontherapie. Die aktuelle internationale Leitlinie zur chronischen Urtikaria äußert sich sehr kritisch gegenüber einer längerfristigen Anwendung von systemischen Glukokortikosteroiden bei der chronisch-spontanen Urtikaria; selbst bei akuten Exazerbationen der chronisch-spontanen Urtikaria sollte die Behandlung auf maximal bis zu 10 Tagen begrenzt werden.

Insbesondere im Fall des Off-Label-Einsatzes von Medikamenten, wie es im aktuellen Fall sowohl bez. der Antihistaminika als auch des systemischen Glukokortikosteroids gegeben war, treffen den behandelnden Arzt besondere Aufklärungspflichten, damit der Patient rechtswirksam zustimmen kann („informed consent“). Die Beweislast für die ordnungsgemäße Aufklärung über einen Off-Label-Use obliegt dem Arzt; diese sollte er zur Vermeidung von Aufklärungsrügen nach Möglichkeit schriftlich dokumentieren.

95 Jahre Universitäts-Hautklinik Jena: Geschichte und Gegenwart

Anlässlich des 95-jährigen Jubiläums der Universitäts-Hautklinik Jena beleuchtet dieser Beitrag die historische Entwicklung des Hauses in den verschiedenen politischen Systemen des letzten Jahrhunderts sowie die aktuelle Situation der Klinik als Teil des Universitätsklinikums Jena. Verschiedene Klinikleitungen in der Vergangenheit prägten die Ausrichtung des Hauses in Bezug auf Therapie und Forschung und setzten Schwerpunkte auf Themen wie Phototherapie, Autoimmunerkrankungen, Dermatoonkologie, Andrologie und Biomaterialforschung. Die Universitäts-Hautklinik vereint neben hochqualitativer Patientenversorgung und Lehre umfangreiche Forschungsaktivitäten.

Disseminierte kutane Sarkoidose mit nekrotisierenden Granulomen und erfolgreicher Dithranol-Therapie bei einem 75-jährigen Patienten

Bei der Sarkoidose handelt es sich um eine inflammatorische Erkrankung unbekannter Ätiologie, die sich hauptsächlich in der Lunge und in den thorakalen Lymphknoten manifestiert, die aber eine Vielzahl weiterer Organsysteme betreffen kann. Die Sarkoidose der Haut kann dabei mit oder ohne einer systemischen Beteiligung einhergehen und sich mit variablem klinischen Bild präsentieren. Die charakteristischen histologischen Befunde sind nicht-verkäsende („nackte“) Granulome ohne oder mit nur wenigen Lymphozyten oder Plasmazellen. In seltenen Fällen kann auch eine zentrale Nekrose beobachtet werden wie bei tuberkuloiden Granulomen.

Topische und/oder systemische Kortikosteroide gelten als Goldstandard für die Behandlung der kutanen Sarkoidose. Dithranol ist in erster Linie als topisches Antipsoriatikum bekannt. Nach unserem Wissen ist über die Verwendung von Dithranol bei kutaner Sarkoidose bisher nicht in der Literatur berichtet worden. Es könnte sich dabei um eine wirksame Therapiealternative zu topischen Kortikosteroiden handeln. Wir berichten über einen Patienten, der unter Dithranol-Monotherapie erfolgreich behandelt wurde.

Zertifizierung: „Impfen für Dermatologen (DDA)“

Das Fachgebiet der Dermatologie umfasst die Vorbeugung, Erkennung, konservative und operative Behandlung, die Nachsorge und Rehabilitation von Krankheiten der Haut sowie von Geschlechtskrankheiten. Historisch war die Dermatologie stark durch infektiöse Hautkrankheiten und sexuell übertragbare Infektionen geprägt wie Tuberkulose und Lepra, Syphilis und Gonorrhoe, aber auch virale Hautkrankheiten wie Pocken-, Herpesvirus- und HPV-Infektionen. Nicht nur die Diagnostik und Therapie von Infektionskrankheiten der Haut gehören zum Fachgebiet der Dermatologie, sondern auch deren spezifische Prävention, für die sich in den vergangenen Jahren neue Möglichkeiten durch die Verfügbarkeit von Impfstoffen ergeben haben.

Die Deutsche Dermatologische Akademie (DDA) hat daher mit dem Zertifikat „Impfen für Dermatologen (DDA)“ ein wichtiges Fortbildungsangebot auf diesem zunehmend wichtigen Teilgebiet der Dermatologie geschaffen.

Die Fortbildungsinhalte für die Zertifizierung „Impfen für Dermatologen (DDA)“ werden in einem ganztägigen Modul (8 Stunden) vermittelt; auch eine Aufteilung in Halbtage im Rahmen größerer Fortbildungsveranstaltungen ist möglich.

Die Seminare sind interaktiv; bestimmend ist die praxisorientierte Präsentation des Wissens und die kollegiale Diskussion mit ausgewiesenen Experten. Zum Erhalt des Zertifikats ist einmal alle 5 Jahre die Teilnahme an einem Qualitätszirkel (2 Stunden) vorgesehen, in dem aktuelle Entwicklungen komprimiert dargestellt und anhand von Falldiskussionen thematisiert werden.

[When sunscreens do not help: allergic contact dermatitis to UV filters]

Ultraviolet (UV) filters may cause allergic and more frequently photoallergic contact dermatitis. Therefore, a photopach test should always be performed in case of a suspected contact sensitivity to UV filters. We report a case of a 65-year-old woman with a recurrent erythema of the face and décolleté after sun exposure despite application of a sunscreen. The (photo)patch test revealed a contact sensitivity to the UV filter butyl-methoxybenzoylmethane. Treatment with a topical glucocorticoid and avoidance of the particular UV filter led to a rapid improvement.

Dose-response relationship of a new Timothy grass pollen allergoid in comparison with a 6-grass pollen allergoid

BACKGROUND

Subcutaneous allergen immunotherapy with grass pollen allergoids has been proven to be effective and safe in the treatment of patients with allergic rhinoconjunctivitis. Based on the extensive cross-reactivity among Pooideae species, it has been suggested that grass pollen extracts could be prepared from a single species, rather than from a multiple species mixture.

OBJECTIVE

To find the optimal dose of a Phleum pratense (P. pratense) allergoid preparation and compare its efficacy and safety to a 6-grass pollen allergoid preparation.

METHODS

In this double-blind, placebo-controlled study (EudraCT: 2011-000674-58), three doses of P. pratense allergoid (1800 therapeutic units (TU), standard-dose 6000 TU and 18 000 TU) were compared with placebo and the marketed 6-grass pollen allergoid (6000 TU). In a pre-seasonal dosing regimen, 102 patients were randomized to five treatment groups and received nine subcutaneous injections. The primary efficacy endpoint was the change in weal size (late-phase reaction [LPR]) in response to the intracutaneous testing (ICT) before and after treatment, comparing the active allergoids to placebo. Secondary outcomes were the change in Total Nasal Symptom Score (TNSS) assessed in the allergen exposure chamber (AEC), the changes in P. pratense-serum-specific IgG₄ and the incidence of adverse events (AEs).

RESULTS

All three doses of the P. pratense and the 6-grass pollen allergoid preparations were significantly superior to placebo for the primary outcome, whereas there were no significant differences in the change in TNSS. Compared to the standard-dose, the high-dose of P. pratense did not produce any additional significant benefit, but showed a slight increase in AEs. Yet this increase in AEs was lower than for the 6-grass pollen preparation.

CONCLUSIONS & CLINICAL RELEVANCE

The standard-dose of the new P. pratense allergoid was comparable to the marketed 6-grass pollen preparation at equal dose for the parameters measured.

[Isolated epidermal cysts of the vulva]

Vulvar cysts are rare und benign entities. They are epidermoid cysts which may develop following trauma or surgery. They can also spontaneously develop. They vary in number and size. They grow slowly and tend to show calcification. The treatment consists of surgical removal. Other methods are pinch-punch excision, heat application, and incision.

[Scabies as an occupational disease]

Scabies is an infectious skin disease caused by the human itch mite (Sarcoptes scabiei var. hominis). It is mainly transmitted by direct skin-to-skin contact. The spread of scabies can cause major difficulties in healthcare institutions, particularly in residential homes for the elderly. The disease is characterized by intense nocturnal itching, erythematous papules arranged in a linear order, and scratching resulting in excoriations. The diagnosis is confirmed by identification of the mite or by finding one or more mite tunnels in the skin. An individually occurring case does not need to be reported. If two or more cases occur in the same institution, the company physician and the appropriate public health department are to be informed in Germany. In case of a suspected scabies infection in medical personnel due to exposure in their work setting, medical notification to the statutory occupational accidents' insurance (Nr. 3101) is to be issued in accordance with § 202, Volume VII of the German Social Code. First line treatment is topical therapy with 5 % permethrin. If scabies control is required in an institution, systemic treatment with ivermectin may be considered. In the case of a scabies outbreak, all patients, contact persons, and staff must be treated simultaneously.

[The notion of occupational skin disease. Medical and legal aspects]

The different definitions of skin disease in medicine and in law are frequently confusing for dermatologists. While a skin disease may be defined medically referring to the definition of health by the WHO as a pathological condition of the skin leading to a disruption of the physical, mental and social well-being of the individual, legal definitions vary depending on the field of insurance law that is referred to. In the law of private health insurance, a skin disease is defined as an anomalous condition of the skin requiring medical treatment that exists independently of the subjective judgement of the insured person and needs to be objectively confirmed by a medical evaluation. In contrast, in the law of the social health insurance, the Federal Court of Social Justice defines disease as irregular physical or mental condition, deviating from the perception of a healthy human being that requires medical treatment or leads to inability to work. Substantial bodily disfigurement may be regarded as an irregular physical condition. In the law of the statutory accident insurance, occupational skin diseases are defined under clause 5101 of the occupational disease regulation as serious or repeatedly relapsing skin diseases that have forced a person to refrain from any work activities causal for the development, the aggravation or the recurrence of the disease. The Federal Court of Social Justice interprets the term "skin disease" from the protective purpose of the law, i.e. the protection against the economic and health consequences of the exposure to harmful agents and a thereby forced change of profession. This broad interpretation of the term "skin disease" leads to the recognition of diseases of the conjunctiva of the eye or diseases of the blood vessels of the skin due to cold damage as skin diseases according to clause 5101. For the correct treatment and possibly notification of occupational skin diseases in collaboration with various insurance carriers, dermatologists should be familiar not only with the medical definition, but also with these different legal definitions of skin disease.

[Exanthems and fever in travellers returning from the tropics]

Dengue fever with its subtle rash is today more common than malaria in travellers returning to Europe from the tropics (meta-analysis Geo Sentinel network). Up to 5 % of all safari tourists experience African tick bite fever during or soon after their journey; it is caused by rickettsiae and clinically presents with exanthems, focal necrotizing vasculitis (eschar, tache noir), lymphadenopathy and moderate fever. Typhoid fever is a severe infectious disease is which is difficult to diagnosis at first assessment. The presence of rose spots, which may be found in up to 33 % of patients with typhoid fever, can lead the way to diagnosis. Exanthems can be subtle and may occur weeks after infection without any other distinctive clinical sign. Particular importance in travel medicine has to be paid to acute HIV infection and secondary syphilis after exposition and infection in the tropics. Also the highly contagious infectious diseases of childhood as measles and rubeola have to be taken into account in adults with no or insufficient vaccination after a stay in tropical countries.

[Common tropical infections with protozoans, worms and ectoparasites]

Infectious diseases of the skin have become rarer in industrialized nations, but they still affect a considerable part of the population in tropical regions. Skin diseases induced by protozoa, worms and ectoparasites are among the 17 "neglected tropical diseases" defined by the WHO (leishmaniasis, dracunculiasis, lymphatic filariasis, onchocerciasis). Skin symptoms in travellers returning from the tropics may challenge dermatologists in Germany regarding differential diagnostic assessment and therapy. Among the 12 most frequent skin diseases in travellers are cutaneous larva migrans, leishmaniasis and myiasis. In this review, diagnosis, treatment and prevention of some the most relevant tropical dermatoses due to protozoa, worms and ectoparasites are discussed.

[Cutaneous manifestation of late-type syphilis]

HISTORY AND CLINICAL FINDINGS

A 49-year-old, otherwise healthy man presented at his dermatologist with tuberous skin changes that had be present for several weeks on head, arm and leg. These were asymptomatic, but disturbed him cosmetically. A skin biopsy was performed.

INVESTIGATIONS

The skin biopsy showed a granulomatous inflammation with prominent plasma cells, consistent with granulomatous infiltrate. Serologic tests confirmed a Treponema pallidum-infection. In addition, the patient was tested positive for hepatitis C and HIV (CDC stage A1). The clinical neurological examination did not show any pathological findings, however, analysis of the cerebrospinal fluid revealed a mild pleocytosis, elevation of protein and the glucose quotient and a normal Treponema pallidum TPPA-antibody index. A mesaortitis was excluded.

THERAPY AND COURSE

We diagnosed a tertiary syphilis (stage III). The patient refused prolonged inpatient treatment with penicillin G i.v., as recommended as first-line therapy in the national guidelines for asymptomatic neurosyphilis. Therefore, after a single oral administration of 100 mg prednisolone he received ceftriaxone intravenously for 14 days. The skin changes resolved. With regard to the HIV infection anti-retro-viral therapy was not yet indicated.

CONCLUSIONS

In view of the increasing incidence of syphilis in Germany clinicians should consider this diagnosis when confronted with oligosymptomatic skin lesions.

Evaluation of commercial skin prick test solutions for selected occupational allergens

BACKGROUND

Skin prick testing (SPT) is an important step in the diagnosis of IgE-mediated occupational allergic diseases. The outcome of SPT is related to the quality of allergen extracts. Thus, the aim of the study was to assess different commercially available SPT solutions for selected occupational allergens.

METHODS

SPT was performed in 116 bakers, 47 farmers and 33 subjects exposed to natural rubber latex (NRL), all with work-related allergic symptoms. The SPT solutions from different manufacturers (n = 3-5) for wheat flour, rye flour, soy, cow hair/dander, storage mites (Tyrophagus putrescentiae, Lepidoglyphus destructor, Acarus siro) and NRL were analysed with respect to their protein and antigen contents. SPT was carried out in 16 allergy centres in six European countries using standardized procedures. Specific IgE values were used as the gold standard to calculate the sensitivity and specificity of SPT solutions. The optimal cut-point for each SPT solution was determined by Youden Index.

RESULTS

Protein and antigen contents and patterns of the SPT solutions varied remarkably depending on the manufacturer. While SPT solutions for wheat flour and soy reached overall low sensitivities, sensitivities of other tested SPT solutions depended on the manufacturer. As a rule, solutions with higher protein and antigen content showed higher sensitivities and test efficiencies.

CONCLUSIONS

There is a wide variability of SPT solutions for occupational allergens, and the sensitivity of several solutions is low. Thus, improvement and standardization of SPT solutions for occupational allergens is essential.

[Rehabilitation for occupational dermatoses. Outpatient and inpatient measures]

In recent years, the number of reports of suspicions of occupational diseases, received by the public statutory employer's liability insurance bodies, has remained constant. The recognition of occupational diseases under number 5101 BKV, however, has decreased considerably. This is more than likely due to improved prevention management concepts by the public statutory employer's liability insurance bodies. Nevertheless there are still severe occupational skin diseases that are resistant to or relapse under therapy, thus threatening discontinuation of the occupation. For these cases, an interdisciplinary inpatient treatment as a tertiary individual prevention measure was introduced. This consists of a three-week inpatient period followed by a three-week outpatient sick leave for further stabilization of the skin condition. During the inpatient stay intensive dermatological diagnosis and treatment are accompanied by in-depth health education seminars and psychological interventions. The selection of individually suitable skin protection measures and their practical trial in a workplace simulation model with an ergotherapist are of particular importance. Evaluations of this program showed that two-thirds of the participants with the defined risk of having to give up their occupation were able to continue with their occupation on a long-term basis.

Antifungal effect of high- and low-molecular-weight chitosan hydrochloride, carboxymethyl chitosan, chitosan oligosaccharide and N-acetyl-D-glucosamine against Candida albicans, Candida krusei and Candida glabrata

OBJECTIVES

Generally, chitosan is a water-insoluble polyaminosaccharide with antimicrobial activity. The antifungal activity of water-soluble low- and high-molecular-weight chitosan hydrochloride, carboxymethyl chitosan, chitosan oligosaccharide and N-acetyl-d-glucosamine against Candida albicans, Candida krusei and Candida glabrata was investigated.

METHODS

Solutions of the tested substances in different concentrations (1, 0.5, 0.25, 0.1, 0.05, 0.025, 0.01, 0.005, and 0.0025%) were prepared and the influence on C. albicans DSM 11225, C. krusei ATCC 6258 and C. glabrata DSM 11226 was investigated. Yeasts (3 x 10(5) cells/mL) were incubated with Sabouraud liquid medium at 30 degrees C. Measurements were done with a microplate nephelometer (NEPHELOstar Galaxy, BMG LABTECH Ltd.) for 24 h. High values of light scattering correlate with strong cultural growth. Results were shown as growth curves and histograms displaying 24 h end points. These were compared with control by Mann-Whitney test. Furthermore, MIC(50%), MIC(80%) and Spearman correlation coefficients were calculated.

RESULTS

C. albicans and C. krusei were the most sensitive species. C. glabrata was also inhibited, whereas 1% of tested substances could not prevent its growth completely. However, only both chitosan hydrochlorides showed a definite antifungal effect with high correlation between inhibition and test concentration. Carboxymethyl chitosan, chitosan oligosaccharide and N-acetyl-D-glucosamine showed only a weak or no antifungal activity, respectively.

CONCLUSIONS

Antifungal activity decreases with declining molecular mass (chitosan oligosaccharide and N-acetyl-D-glucosamine) and increasing masking of the protonated amino groups with functional groups (carboxymethyl chitosan).

[Prevention of allergy by protective skin creams: possibilities and limits]

Despite promising efficacy data for protective creams and many scientifically proven advances that have been achieved concerning the prevention of irritative contact dermatitis, protection against sensitising substances remains a particular problem due to the minimal amounts of allergen that trigger allergic contact dermatitis. Therefore, specific allergen-blocking substances have been tested which are designed to prevent sensitising processes and in particular avoid occurrence of contact dermatitis in already sensitised individuals. In this review, we present the results of current studies mainly focussed on preventing occupational contact dermatitis caused by metal salts, using different chelating agents. In the United States allergic contact dermatitis is often due to strongly sensitising plant allergens of Toxicodendron species, a factor of importance in outdoor professions. Therefore, attempts have been made to use linoleic acid dimers and organoclay materials such as quaternium-18 bentonite for prophylaxis in topical treatments. Most studies investigate effectiveness against experimentally induced allergic contact dermatitis in sensitised volunteers using standardised allergen extracts. Although several preparations showed some benefit by possibly preventing certain quantities of allergen from penetrating the epidermis, further effort will be required before sufficient protective creams with allergen-blocking properties are available for workplaces.