Current problems in dermatology

Publications in this journal

• Article: Clinical spectrum and severity of psoriasis.

  Matthew Meier, Pranav B Sheth
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  ABSTRACT: Psoriasis is a chronic inflammatory skin disease. Associated comorbidities or risks may include psoriatic arthritis, obesity, depression, smoking, diabetes, hyperlipidemia, an increased risk of cardiovascular disease with myocardial infarction, or an increased risk of lymphoma. The clinical presentation of psoriasis can range from the more common red scaling elevated plaques on the elbows, knees, or scalp to the less common superficial pustules scattered on the palms or soles, or in rare cases wide-spread pustules on the body. More specifically, the clinical spectrum of psoriasis includes the plaque, guttate, small plaque, inverse, erythrodermic, and pustular variants. The determinants of the clinical severity of psoriasis, the risk of comorbidities, and the quality of life of a psoriatic patient are influenced by multiple factors. At the minimum, these include variations in the quality and type of psoriasis, the quantity of skin involved, and the distribution of skin lesions (including special areas such as the scalp, nails, face, intertriginous regions, and palmoplantar surfaces). Objective measures used to quantify the severity of psoriasis, including the body surface area involved, Physician's Global Assessment, Psoriasis Area and Severity Index, and quality of life measures, are all assessments that can be useful in guiding approaches to management and therapeutics. In this paper, we review the clinical spectrum of psoriasis, the differential diagnoses, measures and determinants of severity, and the recommendations on when to refer a patient to a specialist in psoriasis. We also briefly review the comorbidities, and note the importance of referring the psoriatic patient to the internist/general practitioner for evaluation and management for these comorbidities.
  Current problems in dermatology 02/2009; 38:1-20.
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  Available from: ucoz.ru

  Article: Treatment and prevention of Lyme disease.

  Yves Hansmann
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  ABSTRACT: Randomized controlled trials have ascertained the efficiency of antibiotics in treating erythema migrans, the hallmark of early stage Lyme borreliosis. Oral amoxicillin and doxycycline are first-line treatment options, though phenoxymethylpenicillin, cefuroxime axetil and azithromycin are alternative second-line options. Treatments for secondary and tertiary Lyme borreliosis are more poorly documented, and antibiotics are not always effective. This is due to the unique pathophysiology of late Lyme borreliosis, which involves not only bacterial infection, but also immunological response. Since there is no completely reliable method of diagnosis, it is difficult to choose the proper treatment and to evaluate treatment efficacy. However, numerous studies have shown that ceftriaxone and doxycycline are the 2 most efficient antibiotics, particularly in Lyme arthritis and in neuroborreliosis. In late Lyme borreliosis, these antibiotics are less efficient, and different treatment schemes with variations in dosage or duration did not produce convincing results.
  Current problems in dermatology 02/2009; 37:111-29.
• Article: Monitoring patients treated with efalizumab or alefacept.

  K A Papp
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  ABSTRACT: Though alefacept and efalizumab do not have robust development for treating inflammatory disorders other than psoriasis, they provided important therapeutic options for patients with chronic plaque psoriasis. Alefacept is administered in 12-week cycles and requires routine monitoring of CD4 lymphocyte counts as apoptosis of memory T cells is a hallmark of its mechanisms of action. In contrast, it is recommended to conduct monthly complete blood counts for patients on efalizumab during the first few months of therapy; efalizumab is intended for continuous long-term therapy. Alefacept works extremely well for a smaller cohort of patients. We cannot yet predetermine those who will respond through many cycles of alefacept. Efalizumab works extremely well for approximately 40% of subjects, and possibly more when retreatment options are considered. Most important for patients on either therapy is appropriate intermittent clinical evaluations to ensure stable, safe, and effective therapy.
  Current problems in dermatology 02/2009; 38:95-106.
• Article: Management of severe psoriasis with TNF antagonists. Adalimumab, etanercept and infliximab.

  Rotraut Mossner, Kristian Reich
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  ABSTRACT: Three specific tumor necrosis factor (TNF) antagonists, adalimumab, etanercept and infliximab, have been approved for the treatment of psoriasis. Their efficacy, not only in psoriasis but also in psoriatic arthritis, has been demonstrated in large prospective randomized placebo-controlled trials. At present, the discussion about the use of these drugs is dominated by issues of the risk-benefit ratio and by economic considerations. In this chapter, we give an introduction to the different TNF antagonists, with the main focus on therapy management and safety issues.
  Current problems in dermatology 02/2009; 38:107-36.
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  Available from: ucoz.ru

  Article: What should be done in case of persistent symptoms after adequate antibiotic treatment for Lyme disease?

  Xavier Puéchal, Jean Sibilia
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  ABSTRACT: The most common cause of treatment failure is incorrect diagnosis. Most patients cured of Lyme disease remain seropositive for long periods, and no laboratory test allows one to differentiate between cured and active infection. The first step is to check that the patient fulfils the diagnostic criteria for Lyme disease and that the antibiotic regimen has been administered according to the current recommendations. In the case of persistent arthritis after a first course of antibiotics, it is generally recommended to give a second course of treatment with a different drug. Ceftriaxone should be administered intravenously for arthritis that did not respond to previous oral therapy with doxycycline or amoxicillin. Despite resolution of the objective manifestations of Lyme disease after antibiotic treatment, a small proportion of patients still complain of subjective musculoskeletal pain, fatigue, difficulties with concentration or short-term memory, or all these symptoms. Given the risk of serious adverse events and the lack of efficacy, a consensus has emerged that repeated courses of antibiotic therapy are not indicated for persistent subjective symptoms following Lyme disease. The patient should be thoroughly examined for medical conditions that could explain the symptoms. If a diagnosis is made for which no specific treatment can be proposed, emotional support and management of pain, fatigue and other symptoms is required.
  Current problems in dermatology 02/2009; 37:191-9.
• Article: Practice of phototherapy in the treatment of moderate-to-severe psoriasis.

  Thao Nguyen, Shilpa Gattu, Rupa Pugashetti, John Koo
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  ABSTRACT: This chapter will discuss the entire spectrum of phototherapy, including narrowband UVB photo-therapy, broadband UVB phototherapy, PUVA, targeted excimer laser phototherapy, and combination treatments. Phototherapy can range from simple treatments in a UVB phototherapy box, with or without concurrent use of various tar preparations, to more elaborate modalities in which the intensity of UVB radiation applied varies according to different anatomical regions. Combining PUVA or UVB phototherapy with topical and systemic agents can also enhance phototherapy. Certain forms of phototherapy, such as the traditional Goeckerman regimen of using black tar daily with UVB light, induce a prolonged remission. Outpatient phototherapy is usually reserved for patients whose disease is not adequately controlled with topical medications, including steroids, vitamin D analogues, tazarotene, tar, or anthralin. It is also indicated for patients with such extensive psoriasis that topical therapy is nearly impossible. Additionally, phototherapy may be an excellent option for patients with specific medical problems for whom systemic medications such as methotrexate, cyclosporine, or biological agents may not be suitable. For patients with generalized psoriasis, phototherapy is a reasonable first choice among the available options because of its superior systemic safety profile in comparison to systemic or biological agents. As with all other forms of psoriasis therapy, it is essential to consider the impact of the treatment on the patient's lifestyle when selecting the treatment plan. Important points to consider when initially discussing phototherapy are the patient's employment schedule, commitment, flexibility, location of the phototherapy unit, and transportation.
  Current problems in dermatology 02/2009; 38:59-78.
• Article: Future perspectives in the treatment of psoriasis.

  K Wippel-Slupetzky, G Stingl
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  ABSTRACT: All available antipsoriatic therapies are of symptomatic character. Treatments established so far are limited in their use due to side effects or lack of efficacy resulting in poor quality of life for affected people. Development of new therapeutic approaches would not only broaden our armamentarium against psoriasis, but could also increase our understanding of the pathogenesis of this disease. In brief, 2 main targets represent attractive candidates, either the keratinocyte itself or the immune system. Promising therapeutic strategies include: (1) the search for new psoriasis susceptibility genes and their resulting phenotypes; (2) the interference with certain parts of cell signaling pathways that are involved in inflammatory processes; (3) the inhibition or elimination of activated T lymphocytes, e.g. by blocking of costimulatory signals or by deviation of a pathogenic immune response into a nonpathogenic one; (4) the blockade of proinflammatory cytokines; (5) the inhibition of leukocyte extravasation or trafficking; (6) the inhibition of angiogenesis. Some of these strategies are in phase 2 trials, others have already reached phase 3 status and are close to being approved by medicine agencies, and some are still visions of the future. This book chapter will give an overview of these new treatment strategies.
  Current problems in dermatology 02/2009; 38:172-89.
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  Available from: ucoz.ru

  Article: Borrelia burgdorferi sensu lato diversity and its influence on pathogenicity in humans.

  Guy Baranton, Sylvie J De Martino
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  ABSTRACT: Among the Spirochaetes, the Borrelia burgdorferi sensu lato complex is responsible for Lyme borreliosis. This complex comprises more than 13 Borrelia species. Four of them are clearly pathogenic for humans: B. burgdorferi sensu stricto, B. afzelii, B. garinii and B. spielmanii. They can generate erythema migrans, an initial skin lesion, and can then spread deeply into the host to invade distant tissues, especially the nervous system, the joints or the skin. In humans, Borrelia pathogenicityseems to be linked with taxonomic position, but in vitro studies show the role of plasmids in B. burgdorferi s.l. pathogenesis. The inter- and intraspecies genetic diversity of B. burgdorferi s.l. evidences a clonal evolution of the chromosome, while plasmid genes are quite variable, suggesting their major role in Borrelia adaptability. The plasmid-encoded adhesins and vlse, crasps and osp genes determine invasiveness and host immune evasion of B. burgdorferi s.l., and select the bacterial host spectrum. The geographic distribution of B. burgdorferi s.l. is closely related to its vectors and competent hosts, and its development within these influences its diversity, taxonomy and pathogenesis, primarily via genetic lateral transfer.
  Current problems in dermatology 02/2009; 37:1-17.
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  Available from: ucoz.ru

  Article: When is the best time to order a Western blot and how should it be interpreted?

  K P Hunfeld, P Kraiczy
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  ABSTRACT: Despite significant progress in the diagnostics of Lyme borreliosis, including molecular methods, the detection of a specific antibody response remains the mainstay in the laboratory diagnosis of the disease. Current guidelines propose the combination of highly sensitive screening assays, such as ELISAs, with very specific confirmatory tests, such as immunoblots, to guarantee a cost-effective, sensitive and specific diagnostic approach. For a correct interpretation of the serological findings, the investigator must always consider a whole series of clinical and laboratory facts. Here, we summarize current laboratory algorithms in the diagnosis of Lyme borreliosis, with a special emphasis on when to order a Western blot and how to interpret it correctly in the context of additional clinical and laboratory information.
  Current problems in dermatology 02/2009; 37:167-77.
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  Available from: ucoz.ru

  Article: What should one do in case of a tick bite?

  Elisabeth Aberer
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  ABSTRACT: Ixodes ricinus is the commonest tick species in Europe, and transmits Lyme borreliosis, tick-borne encephalitis, ehrlichiosis, tularemia, rickettsiosis, and babesiosis. The risk of Borrelia burgdorferi infection increases with the time of tick engorgement, but not every infection necessarily causes erythema migrans or Lyme borreliosis. Therefore, the finding of B. burgdorferi DNA in a tick does not prove that the patient will subsequently develop Lyme borreliosis. Ticks should be removed as early as possible with fine tweezers, taking the tick's head with the forceps. Antibiotic prophylactic therapy after a tick bite is not generally recommended. Tick bites can potentially be prevented by covering the body as much as possible or by applying repellents to the body and permethrin to clothes. Tick bite areas should be inspected for 1 month. Lyme borreliosis should be suspected when an erythema at the tick bite site or a febrile illness develop.
  Current problems in dermatology 02/2009; 37:155-66.
• Article: Impact of comorbidities on the management of psoriasis.

  S Gerdes, U Mrowietz
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  ABSTRACT: Psoriasis is associated with numerous comorbidities that have a major impact on severely affected patients. Besides psoriatic arthritis, other diseases such as metabolic syndrome and cardiovascular diseases are becoming of major importance. In particular, patients with severe forms of psoriasis are at a higher risk of developing cardiovascular diseases and myocardial infarction. In a recent study, a reduction in life expectancy was shown for this subgroup of patients. An increased prevalence of concomitant diseases leads to an increased intake of concomitant medication; thus, it is easy for comorbidities and their treatments to interact with routinely used antipsoriatic therapies and complicate the management of severely affected patients. This patient subgroup has a strong need of sufficient treatment not only for their severe skin symptoms, but also for preventing the possible development of comorbidities and their long-term complications. As dermatologists are often one of the first and most often consulted health care specialists for patients with psoriasis, advanced knowledge of the comorbid state of these patients should influence clinical management and lead to new standards of care. This article will summarize the current knowledge on comorbidities in psoriasis and their impact on patient management.
  Current problems in dermatology 02/2009; 38:21-36.
• Article: Management of difficult to treat locations of psoriasis. Scalp, face, flexures, palm/soles and nails.

  Knud Kragballe
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  ABSTRACT: Psoriasis located on the scalp, face, skin folds, palms/soles and nails may require special consideration due to physical disability and discomfort, and because the treatment efficacy and safety may be different. There are many therapeutic approaches for psoriasis in difficult to treat locations. Only a few of the therapies have been evaluated for efficacy and safety in well-designed and well-controlled clinical studies. Furthermore, comparative studies are often lacking. This chapter describes management of psoriasis located on the scalp, face, skin folds, palm/soles and nails, with special focus on treatment with topical agents.
  Current problems in dermatology 02/2009; 38:160-71.
• Article: Is serological follow-up useful for patients with cutaneous Lyme borreliosis?

  R R Mullegger, M Glatz
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  ABSTRACT: Serologic follow-up examinations are frequently performed in patients with erythema migrans, borrelial lymphocytoma, and acrodermatitis chronica atrophicans (the 3 dermatoborrelioses) to evaluate treatment efficacy. There is, however, substantial proof in the literature that antibody titer development after therapy is unpredictable and variable, and moreover it is largely uncorrelated with the clinical course and mode of antibiotic treatment. For example, persistent positive IgG and/ or IgM antibody titers do not indicate treatment failure. Thus, repeated serologic testing is of very limited value for assessing therapy efficacy, and therefore not recommended in the follow-up of dermatoborrelioses patients. Since cultivation of the etiologic agent, Borrelia burgdorferi sensu lato, and polymerase chain reaction are also inadequate for this purpose, the assessment of patients with cutaneous manifestations of Lyme borreliosis in the follow-up rests primarily on the clinical picture.
  Current problems in dermatology 02/2009; 37:178-82.
• Article: Clinical manifestations and diagnosis of lyme borreliosis.

  Franc Strle, Gerold Stanek
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  ABSTRACT: Lyme borrelosis is a multi-systemic disease caused byBorrelia burgdorferisensu lato. A complete presentation of the disease is an extremely unusual oberservation, in which a skin lesion follows a tick bite, the lesion itself is followed by heart and nervous system involvement, and later on by arthritis; late involvement of the eye, nervous system, joints and skin may also occur. Information on the relative frequency of individual clinical manifestations of Lyme borreliosis is limited; however, the skin is most frequently involved and skin manifestations frequently represent clues for the diagnosis. The only sign that enables a reliable clinical diagnoisis of Lyme borreliosis is a typical erythema migrans. Laboratory confirmation of a borrelial infection is needed for all manifestations of Lyme borreliosis, with the exception of typical skin lesions.
  Current problems in dermatology 02/2009; 37:51-110.
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  Available from: ucoz.ru

  Article: Other tick-borne diseases in Europe.

  Idir Bitam, Didier Raoult
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  ABSTRACT: Ticks are obligate blood-sucking arthropods that transmit pathogens while feeding, and in Europe, more vector-borne diseases are transmitted to humans by ticks than by any other agent. In addition to neurotoxins, ticks can transmit bacteria (e.g. rickettsiae, spirochetes) viruses and protozoa. Some tick-borne diseases, such as Lyme disease and ehrlichiosis, can cause severe or fatal illnesses. Here, we examine tick-borne diseases other than Lyme disease that are found in Europe; namely: anaplasmosis, relapsing fever, tularemia, tick-borne encephalitis, tick-borne babesiosis and tick-borne rickettsiosis. Each disease is broken down into a description, epidemiology, signs and symptoms, diagnosis and treatment, providing clear overviews of each disease course and the interventions required. Furthermore, in the section concerning tick-borne rickettsiosis, a clear summary of the Rickettsia conorii complex and its role in the disease is provided.
  Current problems in dermatology 02/2009; 37:130-54.
• Article: Topical treatment of psoriasis.

  Qurat Ul Ain Kamili, Alan Menter
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  ABSTRACT: Topical therapy forms the cornerstone in the management of psoriasis. Of significant value as monotherapy in mild to moderate psoriasis, it is used predominantly as adjunctive therapy in moderate and severe forms of the disease. Over the past decade, topical treatment of psoriasis has evolved from the age-old applications of tar and dithranol to the more acceptable and efficacious options of topical corticosteroids, retinoids and vitamin D analogues, with the advent of a wide range of appropriately tailored vehicles and sophisticated delivery modes. To ensure therapeutic success, proper patient education about the disease, the treatment options, their specific application modality and adverse effects is essential. This will help alleviate the common problem of poor patient adherence, and inevitably result in more optimal clinical outcomes.
  Current problems in dermatology 02/2009; 38:37-58.