Inpatient care for skin diseases in Germany: multi-source analysis on the current and future health care needs

BACKGROUND

In Germany, skin diseases are mainly treated in the 115 dermatological hospitals.

METHODS

Health care and health economic analysis of dermatological inpatient care and prediction of future care needs based on primary and secondary data.

RESULTS

Outpatient and inpatient care for dermatologic treatment indications is predominantly provided by dermatology specialists. Inpatient treatment was provided for 833,491 cases in 2018, corresponding to 4.21 % of all inpatient cases (19,808,687). Most common treatment cases were: epithelial skin cancer (total 87,386, of which dermatology clinics 52,608), followed by melanoma (23,917/17,774), psoriasis (19,291/13,352), erysipelas (73,337/11,260), other dermatitis (12,671/10,842), atopic dermatitis (AD) (11,421/9,734), and herpes zoster (26,249/9,652). With an average length of stay of 5.69 days, dermatology hospitals were in the bottom third. The proportion of inpatient indications cared for in dermatology hospitals was highest for prurigo (95.2 %), pemphigus (94.9 %), parapsoriasis (94.6 %), pemphigoid (90.3 %), eczema other than AD (85.6 %), and AD (85.2 %). While the total number of inpatient treatment cases in Germany has increased by an average of 17.5 % between 2000 and 2018, this is the case for 26.6 % of skin diseases and over 150 % for individual ones. The projection of current to future inpatient care suggests a continued high demand for inpatient care by dermatology hospitals.

CONCLUSION

Inpatient dermatological care will continue to be an indispensable component of qualified, socially necessary care in Germany.

Erosive Pustular Dermatosis of the Scalp: Clinicopathological Correlation Leading to a Definition of Diagnostic Criteria

INTRODUCTION

Erosive pustular dermatosis of the scalp (EPDS) is frequently misdiagnosed as epithelial tumor or trauma. To the authors’ knowledge, no international guidelines or consistent recommendations for treatment of EPDS exist, and histological findings often are labeled as nonspecific.

OBJECTIVE

This study aimed to identify clinical and histological characteristics unique to EPDS to aid diagnosis.

MATERIALS AND METHODS

The biopsies of 21 patients (age range, 73–90 years) with EPDS and who were diagnosed and treated at the Department of Dermatology at University of Leipzig Medical Center and the Asklepios Medical Center, Weißenfels, Germany, were reevaluated by dermatopathologists. Results were correlated with the clinical findings and course.

RESULTS

Erosive pustular dermatosis of the scalp was observed in elderly patients with androgenetic alopecia and field cancerization of the capillitium; most patients had multiple comorbidities. Therapy used to treat actinic keratosis lesions (eg, imiquimod, ingenol mebutate), photodynamic therapy, cryotherapy, trauma, and surgery all were found to have predisposed for or led to EPDS. Erosive pustular dermatosis of the scalp presented clinically as exophytic crusts and pus overlying shiny granulation tissue. Histopathological findings demonstrated an ulcerated epidermis and dermal infiltrates dominated by lymphocytes together with a multitude of plasma cells. Plasma cells were found in all 21 biopsies and represented a common criterion for the correct diagnosis. The erosive lesions healed well within weeks after therapy with topical steroids.

CONCLUSIONS

Chronic, poorly healing lesions with crusts and pus over shiny granulation tissue on the scalp are suggestive of EPDS, which should be confirmed by biopsy. Histological clues to a diagnosis of EPDS include dermal infiltrates of plasma cells and lymphocytes. The topical application of high-potency steroids showed great effectiveness in the present study.

[Zoster disease after Shingrix vaccination]

Shingrix is a recombinant adjuvant subunit vaccine. The vaccine is approved in Germany for prevention of zoster manifestation and postherpetic neuralgia in adults aged ≥60 years. In the case of bullous skin lesions after vaccination with Shingrix a zoster disease should be considered. Unexpected side effects associated with the vaccination should be reported to the Drug Commission of the German Medical Association.

Complete division of the pedicle of the forehead flap is possible after 1 week of engraftment in selected patients

Background

Recent studies have demonstrated that early division of the forehead flap (FHF) is possible if angiography is performed or a remnant of the pedicle is left behind. Whether or not careful selection of patients allows for complete division of the pedicle has not been studied.

Objective

To assess if careful selection of patients allows for early complete division of the FHF.

Methods

The exclusion criteria were trauma in the donor region, full-thickness defects, or a larger cartilage grafting. In the selected patients, complete division of the FHF pedicle was performed at early time points, when the pedicle was clinically engrafted (n = 12).

Results

The median age of the patients was 80 years ± 8. The average size of the wounds was 6.6 cm² ± 4.0. The complete division of the pedicle was performed in 10 patients after 7 days, 1 patient after 8 days, and 1 patient after 11 days (median 7.4 days ± 1.1). One patient developed a wound infection, and 1 suffered from postoperative bleeding. The latter patient was the only 1 who required debulking in a third surgical procedure. No necrosis or flap failures were observed.

Limitations

Retrospective, single-center study.

Conclusion

Careful selection allows for complete early division of the pedicle of FHF.

[Pityriasis rubra pilaris : Successful treatment with ixekizumab]

Pityriasis rubra pilaris is a rare papulosquamous chronic skin disease. The disease often exists for years and is difficult to treat. Not only is it clinically similar to psoriasis vulgaris, but both diseases also have a similar cytokine profile. The successful use of biologicals is frequently reported in case reports. Studies with large numbers of cases are lacking.

Histologie einer Rezidivvarikose nach Behandlung mit dem Radiofrequenzverfahren

Rezidivvarizen an der saphenofemoralen Mün-dung (SFJ) nach Crossektomie und Stripping der Stammvene sind ein bekanntes Problem. Unter Rezidivvarikose werden Krampfadern verstan-den, die in einem zuvor behandelten Stromgebiet auftreten. Das Auftreten einer Rezidivvarikose der Stammvene nach Behandlung mit dem Radiofrequenzverfahren und deren his-topathologischen Muster sind jedoch unklar. Wir zeigen an einem Fallbericht das histopathologische Muster an einer exzidierten und reperfundierten Stammvene. Der 66-jährige Patient wurde 2007 mit Radiofrequenzablation (VNUS Closure-Plus Verfahren®) an der linken Stammvene (V. saphena magna) behandelt. Ein Jahr danach zeigten sich erneut Seitenastvarizen an der linken unteren Extremität. Duplexsonographisch zeigte sich die Vene an der SFJ rekanalisiert und dilatiert. Es erfolgte eine Crossektomie, Teilsaphenektomie und Seitenastexhairese. Dabei wurde der proximale Anteil der VSM histologisch beurteilt. Neben einer Hämatoxylin/Eosinund Elastica-van-Gieson-Färbung, wurden immunhistochemische Färbungen mit Antikörper gegen α-sma und CD 31 durchgeführt. Der Fall-bericht zeigt, dass im Anschluss einer Radiofrequenzablation ein multiluminaler Rekanalisierungsprozess mit ausgekleideten Endothel auftreten kann. Unklar ist jedoch, welcher Mechanismus und welche Faktoren zur Wiedereröffnung von behandelten Venen führen.

Histopathology of rhinophyma - a clinical-histopathologic correlation

BACKGROUND

Whereas early rhinophyma is histopathologically thought to resemble fully developed rosacea, a fibromatous variant has previously been described for severe rhinophyma. In terms of clinical characteristics, recently a new Rhinophyma Severity Index (RHISI) was introduced.

METHODS

We studied 24 patients who had been treated with wide shave excisions for rhinophyma. Specimens were stained with hematoxylin-eosin, periodic acid-Schiff reaction and a panel of immunohistochemical stains and observed for any correlation between clinical severity and histopathologic features as well as for predictive markers of clinical recurrence.

RESULTS

There were no significant histopathologic differences between the groups reflecting the different clinical expressions. From a histopathologic perspective, clinically severe forms did not show with exclusive fibrotic changes. Further, there was no histopathologic marker predicting the clinical course or possible recurrence of the disease after surgical treatment. Only the clinical pre-operative RHISI score correlated with the postoperative outcome, with a high pre-operative RHISI being a risk factor for recurrence.

CONCLUSION

Histopathologic features do not correlate with the clinical expression of rhinophyma. An exclusively 'fibrotic' rhinophyma form does not appear to exist and could possibly be the result of sampling error based on small biopsies studied.

Trichophyton species of Arthroderma benhamiae - a new infectious agent in dermatology

In Germany, infections due to the zoophilic dermatophyte Trichophyton (T.) species of Arthroderma benhamiae are being more frequently diagnosed. The source of infection of this emerging pathogen overlaps with that of the zoophilic species T. interdigitale. The most common source are guinea pigs. T. species of Arthroderma benhamiae causes inflammatory dermatophytosis in children and adolescents. In addition to tinea capitis, it may cause both tinea corporis, tinea manus and frequently tinea faciei. In Germany, T. species of Arthroderma benhamiae is a frequent zoophilic dermatophyte, which in regions is probably more frequent than Microsporum canis. The mycological identification of the isolates with their yellow stained colonies is based on their macroscopic and microscopic features. However, some exhibit colony features consistent with those of T. interdigitale. These strains only can be identified unambiguously by means of molecular techniques. Using detection methods such as PCR-ELISA or real-time PCR, the dermatophyte can be identified directly from clinical material. Sequencing of the internal transcribed spacer region (ITS) of the ribosomal DNA has been approved as culture confirmation test for T. species of Arthroderma benhamiae. In addition, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI TOF MS) is useful. Widespread dermatophytosis due to T. species of Arthroderma benhamiae, in particular of tinea capitis, requires oral antifungal agents. Terbinafine is most effective, alternatives are fluconazole and itraconazole.

Outcomes of wound closure with the reading man flap technique

BACKGROUND

In dermatologic surgery, numerous flap types have been described for wound closure after skin cancer surgery. The reading man flap was first published in 2008 for the closure of skin defects of the face, trunk, and extremities. Technically, this flap is based on an asymmetrical Z-plasty.

OBJECTIVE

To investigate the feasibility, clinical outcomes, and postoperative complications for wound closure with the reading man flap technique.

METHODS

We treated seven patients (facial and extremity defects) after microscopically controlled surgery using the reading man flap technique. The median defect size was 491.71 mm2. All of the patients were treated under tumescent local anesthesia.

RESULTS

A tension-free defect closure was created in all patients. One minor complication, a wound infection on one leg, was observed.

CONCLUSION

The described technique is an easy and safe dermatologic surgery procedure that can be performed under local anesthesia.

New rhinophyma severity index and mid-term results following shave excision of rhinophyma

BACKGROUND

Rhinophyma is a progressive nasal deformity resulting from hyperplasia of the sebaceous glands and connective tissue, with a negative effect on quality of life. Partial-thickness shave excision has been used for the treatment of rhinophyma, but the mid- and long-term efficacy of the treatment is unknown.

OBJECTIVES

We analysed the clinical outcomes of shave excision in patients with rhinophyma in our centre between 2005 and 2009.

METHODS

The entire nose was shaved using a scalpel while under tumescent anaesthesia. The clinical assessment was scored using a novel Rhinophyma Severity Index.

RESULTS

Thirty-three patients with rhinophyma and shave excision were recruited for the study. A mid-term follow-up examination was possible in 23/33 (69.7%) patients. After a mean follow-up of 37.4 ± 13.2 months, 21 (91.3%) patients showed an improved Rhinophyma Severity Index (3.3 ± 1.1 to 1.7 ± 0.9, p < 0.0001). All patients reported a high level of satisfaction after surgery (excellent or good result). Eleven (47.8%) patients developed rhinophyma recurrence.

CONCLUSION

Shave excision under tumescent anaesthesia is an effective treatment for rhinophyma. The treatment is associated with high patient satisfaction and minimal side effects. A possible recurrence of rhinophyma must be addressed, however, while obtaining informed consent.

Sex steroid hormones are not altered in great saphenous veins after varicose vein treatment in male patients

OBJECTIVE

The objective of this study was to assess differences in blood samples (sex steroid hormone levels and blood counts) before and after surgical treatment of incompetent great saphenous veins (GSV) in males.

METHODS

Antecubital vein and GSV blood samples were taken from 11 men with varicose veins and GSV reflux before and after treatment. Six patients were treated with high ligation, stripping and phlebectomy. Five patients were treated with endoluminal radiofrequency ablation and phlebectomy. After a four-year follow-up period (FU) cubital vein and GSV blood samples were taken again.

RESULTS

In men with varicose veins, significantly higher (P < 0.05) serum testosterone (median 25.18 nmol/L, range 8.82-225.1) and oestradiol (median 179 pmol/L, range 79-941) levels were found in the saphenous vein samples before and after the FU (testosterone 18.8 nmol/L, range 7.96-83.1, oestradiol 171 pmol/L range 125-304) compared with the cubital vein samples before therapy (testosterone 15.72 nmol/L, range 8.36-23.29; oestradiol 84 pmol/L, range 41-147) and after the FU (testosterone 14.5 nmol/L, range 6.10-22.2, oestradiol 117 pmol/L, range 95-165). After the FU, one patient demonstrated recurrent varicose veins with groin neovascularization. Another presented with axial reflux of the anterior accessory saphenous vein. Further differences in blood counts and serum androstenedione levels between the upper and lower extremities were not detected.

CONCLUSION

The differences between testosterone and oestradiol levels in the leg veins compared with the cubital veins persist after treating men with refluxing saphenous veins. These results suggest that local hormone regulation may be different between leg and arm veins in men with varicose veins.

Reconstruction of nasal defects with forehead flaps in patients older than 75 years of age

BACKGROUND

As the number of elderly patients diagnosed with non-melanoma skin cancer (NMSC) increases, the number of patients receiving dermatologic surgery also increases. Multimorbidity in this patient group is common.

OBJECTIVE

The aim of this study is to assess the aesthetic and functional outcomes and complications of forehead flap (FHF) in elderly patients with NMSC.

METHODS

Between 2006 and 2011, data for 28 patients 75 years of age or older who had been treated with FHFs under tumescent local anaesthesia were analysed.

RESULTS

The median age of the study participants was 81 years (range, 75-95 years). Of the 28 total patients, 16 (57%) were female and 12 (43%) were male. The average defect size was 11 cm(2) (5-30 cm(2)). Cartilage grafts were used in four patients (14%). The average time to takedown was 25 days (17-45). The median follow-up for the patients was 10 months (1-60 months). There were seven treatment-related complications due to infectious causes (2), epidermal necrotic tissue (2), bleeding (1), hair on the flap (1) and alar rim notching (1). No life-threatening complications were detected.

CONCLUSIONS

The FHF procedure is a safe and low-risk procedure in patients 75 years of age or older with advanced skin defects. If a defect requires an FHF to obtain a normal and aesthetic appearance, this procedure should be performed. However, dermatologists must weigh the safety of the procedure in relation to the clinical benefits when managing this patient group.

Sonographic abnormality of the substantia nigra in melanoma patients

BACKGROUND

Evidence derived from large epidemiological studies suggests an association between Parkinson's disease (PD) and malignant melanoma. Transcranial sonography of the midbrain reveals an extended echogenic substantia nigra (SN) area in a high proportion of patients with PD. This characteristic, in the context of PD, may signal degeneration of dopaminergic nigrostriatal projection neurons. Demonstration of an increased prevalence of abnormal echogenic SN in melanoma patients could add weight to the hypothesis of an underlying common pathogenic pathway of both diseases.

METHODS

This was a cross-sectional observational study. Transcranial sonography of the SN region was performed on 31 patients suffering from malignant melanoma and 29 healthy participants. In addition, patients and controls were screened for motor and non-motor symptoms of PD.

RESULTS

The echogenic SN area was abnormally extended in 42% of melanoma patients versus 7% of control subjects (χ(2) = 9.811, P = .002). Mean echogenic SN area (SN[R, L]) was significantly larger in melanoma patients than in controls (patients, 0.21 ± 0.07 cm(2); controls, 0.15 ± 0.04 cm(2) [mean ± SD]; unpaired t test, P < .001).

CONCLUSIONS

These findings provide additional evidence in favor of a common pathogenic pathway of PD and malignant melanoma and raise the possibility that their association is closer than previously assumed.

Varicose vein surgery

Venous diseases are common in the general population. After a comprehensive diagnostic evaluation, an individual therapeutic approach should be selected on the basis of the findings, with the aim of treating the diseased vein segments and improving quality of life. Numerous therapeutic options are available for the treatment of varicose veins. In addition to conservative methods such as compression therapy, exercise or drugs, surgical procedures such as traditional surgery, thermal ablation techniques or sclerotherapy can be performed. Recent developments include the use of endoluminal water vapor or mechano-chemical endovenous ablation.

Malignant melanoma during treatment with fumaric acid esters - coincidence or treatment-related?

Psoriasis is today generally considered a systemic disease. Systemic therapies are used frequently. In Germany fumaric acid esters - FAE (Fumaderm(®) ) - are employed in more than 50 % of the patients requiring such therapy. We report for the first time the development of melanoma in two patients during their treatment with FAE. The logical question is - are the tumors coincidental or might they be treatment-related? Further investigations of pathways and immunologic effects as well as careful reports of side effects are necessary to estimate the risks of malignancy of FAE.