[Manifestations of sexually transmitted diseases on oral mucous membranes]

Many believe that oral sex is safe sex and does not pose a risk of getting sexually transmitted diseases. Despite the prevalence of oral sex, the number of diagnosed oral and pharyngeal sexually transmitted infection is lower than that of anal and vaginal sex. Oral contact with the genitals can cause tiny micro traumas through which pathological microorganisms that are present in body fluids can come into contact and be transmitted. This article reviews the literature on the role of oral sex in the transmission of sexually transmitted diseases and the corresponding clinical presentation or oral diseases.

Penile cutaneous horn ten years after treatment of verrucous squamous cell carcinoma on penile glans: case report

Penile cutaneous horn is a clinical term that describes protruding hyperkeratosis, usually conical in shape, located on penile glans. Penile localization of this lesion, predominantly located on sun-exposed areas, is very rare. The association with malignancy on the penis makes proper identification of these lesions essential. We present a 45-year-old man with a cutaneous horn, 25 mm in size, located on the basis of penile glans. The patient had a history of phimosis, pseudoepitheliomatous balanoposthitis, surgical excision of penile verrucous squamous cell carcinoma (SCC) and postoperative radiotherapy of carcinoma in situ on the same localization, ten years before. Complete surgical removal of the horn with separate excision of the margins and base was done. Pathologic examination revealed squamous hyperplasia with suspicion of carcinoma in situ. Additional negative p16(INK4a) immunohistochemical analysis confirmed benign proliferative lesion. DNA polymerase chain reaction for human papilloma virus infection was negative. These findings suggested sparing surgical procedure in our patient, without indication for partial penile amputation, but with mandatory follow-up. Our case confirmed the association of pseudoepitheliomatous balanoposthitis with verrucous SCC, as well as the possible influence of radiotherapy on the development of penile cutaneous horn. Additionally, we showed the important role p16(INK4a) immunohistochemical analysis in the differential diagnosis of alterations adjacent to invasive SCC of the penis.

[Reactions to insect stings and bites]

Reaction to insect sting and bite may be local, such as erythema, edema and pruritus, or systemic, such as anaphylactic reaction. Diagnosis can be made by patient history, clinical picture, skin testing, total and specific IgE level, and provocation test. Local reactions are treated with cold compresses, topical corticosteroids and oral antihistamines. Oral and intramuscular antihistamines and corticosteroids are used for the treatment of mild systemic reactions, and in severe reaction epinephrine injections are added. Hyposensitization is indicated in patients with severe systemic reaction, positive skin tests and high level of specific IgE antibodies.

[Atopic dermatitis in children and adults]

Atopic dermatitis (AD) is a chronic relapsing inflammatory skin disease characterized by itching and typical clinical features, depending on patient age. It is often associated with other atopic diseases such as asthma or allergic rhinitis, resulting from the complex etiology and pathogenesis. It occurs more frequently in people with genetic predisposition for atopic diseases. The intensity and extent of skin lesions (Scoring of Atopic Dermatitis, SCORAD Index) vary significantly among AD patients, depending on whether it is acute or chronic, and there are variations in laboratory parameters, especially immune. In the future, it will be necessary to reach consensus on the new criteria for defining AD instead of the old ones (brought by Hanifin and Rajka 31 years ago). What is needed is effective and safe treatment, and control of the early stages of AD as well as maintaining AD remission. The new therapeutic approach in AD has greatly improved the quality of life of AD patients. As the prevalence of the disease continues to increase, we emphasize the importance of prevention, prompt recognition and optimal treatment of the many patients with AD.

Molecular variants of human papilloma viruses type 16 and 6 in women with different cytological results detected by RFLP analysis

HPV infections are common and the presence of the same high-risk type in cervical specimens can be due to reinfection or persistence. Persistent infection is the most important predictor for development of cervical carcinoma. The aim of this study was to validate PCR-RFLP with two sets of primers: MY09/MY11 that amplify a fragment of L1 and P1/P2 that amplify a fragment of E1 ORF. PCR product of MY09/MY11 was digested with a set of 6 restriction enzymes (RE) and PCR product of P1/P2 with a set of 12 RE. Cervical samples from 110 women patients of the University Gynecologic Clinic CHC Zagreb were analyzed. There were 98 (89.1%) PCR positive samples detected with P1/P2 primers, and 94 (85.5%) PCR positive samples detected with MY09/MY11 primers. Seven HPV types were detected with P1/P2-RFLP technique and 17 with MY09/MY11-RFLP PCR positive samples amplified with both primer pairs agreed with each other in 82 samples; 16 samples were only positive with P1/P2 and 12 samples were only positive by MY09/MY11. HPV 16 was detected in 39 samples with MY09/11-RFLP, out of these two variants (two different patterns) were found with P1/P2 using Dde I, Hae III and Eco I. HPV 6 was detected in 9 samples with MY09/11-RFLP, out of these two variants were found with P1/P2 using HinfI. Combining these two PCR-RFLP methods subtypes of HPV 16 and HPV 6 were detected.

Sexually transmitted infections and adolescence

Sexually transmitted infections (STIs) remain a public health problem of major significance in most of the world. Adolescents make up about 20% of the world population, of whom 85% live in developing countries. They are at a greater risk of STIs because they frequently have unprotected intercourse, biologically may be more susceptible to infection, often are engaged in multiple monogamous relationships of limited duration, and face multiple obstacles in accessing confidential health care services. Young people who begin to have sexual intercourse in early or middle adolescence are more likely to develop an STI than those who postpone intercourse until later adolescence or adulthood. The most common STIs among adolescents are chlamydia, gonorrhea, human papillomavirus infection, and trichomoniasis. Unfortunately, lately the incidence of HIV/AIDS and syphilis among adolescents is growing. Comprehensive sex education programs in schools can increase STI knowledge and prevent risky sexual behaviors. Health care providers can promote STI prevention methods, including counseling about safe sex.

[Diagnostic-therapeutic guidelines for men whose partners have HPV genital infection]

Human papilloma virus infection is the most frequent sexually transmitted disease. HPV infections are connected with different diseases such as benign warts, condylomata acuminata, malignant cervical, vulvar, vaginal, penile and anal carcinoma. Peniscopy with HPV detection is a specific diagnostic method for diagnosis of subclinical HPV genital infection in asymptomatic men. Taking the samples for HPV detection from asymptomatic men with curette is more qualitative way of getting enough samples then taking swab with wooden stick or (tongue) depressor. Early diagnosis and treatment of HPV infections in men is of potential benefit because their eradication can reduce the viral reservoir and as the result of that the incidence of CIN, carcinoma in situ and invasive cervical carcinoma can be reduced. For the correct diagnosis and for choosing the adequate therapeutical technique, we suggest diagnostic-therapeutic guidelines for HPV genital infection in men.

Genital contact allergy

Irritant and allergic contact dermatitis is commonly seen in patients complaining of itching, burning and irritation in the genital area. The aim of this retrospective study was to establish the prevalence of allergic contact dermatitis patients with genital complaints. We followed 33 patients with persistent or recurrent genital redness, itching and burning sensation. Diagnosis was made by history, clinical examination and patch testing. Patch tests were carried out according to the International Contact Dermatitis Research Group with a standard series of allergens. We also tested topical pharmaceutical products that individual patients used for treating genital symptoms and patients self intimate hygiene products. There were 11 male and 22 female patients, mean age 38 years. Thirteen (39%) patients had one or more positive allergic reactions, mainly to nickel-sulfate, thimerosal, balsam of Peru, formaldehyde and neomycin sulfate. In seven of 13 patients with positive patch test results, these reactions were considered to be relevant to their clinical condition. Three patients had positive patch test reactions to their intimate hygiene products. One patient had positive patch test reaction to latex condom. Patients with genital symptoms are at a risk of developing contact sensitivity. Patch testing is useful in the management of these patients and many can be helped by allergen avoidance.

Human papilloma virus associated with genital infection

Genital human papillomavirus (HPV) infections are among the most common sexually transmitted diseases. HPV is associated with a spectrum of diseases ranging from benign vulgar verrucae and condylomata accuminata to malignant cancers of the cervix, vulva, anus and penis. Genital HPV is in most cases transmitted sexually, but non-sexual routes of transmission, such as perinatal and autoinoculation, are possible. Men can be a reservoir of the virus that lives in latent or subclinical form on genital mucosa. Such an asymptomatic infection may be an oncogenic factor in the development of cervical cancer Colposcopic examination of the genitalia after the application of 3-5% acetic acid is a reliable method for the identification of subclinical HPV infection. Successful therapy of anogenital warts is characterized by their complete clearance, as well as by the lack of recurrence. Current treatments do not reliably eradicate HPV infections. The diagnosis and therapy of HPV infection in men is potentially beneficial because the eradication of penile HPV infection may decrease the reservoir of the virus.

Perioral dermatitis

Perioral dermatitis is an inflammatory facial skin disorder that predominantly affects women. It is rarely diagnosed in children. The etiology of perioral dermatitis is unknown; however, uncritical use of topical corticosteroids often precedes skin lesions. There is a written diagnostic work-up, differential diagnosis and treatment.

Epidemiology of sexually transmitted diseases and infections

Sexually transmitted diseases and infections (STDIs) are known to have a major socioeconomic and biologic impact, par notticularly on women (e.g., sterility, ectopic pregnancies, neo notplasms, etc.) and fetus (intrauterine and perinatal mortality, infection, malformations). Sex work noters do not use health services appropriately and are a high-risk category. Despite this evidence, data on prostitution and STDIs in some countries are limited. Sexual health medicine is involved in the community by identifying and minimizing the STDI problems through laboratory screening, diagnostic testing, education, and research.

The human papillomavirus vaccines

Genital human papillomavirus (HPV) infection is the most common sexually transmitted infection (STI) among sexually active couples. Its annual incidence is approximately 5.5 million. Overall, an estimated 75% of sexually active men and women have been exposed to HPV at some point in their lives. HPV-16 and -18 account for about 70% of cancers of the cervix, vagina and anus, and for about 30%-40% of cancers of the vulva, penis and orophaynx. Cancer of the cervix uteri is the second most cancer among women worldwide. Cancer of the penis is a rare cancer, accounting for less than 0.5% of cancers in men. Spontaneous clearance of HPV infection is accompanied by humoral and cellular immune response against virus-specific antigens. Two vaccines, prophylactic and therapeutic ones, are considered. Prophylactic vaccines use L1 and L2 capsid proteins to induce production of conformationally-specific antibodies. They block HPV infection. Lone L1 and L2 proteins self-assemble into a capsid that is identical to the complete virion. In this way, an antibody-mediated response is induced before the body actually comes into contact with the live virion. Therapeutic vaccines are being developed to protect HPV-positive persons against tumor development. For these vaccines, researchers are targeting the activity of the E6 and E7 oncoproteines.On June 8, 2006, the U.S. Food and Drug Administration (FDA) approved an HPV vaccine for clinical use. The HPV vaccine that has been approved is the quadrivalent vaccine that consists of recombinant viral-like particles (VLPs) of HPV 6, 11, 16, 18 mixed with an aluminum-containing adjuvant. It is manufactured by Merck & Co., Inc. and sold under the name of Gardasil?. The new vaccine is approved for use in females 9-26 years of age. The primary target population for vaccination should be females aged 11-12 years. However, vaccination can be given to girls as young as 9 years of age. Vaccination can receive women aged 13-26 years who have been sexually active. There are still no data on the vaccine efficacy in women older than 26, and currently no data to demonstrate the efficacy of vaccination in males; male subjects should not be vaccinated until such data become available. The vaccine is to be administered intramuscularly either into the deltoid muscle of the arm or the high anteriolateral area of the leg. Each patient receives three 0.5 mL doses given according to the following schedule: first dose is given at the elected date, second dose two months after the first dose, and third dose six months after the first dose. According to statements from Merck, the list price of the vaccine is 120 USD per dose. GlaxoSmithKline is now conducting a phase III trial of a bivalent (HPV 16, 18) vaccine, and it is going to be presented under the name of Cervarix. Similar results to those obtained with the quadrivalent HPV vaccine have been reported with the bivalent vaccine. It is expected to be released in June next year. Evaluation of the HPV vaccine efficiency in preventing dysplasia and cancer has been recommended as a globally accepted endpoint for population based studies.

Pyoderma gangrenosum associated with ulcerative colitis

We report the case of a 45-year old man with non-healing ulcers located on his chest, lumbal, sacral, retroauricular areas and forehead. Both clinical and histopathological examinations suggested pyoderma gangrenosum (PG). For six months the diagnosis of ulcerative colitis was established. PG in our patient was presented as a rapidly enlarging, painful ulcer with purple, undermined edges and a necrotic, haemorrhagic base. Initially, he was treated with a high dosage of peroral glucocorticosteroid, sulfasalazine, and systemic antibiotics, together with daily wound care. Ulceration partially regressed. Total colonoscopy showed pancolitis. When the dose of glucocorticosteroids was tapered down to 35 mg, new ulcerations on his right thigh and abdomen were formed. He also developed E. coli sepsis and flare up of bowel disease. Azathioprine, together with two pulse doses of glucocorticosteroids and antibiotics, were administered. He was scheduled for a total colectomy. The management of PG continues to be a therapeutic challenge.

Erysipeloid--case report

Erysipeloid is an acute, bacterial infection of traumatized skin in an individual who was in direct contact with meat or other animal products contaminated with a gram-positive bacillus Erysipelothrix rhusiopathiae. We present a case of a 50-year-old housewife whose hobby was fishing, with a reddish, tender patch on the fifth finger and dorsum of the left hand, which developed a week after she had sustained an injury while boning the fish. The patient was treated with orally administered penicillin V 1,500,000 IU t.i.d. for 7 days, with complete resolution.

[What should we know about contact hypersensitivity to local glucocorticoids?]

Local glucocorticoids are still the most frequently used drugs in dermatology. In recent years there have been an increasing number of reports on contact allergic reactions to glucocorticoid. Patients with contact allergy to glucocorticoid generally present with chronic dermatitis that is exacerbated by and fails to respond to glucocorticoid therapy. Most patients react in patch test to more than one glucocorticoid, but mostly to tixocortol pivalate and budesonide. In patients with prolonged eczematous skin disease and other chronic inflammatory disease who do not improve, or who deteriorate during topical glucocorticoid therapy, contact allergy should be suspected and patch test should be preformed.

Some thoughts about the role of sexually transmitted diseases in everyday life

Sexually transmitted diseases and infections (STDIs) have for centuries been a big concern all around the world. Since they were recognized, many groups have thought how to provide care for those affected with STDIs. They are most prevalent among teenagers and young adults. Nearly two-thirds of all STDIs occur in people younger than 25 years. The incidence of STDIs is rising. STDIs exist in three different forms, viral, bacterial, and parasitic. Screening is recommended in all young people who may have been sexually abused or who have been found to have an STDI. Risk prevention must not be a singular occasion but continuous task. Preventive and curative medical measures must be combined with social and psychological assistance. The prevention and counseling methods together with effective public education are recommended to decrease the spread of STDIs.

A review of sunscreens and their adverse reactions

Sunscreens are used to protect the skin from harmful effects of ultraviolet (UV) light but they do not completely prevent photocarcinogenesis, photoaging and photoimmunosuppression. They are useful for protection against UVB and short-wave UVA. Complete protection against long-wave UVA has not been achieved. There is no universally accepted method to evaluate UVA protection. Sun protection factor is a simple and internationally used method to compare sunscreen protection against UVB induced erythema. Adverse reactions to sunscreens are not common but they should be considered especially in persons with pre-existing eczematous conditions or photodermatoses. The use of sunscreens has increased steadily over the last decade; as a result, allergy and photoallergy to UV filters are now more frequent than in the past. Sensitization can occur from the various sunscreening agents and from the excipients included in formulations. An overview of sunscreens, their effectiveness, and adverse reactions is presented.

Etiopathogenesis of atopic dermatitis--an overview

Atopic eczema/dermatitis syndrome is a term that covers different subtypes of atopic dermatitis. The "intrinsic" type of atopic dermatitis is non-IgE-associated, and the "extrinsic" type is IgE-associated atopic eczema/dermatitis syndrome. In the etiopathogenesis of atopic dermatitis there are well known interactions among genetic, environmental, skin barrier, immune factors, and stress. Genetic factors determine the expression of atopic dermatitis as pure or mixed with concomitant respiratory or intestinal allergy, depending on genetic susceptibility. Immunologic abnormalities of type I and type IV reactions have been described in patients with atopic dermatitis. Immunologic triggers are aeroallergens, food allergens, microbial products, autoallergens and contact allergens. Immune reactions determine many features of atopic dermatitis. These immune reactions also include cell mediated or delayed hypersensitivity. The currently accepted model proposes a predominant Th2 cytokine milieu in the initiating stages of acute atopic dermatitis lesions, and a mixed Th1 and Th2 pattern in chronic lesions. A two-phase model includes Th2 initiation with attraction of macrophages and eosinophils, which in turn produce interleukin 12 that is the activator of Th1 type response. Atopic dermatitis skin contains an increased number of IgE-bearing Langerhans cells which bind allergens via the high-affinity IgE receptor (FcepsilonRI). Langerhans cells play an important role in cutaneous allergen presentation to Th2 cells via major histocompatibility molecules. Eosinophilia and IgE production are influenced by type 2 cytokines. Degranulation of eosinophils occurs in the dermis with the release of toxic proteins such as major basic protein and could account for much of the inflammation. Mast cells are increased in number and produce mediators other than histamine that induce pruritus and may have an effect on interferon gamma expression. Mast cells produce a number of proinflammatory cytokines. There is an elevated production of prostaglandin E2 by peripheral monocytes. Prostaglandin E2 has at least two potential roles in the initiation of atopic dermatitis. Firstly, it reduces interferon-gamma production by T helper cells, thereby favoring the initial, dominant Th2 immune response; and secondly, it directly enhances IgE production by B lymphocytes with an increased secretion of interleukin 4, interleukin 5 and interleukin 13. Many lesions of atopic dermatitis result from scratching, thus it is tempting to speculate that immune perturbations in genetically predisposed individuals provoke the release of local pruritogens and keratinocyte-derived cytokines, which then further exacerbate the previously described immune response.

[Identification of Langerhans cells in dermatology]

This paper describes our own findings on the role of Langerhans' cells in dermatology and discusses literature data on their detection in seven different dermatoses. The skin is an integral part of immune system. During the past 30 years, increasing evidence has been accumulated that the skin contains cellular elements which are needed for the initiation and expression of immune response. Langerhans' cells (LCs) are dendritic cells originating in the bone marrow. They reside mainly within stratified squamous epithelia and constitute approximately 2-4% of epithelial cells. LCs are epidermal antigen presenting cells which play a crucial role in allergic contact hypersensitivity, viral diseases, graft versus host disease and elimination of neo-plastic cell clones. They express antigens conjugated with major histocompatibility complex (MHC) class II positive molecules on their surfaces for presentation to T-helper lymphocytes. LCs cannot be identified in routinely prepared histologic testing but can be visualised at the light microscope level by histochemical and immunologic techniques. Appropriate methods for the detection of Langerhans' cells in dermatology (also shown by our own experience) are histoenzymatic methods of adenosintriphosphatase (ATP-ase), acid phosphatase (AP), alpha-naphthylacetatesterase (ANAE and peroxidase-antiperoxidase immunohistochemistry method with polyclonal S-100 protein antibody (PAP). LCs are the only cells in normal skin with ATP-ase activity. Histoenzymatic methods used in patients with atopic dermatitis, vitiligo, mycosis fungoides, Behcet's disease, lichen ruber planus, psoriasis vulgaris, irritant dermatitis and allergic contact dermatitis demonstrated LSs in epidermis and dermis. ANAE and AP showed concordance and were suitable histochemical markers for LC distribution and macrophages in the dermis in mycosis fungoides, atopic dermatitis, psoriasis vulgaris, irritant chronic dermatitis and Bechet's disease. Our experience of the human skin showed a strong activity of calcium-activated adenosine triphosphatase in LCs. LCs in the guinea pig skin can be demonstrated by Mg++ and Ca++ activated adenosine triphosphatase, but a stronger activity of Ca++ activated adenosine triphosphatase in LCs after irritation. Ca++ ATP-ase as an indicator of energy-dependent pump is the reflection of intracellular calcium level, which is a significant factor for regulating the growth and metabolism of the cells. LCs are found as target cells during the efferent phase of contact allergic reaction. Immunohistochemical methods, define the role of LCs in dermatology more precisely and allow complete immunologic recognition within the epidermis.

Retrospective survey of patch testing at department of dermatology and venerology, zagreb university hospital center in zagreb, croatia

Epicutaneous (patch) test is a standard test to confirm contact allergy. During a six-year period (1998-2003), contact allergic dermatitis was diagnosed in 4132 (65%) of 6341 patients using standard patch test with a Croatian series of allergens according to the International Contact Dermatitis Research Group (ICDRG). The most common clinical diagnoses related to contact allergy (male; female) were contact allergic dermatitis (65.4%; 72.2%); atopic dermatitis (15.9%; 11.7%); contact irritant dermatitis (7.0%; 6.6%) and nummular eczematoid dermatitis (4.2%; 2.4%). According to occupation, positive patch test reaction was most commonly observed in workers, whereas 65% of patients showed positive reactions to one or more substances. There was an increased frequency of positive patch test reactions to potassium dichromate, nickel sulfate, thimerosal and neomycine sulfate, along with a significant decrease in the frequency of positive patch test reactions to cobalt chloride, carba mix, wood tars, detergents, parabens mixture, urushiol and rubber mixture. We strongly recommend keeping up-to-date with the epidemiology of contact allergy in Croatia.

Erythromelalgia

Erythromelalgia is a rare poorly understood clinical condition characterized by intense burning pain, pronounced erythema, and increased skin temperature. Although there are many classifications of the disease, it can basically be divided into primary, which begins spontaneously at any age, and secondary, which is associated with myeloproliferative disorders-related thrombocythemia, polycythemia, collagen-vascular diseases, diabetes mellitus, peripheral neuropathy, autoimmune and infectious diseases, and use of certain medicaments. A wide variety of etiological conditions can cause erythromelalgia, all having a single common pathogenetic mechanism - microvascular arteriovenous shunting. The disease is characterized by severe pain associated with redness and hotness in extremities. The diagnosis is based on the medical history and clinical findings. The most useful oral medications for erythromelalgia seem to be aspirin, propranolol, clonazepam, cyproheptadine, drugs inhibiting serotonin re-uptake (venlafaxine and sertraline), tricyclic antidepressants (amitriptyline, imipramine), anticonvulsants (gabapentin), calcium antagonists (nifedipine, diltiazem), and prostaglandins (micoprostol). Erythromelalgia is usually chronic, sometimes progressive, and disabling disease, which can greatly affect the quality of life. Some patients have stable disease and get better, or even experience full resolution of the disease, with time. This review article presents the etiological basis, diagnostics, and therapy of erythromelalgia.

Nevus comedonicus--case report and review of therapeutical approach

Nevus comedonicus is uncommon abnormality of pilosebaceous unit, clinically characterized as confluent clusters of dilated follicular orifices plugged with pigmented keratinous material that resembles open comedones. It is suggested that nevus comedonicus is an uncommon variant of adnexal hamartoma, which clinically appears as linear group of open comedones. Since Kofmann's description of nevus comedonicus in 1895, there have been reports of this rare cutaneous disorder associated with developmental anomalies. We present a case of a 19-year-old woman with numerous 1-3 mm size darkly pigmented, keratic plugs clustered in linear unilateral patches on left abdominal part. Our treatment consisted of the avoidance of the formulations containing nickel sulfate and carba mixture, daily local application of tretinoin 0.1% gel and corticosteroid ointment (momethasone furoate). After 4 weeks of local therapy cosmetic result was evident. The slight resolution of keratin plugs could also be seen. Two months after the treatment, there were no visible skin exacerbations.

Etiopathogenesis, classification, and current trends in treatment of rosacea

Rosacea is a common chronic dermatosis characterized by varying degrees of flushing, erythema, telangiectasia, edema, papules, pustules, ocular lesions, and phymas. Etiology and pathogenesis of rosacea are still unknown. Many possible causes have been described as inducing the disease or contributing to its manifestation, such as genetic predisposition, abnormal vascular reactivity, changes in vascular mediating mechanisms, Helicobacter pylori infection, Demodex folliculorum infestation, seborrhea, sunlight, hypertension, and psychogenic factors. However, none of these factors has been proved. Rosacea shows a wide spectrum of clinical presentations, which vary over time and with age. Successful management of rosacea requires careful patient evaluation and individualized therapy with appropriate variations and modifications, as the severity of the disorder fluctuates. In mild cases of rosacea, patients are instructed to avoid sun, to apply sun-protective creams, and to avoid facial irritants and other triggers that provoke symptoms. At later stage, drug therapy is often necessary. The disease commonly requires long-term treatment with topical or oral medicaments. Surgical correction may be required for rhinophyma and telangiectasia. We reviewed the current literature on the aspects of the pathogenesis, diagnostic criteria, and treatment options for rosacea.

[Diagnostic approach in vesicular and bullous dermatoses]

Vesicular and bullous dermatoses are etiopathologically different dermatoses, whose basic manifestations are vesicles or bullae. There are hereditary and acquired vesicular and bullous dermatoses. The diagnosis is based on the anamnesis, dermatologic status and laboratory findings, which are presented in detail. The aim of this paper is to show a diagnostic algorithm for vesicular and bullous diseases of the skin and mucous membranes. Correct diagnosis is the precondition an adequate treatment in patients as well as for a better prognosis.

Pemphigus vulgaris: a review of treatment over a 19-year period

BACKGROUND

Pemphigus vulgaris is an autoimmune blistering disease of the skin and mucous membranes with a high mortality if left untreated.

OBJECTIVE

We present a retrospective analysis of 159 patients with pemphigus vulgaris and pemphigus vegetans who were admitted to the Department of Dermatology and Venereology, Zagreb University Hospital Center (Zagreb, Croatia) from 1980 to 1998.

RESULTS

Female to male ratio was approximately 2:1. The mean age was 53 years. During the war years in Croatia (1991-95) we noticed a low incidence of pemphigus vulgaris, and from 1996 to 1998 the incidence almost doubled. Diagnosis was based on histopathology [showing typical pemphigus vulgaris changes in 156 (98%) patients], indirect immunofluorescence [positive in 122 (77%) patients], direct immunofluorescence [positive in 141 (89%) patients], and blister smear cytology (Tzanck test) [positive in 115 (72%) patients]. High dosages of prednisone (100-150 mg) were given to 129 patients, which was combined with azathioprine. Patients with refractory pemphigus vulgaris were treated with intramuscular gold (14 patients) and plasmapheresis (five patients). All patients were treated with local ointments. The prolonged use of high doses of corticosteroids and immunosuppressants caused several complications, in particular, steroid diabetes (37 patients), skin infections (26 patients), arterial hypertension (23 patients), cardiorespiratory diseases (22 patients), sepsis (nine patients), etc. During the hospital treatment, 14 patients died, 10 during 1980-89 and only four during the 1990-98 period. The main causes of death were cardiorespiratory failure (six patients) and sepsis (five patients).

CONCLUSIONS

Although pemphigus vulgaris is still a life-threatening disease, today it can be successfully treated with a combination of immunosuppressive agents. Early diagnosis and treatment of pemphigus vulgaris allow a better prognosis with lower mortality rates.

Tacrolimus ointment: a new therapy for atopic dermatitis--review of the literature

Atopic dermatitis is a chronic inflammatory skin disease characterized by severe pruritus, typical morphology and distribution of skin lesions, and personal and family history of atopy. The management of atopic dermatitis is directed at preventing the inflammation, itch, and secondary lesions. Therapy relies on general management measures, anti-inflammatory agents, antiprurites, antibiotics, and immunosuppressants. Treatment options for patients with severe or longstanding disease, extensive body surface area involvement of facial lesions are limited. Tacrolimus ointment is the first in the class of topical immunomodulators that has been formulated for the treatment of atopic dermatitis in children (2 to 15 years of age) and adult patients. The mechanism of action of tacrolimus in atopic dermatitis seems to involve T-cells, Langerhans cells, mast cells and basophiles. Experimental evidence suggests that tacrolimus inhibits T-lymphocytes activation by binding to an intracellular protein, FKBP-12. This binding phenomenon inhibits the ability of calcineurin to activate the promotor region of the gene for IL-2, IL-3, IL-4, IL-5, interferon gamma, tumor necrosis factor alpha, and granulocyte macrophage colony-stimulating factor, all of which participate in the early immune response and play a role in the pathogenesis of atopic dermatitis. Tacrolimus ointment is not atrophogenic, and is associated with minimal systemic absorption. There were no consistent changes in any laboratory variable during topical tacrolimus therapy. The most common adverse events associated with its use were transient skin burning and pruritus at the site of application. Tacrolimus ointment is safe and efficacious therapy for the treatment of pediatric and adult patients with atopic dermatitis on all skin regions including the face, neck and intertriginous areas. An overview is given of tacrolimus in atopic dermatitis.

Loop excision of the transformation zone (LETZ) as an outpatient method of management for women with cervical intraepithelial neoplasia: our experience

Between March 1996 and July 1998, 90 patients were treated with diathermy loop excision (LETZ) for cytologically, colposcopically and histologically verified cervical intraepithelial neoplasias (CIN), at the outpatient clinic. In average, the patients were 30.22 years of age, and 61.1% of them were nulliparas. In 80 surgical samples (88.9%), the exocervical and endocervical margins were histologically free of disease. From the total of 65 patients with CIN III diagnosis, 58 (89.2%) had free margins samples. In the post-operative period the patients had a changed vaginal discharge for 16 days. A slight feeling of pain in the abdomen lasted for 2.5 days on the average, and most patients did not take analgetics. Moderate postoperative hemorrhage from the excision site occurred in 5 (5.5%) patients, and was outpatiently treated with electrocoagulation, with no need for blood replacement. In 65 patients (90.3%), the cytological control results were normal. During the follow-up period, 9 patients became pregnant, which resulted in 6 terminal deliveries so far; 2 pregnant women are about to deliver, and one is in the first trimester of pregnancy. Cerclage cervicis has not been performed on any of the patients. LETZ is a safe and simple procedure which can be done at outpatient clinics, it is relatively easily mastered, it is short, quite bearable for patients if done only under local analgesia, the equipment costs are acceptable, and the treatment can be used both diagnostically and therapeutically, since an adequate surgical sample is obtained for histological assessment. Cytological and colposcopical check ups are imperative in the postoperative period.