S1 Guideline onychomycosis.

Onychomycosis is a fungal infection of the fingernails and toenails. In Europe, tinea unguium is mainly caused by dermatophytes. The diagnostic workup comprises microscopic examination, culture and/or molecular testing (nail scrapings). Local treatment with antifungal nail polish is recommended for mild or moderate nail infections. In case of moderate to severe onychomycosis, oral treatment is recommended (in the absence of contraindications). Treatment should consist of topical and systemic agents. The aim of this update of the German S1 guideline is to simplify the selection and implementation of appropriate diagnostics and treatment. The guideline was based on current international guidelines and the results of a literature review conducted by the experts of the guideline committee. This multidisciplinary committee consisted of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the Association of German Dermatologists (BVDD), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ), the Working Group for Pediatric Dermatology (APD) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guideline was approved by the participating medical societies following a comprehensive internal and external review.

Diagnosis and therapy of Mycobacterium marinum: a single-center 21-year retrospective analysis.

BACKGROUND AND OBJECTIVES: In Europe, infections with Mycobacterium (M.) marinum are rare. We conducted a retrospective single-center study to assess the clinical spectrum of M. marinum infection and its diagnosis, treatment and outcome under real-world conditions. PATIENTS AND METHODS: Eighteen patients presenting with M. marinum infections between 1998 and 2018 were identified in the data warehouse of the University Hospital Würzburg and considered for detailed analysis. RESULTS: Twelve patients reported aquatic exposure. In 16/18 cases the upper extremities were affected. No invasive infections were detected. Mean time to diagnosis was 15 weeks. Histology revealed granulomatous inflammation in 14 patients while mycobacterial cultures were positive for M. marinum in 16 cases. Most patients received antibiotic monotherapy (14/18) while combination therapy was administered in four cases. Treatment (with a median duration of 10 weeks) was successful in 13 patients. Five patients were lost to follow-up. CONCLUSIONS: Our retrospective analysis of M. marinum infections at a German tertiary referral center revealed a considerable diagnostic delay and the relevance of microbiological culture, PCR and histology for diagnosis. Monotherapy with clarithromycin (rather than doxycycline) appeared as a reasonable treatment option while immunosuppressed or -compromised patients and those with extended disease received combination therapy.

S1 guidelines: Tinea capitis.

Tinea capitis describes a dermatophyte infection of scalp and hair that predominately occurs in children. The diagnostic workup includes microscopic examination, culture and/or molecular tests. Treatment is guided by the specific organism involved and should consist of systemic agents as well as adjuvant topical treatment. The aim of the present update of the interdisciplinary German S1 guidelines is to provide dermatologists, pediatricians and general practitioners with a decision tool for selecting and implementing appropriate diagnostic and therapeutic measures in patients with tinea capitis. The guidelines were developed based on current international guidelines, in particular the 2010 European Society for Pediatric Dermatology guidelines and the 2014 British Association of Dermatologists guidelines, as well as on a review of the literature conducted by the guideline committee. This multidisciplinary committee consists of representatives from the German Society of Dermatology (DDG), the German-Speaking Mycological Society (DMykG), the German Society for Hygiene and Microbiology (DGHM), the German Society of Pediatric and Adolescent Medicine (DGKJ) and the German Society for Pediatric Infectious Diseases (DGPI). The Division of Evidence-based Medicine (dEBM) provided methodological assistance. The guidelines were approved by the participating medical societies following a comprehensive internal and external review.

An update on Peginterferon beta-1a Management in Multiple Sclerosis: results from an interdisciplinary Board of German and Austrian Neurologists and dermatologists.

BACKGROUND: Interferon (IFN) beta drugs have been approved for the treatment of relapsing forms of multiple sclerosis (RMS) for more than 20 years and are considered to offer a favourable benefit-risk profile. In July 2014, subcutaneous (SC) peginterferon beta-1a 125 µg dosed every 2 weeks, a pegylated form of interferon beta-1a, was approved by the EMA for the treatment of adult patients with RRMS and in August 2014 by the FDA for RMS. Peginterferon beta-1a shows a prolonged half-life and increased systemic drug exposure resulting in a reduced dosing frequency compared to other available interferon-based products in MS. In the Phase 3 ADVANCE trial peginterferon beta-1a demonstrated significant positive effects on clinical and MRI outcome measures versus placebo after one year. Furthermore, in the ATTAIN extension study, sustained efficacy with long-term treatment for nearly 6 years was shown. MAIN TEXT: In July 2016, an interdisciplinary panel of German and Austrian experts convened to discuss the management of side effects associated with peginterferon beta-1a and other interferon beta-based treatments in MS in daily practice. The panel was composed of experts from university hospitals and private clinics comprised of neurologists, dermatologists, and an MS nurse. In this paper we report recommendations regarding best practices for adverse event management, focussing on peginterferon beta-1a. Injection site reactions (ISRs) and influenza-like illness are the most common adverse effects of interferon beta therapies and can present a burden for MS patients leading to non-adherence and discontinuation of therapy. Peginterferon beta-1a shows improved pharmacological properties. In clinical trials, the adverse event (AE) profile of peginterferon beta-1a was similar to other interferon beta formulations. The most common AEs were mild to moderate ISRs, influenza-like illness, pyrexia, and headache. Current information on the underlying cause of skin reactions associated with SC interferon treatment, and the management strategies for these AEs are limited. In pivotal trials, ISRs were mainly characterized and classified by neurologists, while dermatologists were only rarely consulted. CONCLUSIONS: This report addresses expert recommendations on the management of most relevant adverse effects related to peginterferon beta-1a and other interferon betas, based on literature and interdisciplinary experience.

The Risk of Bacterial Infection After Tattooing.

BACKGROUND: Tattooing is a globally growing trend. Overall prevalence among adults in industrialized countries is around 10-20%. Given the high and increasing numbers of tattooed people worldwide, medical and public health implications emerging from tattooing trends require greater attention not only by the public, but also by medical professionals and health policy makers. METHODS: We performed a systematic review of the literature on tattooassociated bacterial infections and bacterial contamination of tattoo inks. Furthermore, we surveyed tattoo inks sampled during an international tattoo convention in Germany to study their microbial status. RESULTS: Our systematic review identified 67 cases published between 1984 and 2015, mainly documenting serious bacterial infectious complications after intradermal deposition of tattoo inks. Both local skin infections (e.g. abscesses, necrotizing fasciitis) and systemic infections (e.g. endocarditis, septic shock) were reported. Published bacteriological surveys showed that opened as well as unopened tattoo ink bottles frequently contained clinically relevant levels of bacteria indicating that the manufactured tattoo product itself may be a source of infection. In our bacteriological survey, two of 39 colorants were contaminated with aerobic mesophilic bacteria. CONCLUSION: Inappropriate hygiene measures in tattoo parlors and non-medical wound care are major risk factors for tattoo-related infections. In addition, facultative pathogenic bacterial species can be isolated from tattoo inks in use, which may pose a serious health risk.

Tinea capitis: Erregerspektrum und Epidemiologie im zeitlichen Wandel.

HINTERGRUND: Die Tinea capitis ist die häufigste Dermatomykose des Kindesalters. Das Erregerprofil zeigt unterschiedliche geographische Verteilungsmuster und variiert im Laufe der Zeit. PATIENTEN UND METHODIK: Zwischen 1990-2014 an der Würzburger Universitätsklinik für Dermatologie erhobene Daten von 150 Patienten mit mykologisch gesicherter Tinea capitis wurden hinsichtlich Alter, Geschlecht und Erregerspektrum analysiert und über zwei Zeiträume von jeweils 12,5 Jahren miteinander verglichen. ERGEBNISSE: Obwohl eine Tinea capitis am häufigsten bei Kindern der Altersgruppe zwischen 0 und 5 Jahren diagnostiziert wurde, lag der Anteil betroffener Erwachsener mit 16 % höher als bislang berichtet. Der zoophile Dermatophyt Microsporum canis konnte am häufigsten als Erreger der Tinea capitis identifiziert werden, jedoch war ein Anstieg von Infektionen mit den anthropophilen Pilzen Trichophyton tonsurans und Trichophyton rubrum zu verzeichnen. Tendenziell sank der Anteil zoophiler im Verhältnis zu den anthropophilen Erregern. Im zeitlichen Verlauf zeigte sich eine zunehmende Heterogenität des Erregerspektrums: Dermatophyten wie Trichophyton soudanense und Trichophyton violaceum, Trichophyton anamorph von Arthroderma benhamiae sowie Trichophyton schoenleinii und Microsporum audouinii konnten erstmalig bzw. nach langer Zeit wieder erneut isoliert werden. SCHLUSSFOLGERUNGEN: Wenngleich Microsporum-canis-Infektionen noch dominieren, sind zunehmend anthropophile Erreger nachzuweisen. Angesichts des unerwartet hohen Anteils von Erwachsenen sollte eine Tinea capitis in allen Altersgruppen differenzialdiagnostisch in Betracht gezogen werden.

Tinea capitis: temporal shift in pathogens and epidemiology.

BACKGROUND: Tinea capitis is the most common type of dermatomycosis in children. Its pathogen profile shows geographic variations as well as temporal shifts. PATIENTS AND METHODS: Data from 150 patients with mycologically confirmed tinea capitis treated at the Department of Dermatology, University Hospital Würzburg, between 1990 and 2014 were analyzed with respect to gender, age, and pathogen spectrum. Two time periods, each 12.5 years long, were compared. RESULTS: Although tinea capitis was most frequently diagnosed in children between the ages of 0 and 5, the percentage of adults (16 %) was higher than previously reported. The zoophilic dermatophyte Microsporum canis was most frequently identified as the causative agent of tinea capitis. However, there was a rise in infections caused by the anthropophilic fungi Trichophyton tonsurans and Trichophyton rubrum, and also a trend towards a lower percentage of zoophilic versus anthropophilic pathogens. Over the course of time, we observed an increase in the diversity of the pathogen spectrum. Dermatophytes such as Trichophyton soudanense, the Trichophyton anamorph of Arthroderma benhamiae, Trichophyton schoenleinii, and Microsporum audouinii were isolated either for the first time or for the first time after a long hiatus. CONCLUSIONS: Although Microsporum canis infections still predominate, there has been an increase in anthropophilic pathogens. Given the unexpectedly high percentage of adults, tinea capitis should be included in the differential diagnostic considerations in all age groups.

Cutaneous Adverse Events Associated with Interferon-ß Treatment of Multiple Sclerosis.

Interferons are widely used platform therapies as disease-modifying treatment of patients with multiple sclerosis. Although interferons are usually safe and well tolerated, they frequently cause dermatological side effects. Here, we present a multiple sclerosis (MS) patient treated with interferon-ß who developed new-onset psoriasis. Both her MS as well as her psoriasis finally responded to treatment with fumarates. This case illustrates that interferons not only cause local but also systemic adverse events of the skin. These systemic side effects might indicate that the Th17/IL-17 axis plays a prominent role in the immunopathogenesis of this individual case and that the autoimmune process might be deteriorated by further administration of interferons. In conclusion, we think that neurologists should be aware of systemic cutaneous side effects and have a closer look on interferon-associated skin lesions. Detection of psoriasiform lesions might indicate that interferons are probably not beneficial in the individual situation. We suggest that skin lesions may serve as biomarkers to allocate MS patients to adequate disease-modifying drugs.

Community-acquired skin infections caused by Staphylococcus aureus: What is the role of the Panton-Valentine leukocidin toxin?

BACKGROUND: The data concerning frequency and relevance of the toxin Panton-Valentine leukocidin (PVL) in skin infections caused by Staphylococcus aureus is controversial. The objective of the study was the identification of the role of the toxin in community-acquired skin infections caused by S. aureus. PATIENTS AND METHODS: We performed a retrospective analysis of 112 patients with the diagnosis of skin infections caused by S. aureus. Frequency of PVL was investigated by PCR for the lukSF gene. Risk factors and severity of the disease were analyzed. Furthermore, spa typing was done in 55 of the isolated S. aureus. RESULTS: PVL occurred in 45 % of patients with skin infections caused by methicillin-susceptible S. aureus; methicillin-resistant strains were positive in 63 %. Mean age was 30.9 years in PVL-positive infections and thus statistically highly significantly lower than in PVL-negative infections. There was no correlation between presence of PVL and severity and course of skin infections or presence of special risk factors. The spa types showed a high variability in PVL-positive as well as in PVL-negative strains. CONCLUSIONS: In our study the PVL status of S. aureus isolated from skin infections was neither correlated with methicillin-resistance nor with the severity of disease. Remarkably, PVL-positive S. aureus strains appeared to be more frequent in younger than in older patients. Our results demonstrate that routine determination of PVL status is not required since the outcome has no diagnostic or therapeutic consequences in daily dermatological practice.

A different kind of hedgehog pathway: tinea manus due to Trichophyton erinacei transmitted by an African pygmy hedgehog (Atelerix albiventris).

The unusual case of a 29-year-old woman with tinea manus caused by infection due to Trichophyton erinacei is described. The patient presented with marked erosive inflammation of the entire fifth finger of her right hand. Mycological and genomic diagnostics resulted in identification of T. erinacei as the responsible pathogen, which had been transmitted by a domestic African pygmy hedgehog, Atelerix albiventris. Upon prolonged treatment with topical and systemic antifungal agents skin lesions slowly resolved. This case illustrates that the increasingly popular keeping of extraordinary pets such as hedgehogs may bear the risk of infections with uncommon dermatophytes.

Prevalence dependent calibration of a predictive model for nasal carriage of methicillin-resistant Staphylococcus aureus.

BACKGROUND: Published models predicting nasal colonization with Methicillin-resistant Staphylococcus aureus among hospital admissions predominantly focus on separation of carriers from non-carriers and are frequently evaluated using measures of discrimination. In contrast, accurate estimation of carriage probability, which may inform decisions regarding treatment and infection control, is rarely assessed. Furthermore, no published models adjust for MRSA prevalence. METHODS: Using logistic regression, a scoring system (values from 0 to 200) predicting nasal carriage of MRSA was created using a derivation cohort of 3091 individuals admitted to a European tertiary referral center between July 2007 and March 2008. The expected positive predictive value of a rapid diagnostic test (GeneOhm, Becton & Dickinson Co.) was modeled using non-linear regression according to score. Models were validated on a second cohort from the same hospital consisting of 2043 patients admitted between August 2008 and January 2012. Our suggested correction score for prevalence was proportional to the log-transformed odds ratio between cohorts. Calibration before and after correction, i.e. accurate classification into arbitrary strata, was assessed with the Hosmer-Lemeshow-Test. RESULTS: Treating culture as reference, the rapid diagnostic test had positive predictive values of 64.8% and 54.0% in derivation and internal validation corhorts with prevalences of 2.3% and 1.7%, respectively. In addition to low prevalence, low positive predictive values were due to high proportion (> 66%) of mecA-negative Staphylococcus aureus among false positive results. Age, nursing home residence, admission through the medical emergency department, and ICD-10-GM admission diagnoses starting with "A" or "J" were associated with MRSA carriage and were thus included in the scoring system, which showed good calibration in predicting probability of carriage and the rapid diagnostic test's expected positive predictive value. Calibration for both probability of carriage and expected positive predictive value in the internal validation cohort was improved by applying the correction score. CONCLUSIONS: Given a set of patient parameters, the presented models accurately predict a) probability of nasal carriage of MRSA and b) a rapid diagnostic test's expected positive predictive value. While the former can inform decisions regarding empiric antibiotic treatment and infection control, the latter can influence choice of screening method.