Journal der Deutschen Dermatologischen Gesellschaft

Published by Wiley
Online ISSN: 1610-0387
Print ISSN: 1610-0379
Potent topical corticosteroids are used the intense pruritus in prurigo diseases. Their long-term application leads to local side effects such as atrophy and telangiectasia. We treated 6 women (average age 64 years) with chronic prurigo with tacrolimus 0.1 % ointment (Protopic) to evaluate its efficacy in this clinical setting. Tacrolimus 0.1% ointment was applied twice a day for 4 weeks. After one week, both clinical improvement and reduced pruritus were observed in all patients. Tacrolimus 0.1% ointment represents a therapeutic option for the treatment of prurigo.
Reports of treatment failure of head lice have become increasingly common. Oral ivermectin has been proposed as a potential alternative for the treatment of head lice infestation. The aim of this study was to compare the efficacy of oral ivermectin with topical malathion lotion in the treatment of head lice. Eighty apparently healthy children with head lice infestation were randomly assigned to 2 groups, with 40 patients in each. The first group received oral ivermectin as a single dose of 200 μg/kg and the second group received single topical application of malathion lotion 0.5%. Follow up visits were done at days 8, 15 and 29. A second dose of either drug was given at day 8 in case of treatment failure. After a single dose, complete cure was achieved in 77.5% and 87.5% of ivermectin and malathion groups respectively. After the second dose for nonresponders, the cure rate increased to 92.5% in the ivermectin group and 95% in the malathion group. No major adverse effects were observed in either group. Oral ivermectin is a promising effective approach for the treatment of head lice and could be an ideal substitute for conventional pediculicides.
Local anesthetics supplemented with epinephrine are generally regarded as contraindicated for surgical procedures involving the fingers, toes, penis, outer ear and the tip of the nose [1], but epinephrine is essential if automated tumescence local anesthesia (Auto-TLA) is used. Infiltration anesthesia supplemented with 1:200,000 epinephrine was used from 1985-1997 in our department, while Auto-TLA supplemented with 1:1.000,000 epinephrine was introduced in 1997 for all surgical procedures involving the ear or nose. During this period, 10,201 patients underwent surgery at these locations. In addition, dermal blood flow was analyzed by acral photoplethysmography (APPG) and laser Doppler flowmetry (LDF) in the right ear lobe of five normal volunteers and during epinephrine supplemented Auto-TLA. Epinephrine-induced complications were not observed in a single patient. Cosmetic skin flap surgery was performed in 4,953 of these patients. Even in patients with extended surgical procedures that took up to one to two hours and that included extensive skin flaps or skin grafts, we observed no increase in complications when compared to procedures performed either under general anesthesia or local anesthesia without epinephrine supplementation. Measuring blood perfusion of the earlobe showed a 69% reduction of LDF and a 42% reduction of arterial inflow (APPG) immediately following anesthesia. Epinephrine supplementation of local anesthetics does not block blood perfusion in the ear and did not induce organ, tissue or flap necrosis. Local anesthesia with epinephrine supplementation is therefore safe for acral areas such as the ear or nose. Despite the relatively small influence on blood perfusion, epinephrine supplementation results in a relatively bloodless operating field and longer effectiveness of local anesthesia. The relative absence of blood in the operating field of the ear and nose significantly reduces the duration of surgery and increases the healing rate, as less electrocautery is needed.
Localized scleroderma is a rare autoimmune disease with primary affection of the skin, and occasional involvement of the fat tissue, muscle, fascia, and bone. Depending on the clinical subtype, the spectrum of skin lesions ranges from singular plaque lesions to severe generalized or linear subtypes which may lead to movement restrictions and permanent disability. This German S1-guideline proposes a classification of localized scleroderma that, considering the extent and depth of fibrosis, distinguishes limited, generalized, linear, and deep forms of localized scleroderma, together with its associated subtypes. The guideline includes a description of the pathogenesis, of differential diagnoses, and particular aspects of juvenile localized scleroderma, as well as recommendations for histopathologic, serologic, and biometric diagnostic procedures. Based on studies of topical and systemic treatments as well as phototherapy for localized scleroderma published in international literature, a treatment algorithm was developed which takes account of the different subtypes and the extent of disease.
Nd:YAG lasers could be a safe and effective treatment modality for onychomycosis, without the side effects of drugs. Long and short-pulsed Nd:YAG lasers were used in this clinical study in a side-comparison manner without removal of onychomycotic nail material before treatment. Big toenails of 10 patients were treated twice in a side-comparison manner with the short-pulsed PinPointe™ Footlaser™ and a long-pulsed Nd:YAG laser (Elite™, Cynosure®). Fungal cultures were taken and a histological examination was performed before treatment and after 9 months. Two independent investigators rated clearance using the "Onychomycosis Severity Index (OSI)" and standardized photographs at 3-month intervals. OSI-Scores decreased for 3.8 (15 %; p = 0.006), 4.8 (19 %; p = 0.0002) and 2.9 points (12 %; p = 0.04) within 3, 6 and 9 months. The positive culture rate at 9 months was significantly reduced to 35 % (p = 0.0003). Classification of severity of onychomycosis showed no change. The difference between the treatment regimens was not significant. These results suggest that treatment of onychomycosis with the Nd:YAG laser without removing mycotic nail material can lead to a temporary clinical improvement, a reduction of positive fungal cultures and an improvement of the Onychomycosis Severity Index. The treatment regimen should be optimized to be used as an effective antimycotic monotherapy.
The diagnostic approach to eyelid eczema is often a great problem in daily practice. A 16-year old girl developed recurrent severe pruritic edema of the eyelids, followed by redness and scaling. Various cosmetics particularly an eyeliner were considered as possible causes. Patch testing was performed with the standard series, some supplemental series and all ingredients of the eyeliner. The eyeliner produced a papular reaction after 2 days of open application, confirming a high degree of contact sensitization. The patient reacted with a 3+ reaction to the ingredients shellac (20% in ethanol) and 1,3-butylene glycol (2% in water). All remaining materials failed to produce a reaction. Careful allergologic investigations are necessary in cases of edema and/or eczema of the eyelids; the cosmetics used by the patients are of utmost importance. The causative allergen may not be present in the usual patch test series and can only be identified by testing all ingredients. Shellac is now widely used in cosmetics and is increasingly identified as a contact allergen in eye make up.
Management of patients with lichen planopilaris (LPP) and frontal fibrosing alopecia (FFA) is rendered difficult as robust epidemiologic data, insights on pathogenesis, associated diseases, possible relevance of concomitant medications or environmental factors are lacking. Retrospective analysis of demography, skin status, concomitant medication and diagnostic procedures were performed on 104 medical records (71 classic LPP, 32 FFA, and one Graham-Little-Piccardi-Lassueur syndrome). Women were more often affected (distribution F: M classic LPP 4.9: 1; FFA: 31: 1). Compared to LPP patients, patients with FFA were significantly older (p < 0.001), more often postmenopausal, and more frequently on hormone replacement therapy. No other specific associations were identified. An association with lichen planus, other autoimmune diseases, or hepatitis virus infection was found only in individual patients. Clinically, FFA patients were significantly more often reported to have reduced eyebrows (p < 0.005), axillary, and/or pubic hair (p = 0.050). The findings obtained from this study, with currently largest LPP/FFA patient cohort in Germany, encouraged us to set up a national FFA patient registry. Prospective data collected from larger numbers of patients with standardized questionnaires will help to assess assumed associations and influencing factors and to develop, in the long-term, recommendations for diagnosis and treatment.
Infantile acne is a rare condition which usually begins after the third month of life and appears mainly on the cheeks. Spontaneous healing typically occurs within 2 years. A 2-year-old boy developed acne infantum during the first days after birth; it failed to respond to topical treatment. Detailed physical examination and endocrinologic evaluation confirmed the presumed diagnosis of congenital adrenal hyperplasia (CAH), and showed it was caused by 11-beta-hydroxylase deficiency. CAH comprises a group of autosomal-recessively inherited disorders. These hereditary enzyme defects in steroid biosynthesis cause glucocorticoid deficiency and an overproduction of biosynthetic precursor steroids. Adrenal androgen biosynthesis is not impaired but shows a massive reactive overproduction due to the increased ACTH secretion within the up-regulated hypothalamo-pituitary-adrenal system. The characteristic features of CAH in male infants are demonstrated on the basis of this case report.
Acne papulopustulosa induced by anabolic-androgenic steroids.
Acne conglobata induced by anabolic-androgenic steroids.
Abuse of anabolic-androgenic steroids (AAS) by members of fitness centers and others in Germany has reached alarming dimensions. The health care system provides the illegal AAS to 48.1 % of abusers. Physicians are involved in illegal prescription of AAS and monitoring of 32.1 % of AAS abusers. Besides health-threatening cardiovascular, hepatotoxic and psychiatric long-term side effects of AAS, acne occurs in about 50 % of AAS abusers and is an important clinical indicator of AAS abuse, especially in young men 18-26 years of age. Both acne conglobata and acne fulminans can be induced by AAS abuse. The dermatologist should recognize bodybuilding acne, address the AAS abuse, and warn the patient about other potential hazards.
 Approximately 15 % of all cases of melanoma are diagnosed before age 35 years. In Germany, individuals ≥ 35 years are eligible for the national skin cancer screening program. The effectiveness of a population-based skin cancer screening in general and in particular for young adults is unclear.  Assessment of the effectiveness of a skin cancer screening program and of risk factors for detection of a melanoma/atypical nevus in the setting of a screening for the age group 14 to 34 years.  A total of 12,187 individuals age 14 to 34 years were screened in Saxony for skin cancer by a dermatologist in the program "Haut-Check 14-34 Jahre" of the AOK PLUS, a large German health insurance, between January and July 2009. Demographic, clinical and histopathological data and UV-exposure data were collected from each participant. Multivariate logistic regression models were used to assess risk factors for the detection of a (histopathologically confirmed) melanoma or atypical nevus.  2.8 % of the eligible individuals participated in the skin cancer screening program with women being more likely to do so. In 1 072 individuals (8.8 %) screening included at least one excision of a skin lesion leading to the diagnosis of melanoma in two participants, melanoma in situ in four persons, and atypical nevus in 641 persons. Use of tanning beds, higher age, number of nevi, and previous cutaneous excision were independent risk factors for the detection of a melanoma or atypical nevus.  In 5.5 % of all cases skin cancer screening resulted in the excision of a malignant or atypical melanocytic lesion. It remains unclear what proportion of these cases would have been detected in routine care. The rate of excisions per newly diagnosed melanoma was 179 : 1. Further investigations are necessary to explore the reasons for this low diagnostic specificity. This study highlights the possibilities and limitations of routine data to evaluate screening programs and indicates the need to collect additional information on healthcare utilization behaviour.
In 2004 we commemorate the 150th day of death of Carl Adolph von Basedow, who takes a lasting place in the history of medicine for his description of the Merseburg triad (exophthalmos, goitre, tachycardia) with hyperthyroidism. There has been a long-lasting dispute over who first described these diagnostic features. In Germany, the dermatologically-relevant features of hyperthyroidism are known as Basedow disease. In the Anglo-American literature the name "Graves' disease" is predominately used, but also authors such as Parry or Flajani are also recognised. More than 60 other publications concerning arsenic poisoning, gonorrhoeal arthritis, anthrax, thrombophlebitis as well as a variety of surgical and gynaecological problems reflect the vast field of activity and broad scientific interests of the family doctor Basedow, who reached brilliant and lasting achievements on his own and without considerable resources.
The high prevalence of allergic rhinitis (AR) leads to high morbidity and costs. Specific immunotherapy (SIT) is a potentially curative therapy for AR. The -decision whether or not to employ SIT is often not totally clear. In 2012/13, as part of company skin cancer screening -programs, employed persons between the ages of 16-70 were asked about use of allergy-related medications and atopic conditions, as well as the use of SIT or possible reasons preventing its use. Of the 15,164 persons surveyed, 26.2% (n = 3,966) reported they had allergies that might benefit from SIT therapy. Of these, only 31.7% (n = 1,470) had undergone SIT therapy, with 63.3% (n = 931) describing the treatment as successful. The main reasons given for not undergoing SIT were relatively minor symptoms (51.2%; n = 1,278), little confidence in the success of therapy, and lack of time (12%; n = 300). Only 5.2%, n = 129) stated that avoiding allergens was sufficient or that they could not undergo SIT because of other health problems. Another 5.2% (n = 130) said they had either not heard of SIT, or had not found a place to undergo treatment. Although about one-quarter of respondents reported allergies that might benefit from SIT, less than one-third had undergone treatment. The main -reason was having mild symptoms; guideline or healthcare-related issues were -responsible only to a limited extent.
A 30-year old white male presented with sharply demarcated pruritic lesions in a black and red tattoo on his wrist. The strongly infiltrated and slightly scaly eruptions started four months after tattoo application and were notably restricted to the red-colored areas. Symptoms got worse after UV exposure. Patch testing and photo patch testing with the used azo dye Pigment Red 170 (C.I. 12475) was negative. Histology revealed lichenoid dermatitis without signs of a granulomatous reaction. The verification of allergic sensitization in hypersensitivity reactions to tattoos by patch testing may be difficult due to the poor penetration into the skin of the applied azo pigments. Intradermal testing may be more sensitive but bears the risk of long lasting skin reactions.
Pyoderma gangrenosum (PG) is an idiopathic ulcerative neutrophilic inflammatory skin disease characterized by variable clinical presentation and outcome. Because its incidence is low, no prospective randomized controlled trials and only a few large case studies on PG have been reported. We demonstrate the clinical presentation and outcome in 18 cases with severe and chronic PG. In our 18 patients, the female/male ratio was 3.5:1, the mean onset age was 53.1 yrs (range 23-78); six cases (33%) had associated diseases (inflammatory bowel disease [n = 2, 11%], monoclonal gammopathy [n = 2, 11%], rheumatoid arthritis [n = 1, 6%], diabetes mellitus [n = 1, 6%]). Anatomic locations involved were lower leg (n = 14, 78%), abdomen (n = 5, 28%), arm (n = 3, 17%), breast (n = 2, 11%), and buttocks (n = 1,6%). Five patients (28%) had multiple lesions (n > or = 2). Immunosuppressive monotherapies (n = 3, 17%) and polytherapies (n = 15, 83%) were used. 13 patients (72%) showed complete remission (mean duration to complete remission: 1.29 yrs), three patients (17%) persistent disease (mean duration: 8 yrs), contact was lost to one patient (6%) and one patient died (6%). Our observations add to the growing body of evidence that PG responds in most cases to systemic immunosuppressive treatment, with corticosteroids and cyclosporine representing first-line therapies. Besides reporting the clinical outcome in our 18 patients, we review the literature and discuss treatment recommendations that take additional factors including associated conditions, disease severity and localization of lesions into consideration.
In Germany little data on the epidemiology and histology of lip cancers are available, as lip cancers are commonly pooled together with head and neck tumors. Retrospective analysis of 181 patients with malignant tumors of the lips with respect to gender, location, histology, risk factors and comorbidity. There were 90 women and 91 men with a mean age of 71 years. 98 had a tumor on the upper lip and 83 patients on the lower lip. Tumors of the upper lip showed a slight female preference (61%). In contrast lower lip cancer was more common (64%) in men. Histological analysis revealed that in both regions nodular basal cell carcinomas as well as squamous cell carcinomas (NOS) are the most common subtypes. Vertical tumor thickness of squamous cell carcinomas was in most cases smaller than 6 mm (n = 71) and only in 4 cases was a tumor thickness of >6 mm detected. Altogether, 57% of the patients reported a high to very high sun exposure. In comparison to previous studies we found a weaker preference for women for tumors of the upper lip and also a weaker preference for men for tumors of the lower lip. The causes remain unclear, but could be causally related to an increased life expectancy and/or changed risk profile.
With the number of tattoos increasing, a rising number of complications have also been reported, such as allergic and foreign body reactions or the development of malignant tumors. We discuss 19 patients with alterations in skin tattoos, define clinicopathologic characteristics and give a brief review of the literature. Biopsy specimens were obtained in 13 of 19 patients. In all cases, staining was performed with hematoxylin-eosin, periodic acid-Schiff, CD68, CD123, and CD163. The inflammatory infiltrate was classified according to the pattern analysis of Ackerman. Three of 19 patients (15.8%) had temporary tattoos with henna and 16 (84.2%) had permanent tattoos. Histologically, among the 13 biopsy specimens we found signs of acute contact dermatitis in 2 (15.3%), lupus-like patterns in 2 (15.3%), foreign body dermatitis in 5 (38.4%), deposition of pigment without inflammation or simple scarring in 2 (15.3%), and tumors in 2 patients (15.2%), 1 of which was a malignant melanoma. Clinical presentation frequently, but not always, correlates with the histologic pattern. Obtaining a biopsy can be helpful in determining further investigations, for example allergy testing or a search for systemic involvement in cases of tattoo sarcoidosis.
Molluscum contagiosum is a common, self-limiting viral disease of childhood caused by a poxvirus. Often the children themselves and their parents desire treatment for cosmetic reasons or because of pruritus. Laser therapy offers another option to the traditional methods of treatment. 19 children aged between 2 and 13 years (median:6) with molluscum contagiosum were treated in a prospective, non-randomized pilot study with the flashlamp pumped pulsed dye laser (wave length:585 nm, pulse duration 0,45 ms, spot size 7 mm, energy density 6-7 J/cm(2)). All patients tolerated the laser treatment well. In 84.3% one laser treatment led to total remission. In 10.5% a further laser session was necessary and one patient was treated three times to achieve total remission. Treatment of molluscum contagiosum with the flashlamp pulsed dye laser is a safe and efficient treatment modality.
The efficacy of topically applied diclofenac 3 % in combination with hyaluronic acid 2.5 % in the treatment of actinic keratoses (AKs) has been demonstrated in several clinical studies, but the exact mode of action is still unclear. This study evaluates the potential molecular and cellular main modes of action of topically applied diclofenac in the treatment of AKs. In this prospective study 20 male patients with AKs were treated for 90 days with topically applied diclofenac 3 %/hyaluronic acid 2.5 %. Before and after treatment, skin biopsies were taken from the treatment area and were investigated histologically and immunohistochemically as well as compared to healthy skin. For this purpose, markers for inflammation (COX-2, CD3, CD8), apoptosis (p53), cell cycle arrest (p53, p21), proliferation (Ki67), and angiogenesis (CD31) were examined. The immunohistochemical analysis demonstrated a significant decrease in expression of COX-2, CD3 and CD8. Furthermore, there was a clear reduction of CD31 expression as a marker for angiogenetic processes. Additionally, there was a tendency toward a reduction in markers for proliferation and apoptosis. The efficacy of diclofenac 3 %/hyaluronic acid 2.5 % in the treatment of AKs is probably due to anti-inflammatory and anti-angiogenic effects, potentially associated with anti-proliferative and apoptosis-inducing underlying mechanisms.
Rising melanoma incidences have created the need of assessment of epidemiological and clinical data. We investigated the natural history of invasive cutaneous melanoma in Styria, a province of Austria, in the years 2001-2003. 1082 patients, 511 men and 571 women, mean age 58.2 +/- 16.7 years, were collected. Besides basic melanoma data, special histologic features such as regression structures, ulceration, microsatellites and vascular invasion were investigated. Furthermore, lymph node pathology in case of sentinel node biopsy and/or lymph node dissection was recorded. Mean annual incidence (crude rate) was 28.6 per 100,000 inhabitants, age standardized rate 24.5 per 100,000 (95 % CI 22.4-26.6). Cumulative risk (0- 74 years) was 1.92, lifetime risk 1 in 52. Superficial spreading melanoma was the most common type in both sexes, men on the trunk and women on the extremities. Only 11 % of all melanomas were in easily visible areas. Median tumor thickness was 0.75 mm, ranging between 0.2 and 50.0 mm. Sentinel node biopsy was performed in 158 melanomas (14.6 %),and was positive in 22 %.Primary therapeutic lymph node dissection was performed in 19 patients, showing metastases in 18 patients. The investigation revealed an unclear high melanoma incidence for invasive melanomas in our province, requiring further investigation.
The G-DRG per case payments are calculated annually on the basis of present output and cost data provided from German hospitals. The economic valuation of dermatology-related DRGs depends largely on inpatients' length of stay. At present, longitudinal analyses of dermatologic hospital data considering the development of length of stay under DRG conditions are not available. A multicenter, longitudinal study of clinical data from hospitals with different care levels was performed (n = 23). Frequent and relevant dermatologic diagnoses were grouped and analyzed over a time period of four years (2003-2006). The development of lengths of stay and of G-DRG cost weights were studied in detail. Descriptive statistical methods were applied. After introduction of DRG, the data reveal a) reduction of length of stay in inpatient dermatology and b) after an initial abrupt rise, DRG valuation of dermatologic groups moderately decreased over time. Both trends changed most rapidly in the early years but reached a stable niveau in 2006. The study furthermore points out that not only length of stay, but also other type of costs influence DRG calculations. German dermatology reflects the international trend showing reductions of length of stay after introduction of a DRG-based hospital funding system. The DRG calculation and valuation of inpatient services depend on the duration of hospital stay. However, increasing per diem costs resulting from higher performances of every inpatient bed day are also taken into account. Further reduction of length of stay must not threaten the quality of inpatient care in dermatology.
Top-cited authors
Matthias Augustin
  • University of Hamburg
Alexander Nast
  • Charité Universitätsmedizin Berlin
Thomas L Diepgen
  • Universität Heidelberg
Peter Elsner
  • Private Dermatology Practice SRH Hospital Gera
Claus Garbe
  • University of Tuebingen