[Cutaneous leishmaniasis. Diagnosis and therapy in northern Afghanistan]. / Erfahrungen mit der kutanen Leishmaniasis. Diagnostik und Therapie im Einsatz in Nordafghanistan.

BACKGROUND: The German S1 guidelines from 2009 contain a variety of recommendations for the treatment of cutaneous leishmaniasis. PATIENTS AND METHODS: We report the results of our diagnostic procedures and treatment of 32 international patients in autumn 2010 in northern Afghanistan. RESULTS: Giemsa stain confirmed the clinical diagnosis within 24 hours. Eleven simple lesions and one larger ulcer responded well to cryotherapy and intralesional sodium stibogluconate. More complex lesions in 19 patients responded well to oral miltefosine. One patient refused outpatient therapy. CONCLUSIONS: Cryotherapy and intralesional antimony compounds showed good results in early lesions of cutaneous leishmaniasis in northern Afghanistan. Outpatient treatment of complex lesions with miltefosine was successful in all cases.

[Treatment of gunpowder tattoo and foreign bodies after blast injuries]. / Behandlung von Pulverschmauch- und Fremdkörpereinsprengungen.

Gunpowder traumatic tattoo and foreign bodies in the skin secondary to explosions or gunshots need to be treated within 72 h if possible to achieve good aesthetic results. Hypertrophic scars can be treated by skin resurfacing using the Erb-YAG laser or the CO2 laser, while traumatic tattoos can be removed with the Q-switched rubin laser.

A teledermatological approach to enhance diagnostic accuracy in dermatohistopathology.

We determined whether digital photographs of skin lesions could enhance diagnostic accuracy in dermatohistological evaluations. Two dermatohistopathologists examined 375 unsorted consecutive cases. On a standardized questionnaire they recorded whether the final diagnostic interpretation would be improved by the availability of digital images of the skin lesions. In 101 cases (27%) they said that digital photographs would be helpful. Subsequently, 30 histological analyses were performed with and without digital photographs of the skin lesions. Presentation of digital photographs reduced the number of differential diagnoses significantly, from a median of 3 to 2. Ratings of ability to make a single definitive diagnosis increased significantly with the presentation of digital photographs. Enhancement of information given by the digital images was scored a median of 6 (on a scale of 0-10, with higher scores reflecting greater enhancement). Digital photographs of skin lesions are likely to refine diagnostic accuracy in histopathology.

[Phototherapy and photochemotherapy of inflammatory dermatoses]. / Phototherapie bringt selbst hartnäckige Dermatosen zum Abklingen. Heilsames Bad im Licht.

Stubborn and extensive dermatoses, such as psoriasis vulgaris or atopic dermatitis (eczema), are indications for phototherapeutic methods. These include UVB phototherapy, UVA photochemotherapy (PUVA), UVA irradiation following prior photosensitization, UVA, treatment and combination treatments. Phototherapy is contraindicated in the case of light-induced dermatoses. Caution must also be exercised in patients receiving photosensitizing medications. When establishing the indication, consideration must be given to the treatment-related increased risk of developing skin cancer. The patient must also be informed of such undesired potential side effects as burns and premature aging of the skin.

Varicella zoster viraemia during herpes zoster is not associated with neoplasia.

BACKGROUND: Shingles are caused by an endogenous or exogenous reinfection with varicella zoster virus (VZV). Up to 50% of individuals with Hodgkin's disease develop herpes zoster; however, no association could be shown between the occurrence of herpes zoster and underlying subclinical malignancies. OBJECTIVE: This study was conducted to investigate whether VZV DNA could be detected by polymerase chain reaction (PCR) in the blood of herpes zoster patients and whether there was an association between VZV viraemia and previous or concurrent neoplasias. METHODS: At least five blood samples from 28 patients with herpes zoster were investigated by internally controlled PCR enzyme-linked immunosorbent assay prior to and during therapy with aciclovir. RESULTS: None of 13 patients, two with a history of neoplasia and two with a neoplasia at the time of the study, showed any signs of viraemia with VZV, and 14 patients had inconsistent viraemia, one with a history of neoplasia and two with neoplasia at the time of the study. In one patient VZV DNA was detected in the blood for 6 days. This patient died soon after from metastatic malignant melanoma. CONCLUSIONS: VZV viraemia may occur during herpes zoster episodes, even in patients without evidence of immunosuppression; however, this viraemia is, in most cases, inconsistent and does not provide any specific information concerning underlying unrecognized malignancies.

Does the minimal phototoxic dose after 8-methoxypsoralen baths correlate with the individual's skin phototype?

BACKGROUND/AIMS: Up to now no data have been available concerning whether there is a significant correlation between skin phototypes and the minimum phototoxic dose (MPD) after bath water delivery of 8-MOP. METHODS: The skin phototype of each of 46 patients was determined based on the individual past history of solar-induced burning and tanning. In addition, the MPD of each patient was assesed after photosensitization with a warm water bath (37 degrees C, 98.6 degrees F) containing 1.0 mg/l 8-methoxypsoralen (8-MOP). Statistical analysis was performed using a Mann-Whitney U-test and Spearman rank order correlation. RESULTS: The median MPD in patients with skin phototype II was 2.0 J/cm2 (range < or =0.5 to > or =3.5) versus 1.5 J/cm2 (range 1.0 to > or =3.5) in patients with skin phototype III. There was a considerable overlap between both groups. No significant difference was detected comparing both groups (P=0.7326) and Spearman rank order correlation revealed no correlation between skin phototype and MPD. CONCLUSION: Erythemal sensitivity in PUVA bath therapy, measured as MPD, is not correlated with sun-reactive skin phototype in skin types II and III. Thus skin phototype is not a suitable indicator for the initial UVA dose in PUVA bath photochemotherapy.

Competitive polymerase chain reaction used to diagnose cutaneous leishmaniasis in German soldiers infected during military exercises in French Guiana.

A competitive polymerase chain reaction (PCR) followed by enzyme-linked-immunoassay-based verification of PCR products has been developed, which facilitated the diagnosis of leishmaniasis in two German soldiers who underwent survival training in the jungle of French Guiana and returned with therapy-resistant pyoderma-like lesions. After treatment with liposomal amphotericin B, the skin manifestations disappeared, and leishmania DNA could no longer be detected by PCR. In the context of growing military involvement in areas where leishmaniasis is prevalent, this assay may help detect or, due to its internal controls, exclude cases of infection with this parasite.

[Evaluation of a telemedicine pilot project]. / Evaluation eines telemedizinischen Pilotprojekts.

BACKGROUND AND OBJECTIVE: Rapid progress in computer and information technologies has led to an increased interest in the use of telemedicine during the past few years. Thus it should be clarified, whether teledermatology can achieve comparable results to conventional specialist examination and advice. PATIENTS/METHODS: We initiated a pilot study, comparing teledermatology with conventional examination in a dermatology outpatient setting. 60 patients were included. RESULTS: Out of 60 teledermatological examinations, remote clinicians were in agreement with face-to-face clinicians in 90%. Teledermatology was unable to make a useful diagnosis in 6 patients, however further diagnostic procedures were ordered, enabling teledermatologists to achieve correct diagnoses. Regarding need for further diagnostic tests, there was no difference between teledermatology and conventional examination. CONCLUSIONS: Teledermatology appears suitable to transfer a dermatologist's expertise over large distances.

Calcipotriol vs. tazarotene as combination therapy with narrowband ultraviolet B (311 nm): efficacy in patients with severe psoriasis.

BACKGROUND: Phototherapy has been shown to be one of the most effective treatment modalities for patients with psoriasis. Nevertheless, photocombination therapies capable both of reducing cumulative ultraviolet (UV) doses and of accelerating clearance of skin lesions are important and of high interest. There have been no published studies comparing the effect of narrowband UVB irradiation in combination with topical application of tazarotene vs. calcipotriol. OBJECTIVES: To determine, in a half-side manner, whether a combination of UVB (311 nm) and tazarotene is superior to UVB (311 nm) plus calcipotriol or vice versa. METHODS: Ten patients suffering from widespread symmetrical psoriasis were treated for at least 4 weeks with topical calcipotriol and tazarotene in a half-side distribution. Additionally, the whole body was irradiated with narrowband UVB (311 nm) four times a week. Before treatment and once weekly during therapy a modified Psoriasis Area and Severity Index was estimated for each body half. The total treatment time, number of treatment sessions and cumulative UVB dose necessary for clearance of skin lesions were determined in an observer-blind fashion for each patient. Furthermore, all patients completed a quality of life questionnaire. RESULTS: Clearance of psoriasis was observed after a median of 19 treatment sessions (range 14-28) and a median cumulative UVB dose of 22.98 J cm-2 (range 9.24-58.22) simultaneously for both body halves. On the side treated with topical tazarotene gel, four patients complained of itching and dryness of the skin, and skin irritation was observed in three of them. Six patients preferred the application of tazarotene gel, while four preferred calcipotriol. CONCLUSIONS: Our clinical comparison of narrowband UVB with either topical calcipotriol or topical tazarotene revealed no significant therapeutic difference between both regimens. Although these results need to be confirmed in larger patient groups, we feel that both photocombination therapies can broaden the therapeutic options for moderate to severe psoriasis vulgaris and may reduce the cumulative UVB dose during therapy.

Eosinophilic fasciitis treated with psoralen-ultraviolet A bath photochemotherapy.

Eosinophilic fasciitis is a rare disorder which can markedly affect the quality of life in individual patients. So far, no generally accepted and effective treatment modality has been available. Although the precise nature of eosinophilic fasciitis is still unknown, it is often regarded as a variant of localized scleroderma (morphoea). Phototherapy and photochemotherapy have been shown to be effective in the treatment of sclerodermatous skin lesions. We report a patient with eosinophilic fasciitis which was successfully treated with psoralen plus ultraviolet A bath photochemotherapy within 6 months.

Late-type allergy to the X-ray contrast medium Solutrast (iopamidol).

In the past few years, there have been an increasing number of publications on delayed intolerance reactions, including rashes, following the use of X-ray contrast media. We report a patient in whom infiltrated erythema of the face and generalized maculopapular rashes occurred on 2 occasions, within 1 day, following the use of the X-ray contrast medium Solutrast (iopamidol) for coronary angiography. The allergological investigations for clarification included prick tests and patch tests using a series of contrast media, as well as individual intravenous provocation tests. We found the cause to be a late-type allergy to the active substance iopamidol contained in the contrast medium Solutrast. We found a concomitant cross-reactivity to the contrast media iopromid and iomeprol. All 3 contrast media represent the monomeric, non-ionic type.

[Meningeal irritation--a complication of herpes zoster]. / Meningeale Reizung--eine Komplikation des Herpes zoster.

HISTORY AND CLINICAL FINDINGS: A previously healthy 26-year-old man complained of gradually increasing headache after an attack of flu. After 4 days an erythema with papules but no blisters was noted in the area of distribution of the left 10th thoracic nerve. As a child he had varicella (chickenpox) without complications. INVESTIGATIONS: Lymphocytic pleocytosis and evidence of an abnormal blood-brain barrier were noted in cerebrospinal fluid (CSF). Serology for varicella zoster virus revealed an IgG titre of > 7400 IU/l in serum and 21 IU/l in CSF. The corresponding IgM titres were negative. TREATMENT AND COURSE: The headaches and cutaneous changes regressed under i.v. treatment with acyclovir, 10 mg/kg body weight, 3 x daily for 10 days. Repeat CSF examination after 10 days showed merely minimal residual changes of inflammation. CONCLUSION: This case illustrates the risk of severe neurological complications of herpes zoster infection. A seemingly minor rash with headache must be correctly diagnosed and immediate high-dosage acyclovir treatment instituted to prevent life-threatening and severe complications of herpes zoster meningitis or encephalitis.

Occupational protein contact dermatitis caused by meat and fish.

BACKGROUND: Protein contact dermatitis is a form of contact dermatitis possibly triggered by proteinaceous allergens. MATERIALS AND METHODS: We report two patients with a history of erythematous and urticarial skin reactions followed by transformation into prolonged papular symptoms upon contact with proteinaceous material. RESULTS: The symptoms reported by the patients were reproducible by skin testing with meat (cow) and fish (salmon). Both patients experienced extracutaneous manifestations after ingestion of meat and fish, as proven by oral challenge. Specific immunoglobulin E (IgE) antibodies were detected in the patients' blood. CONCLUSIONS: Both cases meet all major criteria of protein contact dermatitis, suggesting IgE-mediated immediate-type hypersensitivity with late-phase cutaneous reactions.

[Suppurative acrodermatitis continua of Hallopeau. A differential diagnosis of paronychia]. / Acrodermatitis continua suppurative (Hallopeau). Eine Differentialdiagnose der Paronychie.

HISTORY AND CLINICAL FINDINGS: A 39-year-old man was admitted for treatment of bilateral inflammatory-pustular skin changes in the area of the large toes and soles of the feet. Antibiotic treatment and an Emmert wedge resection had already been unsuccessfully performed at another hospital for what was diagnosed as paronychia. On admission there were inflammatory, in part erosive, red areas with yellow and partly confluent pustules on the distal phalanges of both great toes. The entire right nail-bed and left medial nail-bed were missing. In the area of the capillitium, both lower arms and the sulcus coronarius there were erythematous squamous plaques. INVESTIGATIONS: Radiography of the great toes demonstrated dystrophic demineralisation, in part with subchondral cystic changes of the spongiosa. Histological examination of the nail-bed showed hyperplasia and papillomatosis, definite hyperkeratosis with a prominent granular layer, as well as ortho- and parahyperkeratosis. Laboratory tests for inflammatory disease were unremarkable and there was no association with HLA B27. DIAGNOSIS, TREATMENT AND COURSE: Suppurative acrodermatitis continua of Hallopeau was diagnosed and immunosuppressive treatment with cyclosporin A given (initially 4.4 mg/kg. stepwise reduction to 2.5 mg/kg within 6 weeks, this dosage then continued for a further 10 weeks). Nearly complete healing was achieved, but the condition recurred in a mild form 2 weeks after the end of treatment. CONCLUSION: Suppurative acrodermatitis continua of Hallopeau should be included in the differential diagnosis of inflammatory changes of the distal phalanges.

[Dermatomyositis-like skin changes with long-term hydroxyurea (Litalir) therapy]. / Dermatomyositisartige Hautveränderungen unter Hydroxyurea (Litalir)-Langzeittherapie.

We report on dermatomyositis-like adverse cutaneous reactions following long-term maintenance therapy with hydroxyurea in two patients suffering from chronic myelogenous leukaemia (CML). In addition to non-specific side effects, such as xerosis, pruritus and hyperpigmentation, both patients presented with more specific skin changes, i.e. erythematous lesions, scaling, and partially atrophic areas distributed in a linear fashion on the dorsal aspects of the hands and fingers. In addition, teleangiectatic erythema of the face was present in both patients, and this was associated with oedema of the eyelids in one patient. Despite these dermatomyositis-like features there were no clinical signs of muscular involvement, and muscle-specific enzymes were within normal ranges. Skin biopsy specimens revealed an interface dermatitis characterized by a lichenoid cell infiltrate, vacuolar alteration of basal cells, necrotic keratinocytes within the spinous zone, focal hypergranulosis, ortho-hyperkeratosis and telangiectases in the upper part of the dermis. Analogous histopathological findings have been documented in lichen planus-like skin changes on the hands following hydroxyurea therapy. It seems doubtful whether there are actually any major differences between those skin changes described as dermatomyositis-like and those interpreted as lichen planus-like in patients receiving long-term hydroxyurea therapy.