S2k Guidelines for the diagnosis and treatment of chronic pruritus - update - short version.

Associated with a host of different diseases, pruritus is a cardinal symptom that poses an interdisciplinary diagnostic and therapeutic challenge. Over time, that symptom may progress independently of the initial cause, thus losing its function as a warning sign and turning into a clinically relevant disease of its own. In Germany, approximately 13.5 % of the general population are affected by chronic pruritus, with an incidence of 7 %. All forms of chronic pruritus require targeted treatment consisting of (a) diagnosis and management of the underlying disease, (b) dermatological treatment of primary or secondary (for example, dry skin, scratch lesions) symptoms, (c) symptomatic antipruritic treatment, and (d) psychological/psychotherapeutic treatment in case of an underlying or associated psychological or psychosomatic condition. Medical care of patients with chronic pruritus should therefore include an interdisciplinary approach, in particular with respect to diagnosis and therapy of the underlying disease as well as in terms of the management of treatment and adverse events. The objective of the present interdisciplinary guidelines is to define and standardize diagnostic and therapeutic procedures in patients with chronic pruritus. This is a short version of the current S2 guidelines on chronic pruritus. The long version may be found at www.awmf.org.

Mental stress in atopic dermatitis--neuronal plasticity and the cholinergic system are affected in atopic dermatitis and in response to acute experimental mental stress in a randomized controlled pilot study.

RATIONALE: In mouse models for atopic dermatitis (AD) hypothalamus pituitary adrenal axis (HPA) dysfunction and neuropeptide-dependent neurogenic inflammation explain stress-aggravated flares to some extent. Lately, cholinergic signaling has emerged as a link between innate and adaptive immunity as well as stress responses in chronic inflammatory diseases. Here we aim to determine in humans the impact of acute stress on neuro-immune interaction as well as on the non-neuronal cholinergic system (NNCS). METHODS: Skin biopsies were obtained from 22 individuals (AD patients and matched healthy control subjects) before and after the Trier social stress test (TSST). To assess neuro-immune interaction, nerve fiber (NF)-density, NF-mast cell contacts and mast cell activation were determined by immunohistomorphometry. To evaluate NNCS effects, expression of secreted mammal Ly-6/urokinase-type plasminogen activator receptor-related protein (SLURP) 1 and 2 (endogenous nicotinic acetylcholine receptor ligands) and their main corresponding receptors were assessed by quantitative RT-PCR. RESULTS: With respect to neuro-immune interaction we found higher numbers of NGF+ dermal NF in lesional compared to non-lesional AD but lower numbers of Gap43+ growing NF at baseline. Mast cell-NF contacts correlated with SCORAD and itch in lesional skin. With respect to the NNCS, nicotinic acetylcholine receptor α7 (α7nAChR) mRNA was significantly lower in lesional AD skin at baseline. After TSST, PGP 9.5+ NF numbers dropped in lesional AD as did their contacts with mast cells. NGF+ NF now correlated with SCORAD and mast cell-NF contacts with itch in non-lesional skin. At the same time, SLURP-2 levels increased in lesional AD skin. CONCLUSIONS: In humans chronic inflammatory and highly acute psycho-emotional stress interact to modulate cutaneous neuro-immune communication and NNCS marker expression. These findings may have consequences for understanding and treatment of chronic inflammatory diseases in the future.

[Acne vulgaris--psychosomatic aspects]. / Acne vulgaris--Psychosomatische Aspekte.

More than a cosmetic nuisance, acne can produce anxiety, depression, and other psychological problems that affect patients' lives in ways comparable to life-threatening or disabling diseases. Emotional problems due to the disease should be taken seriously and included in the treatment plan. A purely dermatological therapy by itself may not achieve its purpose. Even mild to moderate disease can be associated with significant depression and suicidal ideation, and psychologic change does not necessarily correlate with disease severity. Acne patients suffer particularly under social limitations and reduced quality of life. Psychological comorbidities in acne are probably greater than generally assumed. Attention should be paid to psychosomatic aspects especially if depressive-anxious disorders are suspected, particularly with evidence of suicidal tendencies, body dysmorphic disorders, or also in disrupted compliance. Therefore, patients who report particularly high emotional distress or dysmorphic tendencies due to the disease should be treated, if possible, by interdisciplinary therapy. The dermatologist should have some knowledge of the basics of psychotherapy and psychopharmacology, which sometimes must be combined with systemic and topical treatment of acne in conjunction with basic psychosomatic treatment.

Psychopharmacological treatment of dermatological patients--when simply talking does not help.

In dermatology, primary emotional disorders with cutaneous manifestations, secondary emotional disorders caused by dermatoses and multifactorial diseases are possible indications for the use of psychopharmaceuticals. Neuroleptics (anti-psychotics) are usually used in psychiatric illnesses, while antidepressants are foremost in treating depression as well as obsessive-compulsive, anxiety and panic disorders. Minor tranquilizers may be used symptomatically. To define the indications for mid- and long-term treatment with psychopharmaceuticals, the unequivocal diagnosis of the main and secondary psychiatric symptoms as well as the primary target symptoms must be designated. At the start of therapy planning, any possible desired and undesired side effects must be taken into account, such as stimulation, sedation, anticholinergic side effects or weight gain. The main antidepressants are the well-tolerated selective serotonin reuptake inhibitors (SSRI) such as sertraline, fluoxetine or citalopram. A clear long-term plan and how to monitor it must be discussed with patient carefully because of the need for individual dose titration and the late onset of action of many of these medications. Good results can be achieved in dermatologic patients requiring psychopharmaceuticals if the indications are carefully assessed and the therapy logically structured.

Intermedin: a skin peptide that is downregulated in atopic dermatitis.

Intermedin (IMD), also called adrenomedullin-2, is a peptide that belongs to the calcitonin/calcitonin gene-related peptide/amylin peptide family. IMD exerts many effects on the cardiovascular system, gastrointestinal tract, and central nervous system. Here, we analyzed the expression of the IMD peptide in human skin of healthy controls, in biopsies from lesional and non-lesional areas of atopic dermatitis (AD) skin, in cultured human keratinocytes, and in the HaCaT keratinocyte cell line at the transcriptional (quantitative reverse transcription-PCR) and translational (immunohistochemistry) level. IMD messenger RNA (mRNA) and protein could be detected in keratinocytes and human skin. Keratinocytes, nerve fibers, periglandular cells, arterial/arteriolar smooth muscle cells, and pericytes of dermal microvessels were intensely IMD-immunoreactive. The IMD mRNA was, compared to healthy skin, significantly reduced in lesional and non-lesional areas of AD skin. This was accompanied by a reduction of IMD immunoreactivity in pericytes of the upper dermis indicating that skin from AD patients is generally affected, and downregulation of IMD in AD skin is not a secondary phenomenon caused by acute inflammation but is a general characteristic of AD skin. These data further point to a role of IMD expressed by pericytes in conferring higher susceptibility of the skin of AD patients to inflammatory stimuli.

Acne vulgaris--psychosomatic aspects.

More than a cosmetic nuisance, acne can produce anxiety, depression, and other psychological problems that affect patients' lives in ways comparable to life-threatening or disabling diseases. Emotional problems due to the disease should be taken seriously and included in the treatment plan. A purely dermatological therapy by itself may not achieve its purpose. Even mild to moderate disease can be associated with significant depression and suicidal ideation, and psychologic change does not necessarily correlate with disease severity. Acne patients suffer particularly under social limitations and reduced quality of life. Psychological comorbidities in acne are probably greater than generally assumed. Attention should be paid to psychosomatic aspects especially if depressive-anxious disorders are suspected, particularly with evidence of suicidal tendencies, body dysmorphic disorders, or also in disrupted compliance.Therefore, patients who report particularly high emotional distress or dysmorphic tendencies due to the disease should be treated, if possible, by interdisciplinary therapy. The dermatologist should have some knowledge of the basics of psychotherapy and psychopharmacology, which sometimes must be combined with systemic and topical treatment of acne in conjunction with basic psychosomatic treatment.

Manifestation of atopic eczema in children after heart transplantation in the first year of life.

Children undergoing heart transplantation in the first year of life appear in clinical observation to develop atopic eczema at an above-chance frequency despite immunosuppressive therapy with cyclosporine A. A clinical study was undertaken to clarify the extent to which those children develop atopic eczema with above-chance frequency. In this cross-sectional study, we examined 41 consecutive children after heart transplantation. Twenty-seven underwent heart transplantation in the first year of life, seven after the first birthday, and seven had cardiac surgery other than heart transplantation in the first year of life and served as a control group. Atopic eczema was diagnosed in 11 out of 27 children with heart transplant in the first year of life. No atopic eczema was diagnosed in the other two groups. Children undergoing heart transplant prior to the first birthday apparently develop atopic eczema more frequently than children whose surgery was performed after the first birthday, and also more frequently than children undergoing organ-preserving procedures, despite immunotherapy. It remains an open question whether a surgical procedure within the first months of life with subsequent immunosuppression causes an alteration in the reactivity of the immune system in these children compared to older children which promotes the occurrence of atopic eczema despite immunosuppression.

[Stress and psoriasis -- a psychoneuroimmunological study]. / Stress und Psoriasis -- eine psychoneuroimmunologische Studie.

UNLABELLED: Psoriasis is a polygenetic hereditary multifactorial disease which may be influenced by a number of environmental factors. To date only a few studies experimentally investigated the influence of stress on psoriasis. One problem of these studies is that it remains unclear whether the experimental findings are relevant for the entire group of patients, or whether there are subgroups who are particularly susceptible to stress. Therefore our main objective is to examine whether experimental stressors can identify subgroups of patients who are particularly susceptible to stress and if these differ in immunological parameters. METHOD: The Trier Social Stress Test (TSST) was used as stressor. The severity was recorded both objectively using the PASI (Psoriasis Area and Severity Index) as well as subjectively by the patient. Somatic parameters for which stress reactivity is known but no direct relationship to psoriasis is assumed were selected and exploratively examined within the present study (salivary cortisol). The second set of parameters for which the stress reactivity was unclear included variables which are linked to the pathophysiology and/or the severity of psoriasis. In addition to salivary cortisol, eosinophils, ICAM-3, and sIL-2R were determined in serum. 38 psoriasis patients and 38 control subjects were examined (21 male and 17 female participants within each group). RESULTS: The PASI correlated very inconsistently with the subjective severity parameters. The relationships between severity and blood parameters tested showed a systematic relationship for eosinophils only. The TSST is suitable for eliciting stress in psoriasis patients. In one subgroup, there was an increase in skin affliction, while skin affliction in the second group remained constant or decreased. A classification into stress-reactive or non-reactive patients cannot, however, be supported by the immunological parameters tested.

[Are patients with glossodynia unremarkable? A hard-to-grasp psychodiagnostic disease]. / Sind Patienten mit Glossodynie psychisch unauffällig? - Eine psychodiagnostisch schwer fassbare Erkrankung.

INTRODUCTION: Idiopathic glossodynia is generally considered a disease with profound psychical involvement. Nevertheless, psychodiagnostic studies on this disease have been rare. The patients usually have low emotional self-reference, are focused on their physical complaints and refuse a psychosomatic attribute. Therefore, the doctor-patient relationship is often complicated, which impedes the initiation of an adequate therapy. PATIENTS AND METHODS: Seventeen patients diagnosed to have glossodynia or orofascial pain syndrome were examined within the psychosomatic consultation-liaison service of two dermatological hospitals. The Coping with Skin Disease Questionnaire (CSD) and the Symptom Check List (SCL-90R) were used as test inventory. Patients with glossodynia were compared with other dermatological patients in the consultation-liaison service (n = 356) and with the standard random sample of the SCL-90R. RESULTS: By comparing the test inventories it was found that glossodynia patients appeared particularly "inconspicious" on nearly all dimensions. Compared with the standard random sample of the SCL-90R (n = 1006) higher values were only observed for the scores "somatization" and "anxiety". CONCLUSION: Based on the two psychological test inventories, no indication of depression was found, which is often suspected in glossodynia patients. It appears that psychosomatic (accompanying) symptoms in these individuals are not sufficiently assessed by many psychological test instruments.