Inpatient care for skin diseases in Germany: multi-source analysis on the current and future health care needs.

BACKGROUND: In Germany, skin diseases are mainly treated in the 115 dermatological hospitals. METHODS: Health care and health economic analysis of dermatological inpatient care and prediction of future care needs based on primary and secondary data. RESULTS: Outpatient and inpatient care for dermatologic treatment indications is predominantly provided by dermatology specialists. Inpatient treatment was provided for 833,491 cases in 2018, corresponding to 4.21 % of all inpatient cases (19,808,687). Most common treatment cases were: epithelial skin cancer (total 87,386, of which dermatology clinics 52,608), followed by melanoma (23,917/17,774), psoriasis (19,291/13,352), erysipelas (73,337/11,260), other dermatitis (12,671/10,842), atopic dermatitis (AD) (11,421/9,734), and herpes zoster (26,249/9,652). With an average length of stay of 5.69 days, dermatology hospitals were in the bottom third. The proportion of inpatient indications cared for in dermatology hospitals was highest for prurigo (95.2 %), pemphigus (94.9 %), parapsoriasis (94.6 %), pemphigoid (90.3 %), eczema other than AD (85.6 %), and AD (85.2 %). While the total number of inpatient treatment cases in Germany has increased by an average of 17.5 % between 2000 and 2018, this is the case for 26.6 % of skin diseases and over 150 % for individual ones. The projection of current to future inpatient care suggests a continued high demand for inpatient care by dermatology hospitals. CONCLUSION: Inpatient dermatological care will continue to be an indispensable component of qualified, socially necessary care in Germany.

Complete division of the pedicle of the forehead flap is possible after 1 week of engraftment in selected patients.

BACKGROUND: Recent studies have demonstrated that early division of the forehead flap (FHF) is possible if angiography is performed or a remnant of the pedicle is left behind. Whether or not careful selection of patients allows for complete division of the pedicle has not been studied. OBJECTIVE: To assess if careful selection of patients allows for early complete division of the FHF. METHODS: The exclusion criteria were trauma in the donor region, full-thickness defects, or a larger cartilage grafting. In the selected patients, complete division of the FHF pedicle was performed at early time points, when the pedicle was clinically engrafted (n = 12). RESULTS: The median age of the patients was 80 years ± 8. The average size of the wounds was 6.6 cm2 ± 4.0. The complete division of the pedicle was performed in 10 patients after 7 days, 1 patient after 8 days, and 1 patient after 11 days (median 7.4 days ± 1.1). One patient developed a wound infection, and 1 suffered from postoperative bleeding. The latter patient was the only 1 who required debulking in a third surgical procedure. No necrosis or flap failures were observed. LIMITATIONS: Retrospective, single-center study. CONCLUSION: Careful selection allows for complete early division of the pedicle of FHF.

Erosive Pustular Dermatosis of the Scalp: Clinicopathological Correlation Leading to a Definition of Diagnostic Criteria.

INTRODUCTION: Erosive pustular dermatosis of the scalp (EPDS) is frequently misdiagnosed as epithelial tumor or trauma. To the authors' knowledge, no international guidelines or consistent recommendations for treatment of EPDS exist, and histological findings often are labeled as nonspecific. OBJECTIVE: This study aimed to identify clinical and histological characteristics unique to EPDS to aid diagnosis. MATERIALS AND METHODS: The biopsies of 21 patients (age range, 73­90 years) with EPDS and who were diagnosed and treated at the Department of Dermatology at University of Leipzig Medical Center and the Asklepios Medical Center, Weißenfels, Germany, were reevaluated by dermatopathologists. Results were correlated with the clinical findings and course. RESULTS: Erosive pustular dermatosis of the scalp was observed in elderly patients with androgenetic alopecia and field cancerization of the capillitium; most patients had multiple comorbidities. Therapy used to treat actinic keratosis lesions (eg, imiquimod, ingenol mebutate), photodynamic therapy, cryotherapy, trauma, and surgery all were found to have predisposed for or led to EPDS. Erosive pustular dermatosis of the scalp presented clinically as exophytic crusts and pus overlying shiny granulation tissue. Histopathological findings demonstrated an ulcerated epidermis and dermal infiltrates dominated by lymphocytes together with a multitude of plasma cells. Plasma cells were found in all 21 biopsies and represented a common criterion for the correct diagnosis. The erosive lesions healed well within weeks after therapy with topical steroids. CONCLUSIONS: Chronic, poorly healing lesions with crusts and pus over shiny granulation tissue on the scalp are suggestive of EPDS, which should be confirmed by biopsy. Histological clues to a diagnosis of EPDS include dermal infiltrates of plasma cells and lymphocytes. The topical application of high-potency steroids showed great effectiveness in the present study.

[Personal preference, experience, intuition and school of surgery dominate the use of wound drainage in dermatosurgery]. / Persönliche Präferenz, Erfahrung, Intuition und operative Schule dominieren die Verwendung postoperativer Wunddrainagen in der Dermatochirurgie.

BACKGROUND: The use of drainage systems in dermatosurgery has so far been carried out without evidence-based data. The indications, complications and contraindications are traditionally passed on from surgeon to surgeon but have so far not been defined. METHOD: An Internet-based survey was created and sent out to members of the German Society for Dermatosurgery (DGDC). The questions were on the general treatment approach in German language countries with reference to the use of wound drainage following dermatological operations as well as the utilization habits and experiences with drainage-associated complications. RESULTS: Of the DGDC members contacted 12.73% completed the questionnaire. Drainages were predominantly used in the clinical environment and all drainage systems in question were used. The extent and complexity of the intervention were essential criteria when evaluating the indications. The use of drainages was dependent on the age of the participant and mostly carried out in patients where complications in the postoperative course were to be expected (e.g. obesity, nicotine use, diabetes). CONCLUSION: In summary, the majority of the participants used wound drainages and mostly intuitively. Uniform and fixed evidence-based parameters for the use of wound drainages are lacking. In the assessment of the necessity for a wound drainage, an individually expressed need of safety seems to play a large role for some dermatosurgeons and an eminence-based action for others.

Histopathology of rhinophyma - a clinical-histopathologic correlation.

BACKGROUND: Whereas early rhinophyma is histopathologically thought to resemble fully developed rosacea, a fibromatous variant has previously been described for severe rhinophyma. In terms of clinical characteristics, recently a new Rhinophyma Severity Index (RHISI) was introduced. METHODS: We studied 24 patients who had been treated with wide shave excisions for rhinophyma. Specimens were stained with hematoxylin-eosin, periodic acid-Schiff reaction and a panel of immunohistochemical stains and observed for any correlation between clinical severity and histopathologic features as well as for predictive markers of clinical recurrence. RESULTS: There were no significant histopathologic differences between the groups reflecting the different clinical expressions. From a histopathologic perspective, clinically severe forms did not show with exclusive fibrotic changes. Further, there was no histopathologic marker predicting the clinical course or possible recurrence of the disease after surgical treatment. Only the clinical pre-operative RHISI score correlated with the postoperative outcome, with a high pre-operative RHISI being a risk factor for recurrence. CONCLUSION: Histopathologic features do not correlate with the clinical expression of rhinophyma. An exclusively 'fibrotic' rhinophyma form does not appear to exist and could possibly be the result of sampling error based on small biopsies studied.

Trichophyton species of Arthroderma benhamiae - a new infectious agent in dermatology.

In Germany, infections due to the zoophilic dermatophyte Trichophyton (T.) species of Arthroderma benhamiae are being more frequently diagnosed. The source of infection of this emerging pathogen overlaps with that of the zoophilic species T. interdigitale. The most common source are guinea pigs. T. species of Arthroderma benhamiae causes inflammatory dermatophytosis in children and adolescents. In addition to tinea capitis, it may cause both tinea corporis, tinea manus and frequently tinea faciei. In Germany, T. species of Arthroderma benhamiae is a frequent zoophilic dermatophyte, which in regions is probably more frequent than Microsporum canis. The mycological identification of the isolates with their yellow stained colonies is based on their macroscopic and microscopic features. However, some exhibit colony features consistent with those of T. interdigitale. These strains only can be identified unambiguously by means of molecular techniques. Using detection methods such as PCR-ELISA or real-time PCR, the dermatophyte can be identified directly from clinical material. Sequencing of the internal transcribed spacer region (ITS) of the ribosomal DNA has been approved as culture confirmation test for T. species of Arthroderma benhamiae. In addition, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI TOF MS) is useful. Widespread dermatophytosis due to T. species of Arthroderma benhamiae, in particular of tinea capitis, requires oral antifungal agents. Terbinafine is most effective, alternatives are fluconazole and itraconazole.

Outcomes of wound closure with the reading man flap technique.

BACKGROUND: In dermatologic surgery, numerous flap types have been described for wound closure after skin cancer surgery. The reading man flap was first published in 2008 for the closure of skin defects of the face, trunk, and extremities. Technically, this flap is based on an asymmetrical Z-plasty. OBJECTIVE: To investigate the feasibility, clinical outcomes, and postoperative complications for wound closure with the reading man flap technique. METHODS: We treated seven patients (facial and extremity defects) after microscopically controlled surgery using the reading man flap technique. The median defect size was 491.71 mm2. All of the patients were treated under tumescent local anesthesia. RESULTS: A tension-free defect closure was created in all patients. One minor complication, a wound infection on one leg, was observed. CONCLUSION: The described technique is an easy and safe dermatologic surgery procedure that can be performed under local anesthesia.