Therapeutic management of anal eczema: an evidence-based review.

AIM: To conduct a systematic review of treatments for anal eczema (AE). METHODS: We conducted a Medline search for clinical trial data for the treatment of perianal diseases including AE, including papers not published in the English language. We assessed the study reports using the system recommended by the Oxford Centre for Evidence-based Medicine. No meta-analysis was attempted. RESULTS: The evidence base for topical treatments used to treat AE is very poor: there are very few studies and many of those that exist are of poor quality. The best evidence was found for medications that are yet to be licensed for AE. Among products with existing licences for the treatment of eczema, our assessment found some evidence to support the continued use of mild-to-moderate corticosteroids first line in most patients. DISCUSSION: Features of the perianal region, and the fact that it is almost always occluded, mean that not all medications recommended in the general treatment guidelines for eczema are appropriate for AE. However, there are no specific treatment guidelines for these patients. This may in part be because of the lack of high-quality evidence-based medicine in this therapy area. Many frequently prescribed medications were developed and licensed many years ago, in an era when clinical trial design was not expected to be as rigorous as it is today. CONCLUSION: This review highlights the need to conduct more high-quality clinical trials in patients with AE in order that specific guidelines for the management of this difficult proctological condition can be prepared.

Protease-modulating polyacrylate-based hydrogel stimulates wound bed preparation in venous leg ulcers--a randomized controlled trial.

BACKGROUND: Stringent control of proteolytic activity represents a major therapeutic approach for wound-bed preparation. OBJECTIVES: We tested whether a protease-modulating polyacrylate- (PA-) containing hydrogel resulted in a more efficient wound-bed preparation of venous leg ulcers when compared to an amorphous hydrogel without known protease-modulating properties. METHODS: Patients were randomized to the polyacrylate-based hydrogel (n = 34) or to an amorphous hydrogel (n = 41). Wound beds were evaluated by three blinded experts using photographs taken on days 0, 7 and 14. RESULTS: After 14 days of treatment there was an absolute decrease in fibrin and necrotic tissue of 37.6 ± 29.9 percentage points in the PA-based hydrogel group and by 16.8 ± 23.0 percentage points in the amorphous hydrogel group. The absolute increase in the proportion of ulcer area covered by granulation tissue was 36.0 ± 27.4 percentage points in the PA-based hydrogel group and 14.5 ± 22.0 percentage points in the control group. The differences between the groups were significant (decrease in fibrin and necrotic tissue P = 0.004 and increase in granulation tissue P = 0.0005, respectively). CONCLUSION: In particular, long-standing wounds profited from the treatment with the PA-based hydrogel. These data suggest that PA-based hydrogel dressings can stimulate normalization of the wound environment, particularly in hard-to-heal ulcers.

Segmental multilayered argon plasma coagulation: effective therapy option for perianal and scrotal Hailey-Hailey disease.

AIM: Hailey-Hailey disease (HHD) is a genodermatosis characterized by recurrent chronic weeping plaques at intertriginous sites. In severe cases, topical and systemic treatments are often insufficient. Extensive excisions are traumatic for patients and have a high morbidity. Superficial ablative procedures such as dermabrasion have become established, but are difficult to perform in the perianal region and scrotum. Therefore, alternative therapies are required. METHOD: Four patients with extensive anogenital HHD were treated by argon plasma coagulation (APC). This leads to a controlled coagulation of nearly constant depth. After dividing the affected areas into segments, a multilayered APC was performed in every second segment to the upper corium. The remaining segments were treated in the same way after healing of the initially treated parts. RESULTS: A disease-free period of up to 37 months was observed in all four patients. There was no case of reduced cutaneous sensitivity or extensive scarring. CONCLUSIONS: Argon plasma coagulation is effective and safe for perianal and scrotal HHD. The benefits include the accessibility to difficult anatomic sites and good control of ablation. The risk of anal stenosis is minimized by the segmental two-step procedure. The rapid re-epithelialization occurs from structures not affected by the disease and allows rapid mobilization of patients.

[New surgical approaches for the treatment of anogenital HPV infections]. / Neue operative Ansätze zur Sanierung anogenitaler HPV-Infektionen.

HPV infections in the anogenital region may have very heterogeneous clinical features. Most often typical papillomatous condylomata acuminata are observed that usually present no differential diagnostic difficulty. In contrast, the clinical findings of higher grade intraepithelial dysplasias with flat papules and erythematous/ eczematous lesions are often quite inconspicuous and hardly characteristic. The goal of therapy is to prevent further progression to carcinoma, removal of bothersome tumors and avoidance of complications. Surgical methods are preferentially employed for extensive lesions, unfavorable locations and higher grade dysplasia. Options include removal with scissors or scalpel, laser therapy and electrocautery. For purely intraepithelial alterations, superficial ablative techniques are usually preferable over excision. Further developments such as argon plasma coagulation reduce the risk of unwanted deep thermal destruction with the accompanying complications. The risks for the surgeon and the surgical team during treatment should also not be neglected. With consideration of all relevant aspects, the combination of different methods may reduce the risk of complications and frequency of recurrences. Due to the high recurrence rate independent of the selected therapy, consistent follow-up after primary therapy is crucial for the long-term success.

[Acute and chronic anal ulcers]. / Chronische und akute Analulzera.

Classic types of anal ulcers are acute and chronic anal fissure. Characteristic symptoms of chronic fissures are severe pain during defecation accompanied by the triad of ulceration, hypertrophic anal papilla and external skin tag. If the symptoms deviate other causes of ulceration must be considered. Primarily, malignancies should be excluded. The special setting in the anal fold, especially with concurrent immunosuppression, could lead to nonspecific manifestations of different proctological, dermatological and infectious diseases, which can only be clarified by further diagnostic workup and histopathology. Only the correct diagnosis will lead to causal and effective therapy. Successfully treated inflammatory dermatoses and precancerous lesions require regular follow-up because a recurrent or persistent course of the disease may result in malignant transformation.

[Successful dexamethasone pulse therapy for widespread erosive perianal lichen planus]. / Erfolgreiche Dexamethason-Pulstherapie bei grossflächig erosivem perianalen Lichen ruber.

A 70-year-old man presented with a 6-month history of extensive, progressive perianal erosions. In addition, he had white reticulate striae and small erosions on the penis. The clinical diagnosis of erosive lichen planus was confirmed histologically. After several topical approaches failed and his ss-blocker was stooped, 3 pulses of dexamethasone (100 mg dexamethasone i.v. on 3 consecutive days every 4 weeks) led to complete and long-lasting remission.

[Surgical management of acne inversa]. / Operative Therapie der Acne inversa.

The pathogenesis of acne inversa is follicular hyperkeratosis with occlusion and rupture. The subsequent acute inflammatory response leads to erythema, abscesses, fistulas, sinus tracts and scarring. Sites of predilection are the intertriginous regions. Many conservative therapies have only a supportive character. Therapy of choice is the early surgical intervention with complete excision of the involved areas, as conservative therapy is at best supportive. Although healing by second intention is preferred, all variations of flaps and grafts have been used. Usually the course of acne inversa lasts years until patients elect surgery after a physical and psychological odyssey.

[Networking as an opportunity to profile a clinic? Strategy options after the evaluation of resource allocation]. / Vernetzung als Chance zur Profilierung einer Klinik? Strategieoptionen nach Evaluation der Zuweiser.

BACKGROUND AND OBJECTIVES: Diagnosis-related groups of medical services has recently been introduced for reimbursing hospital services. The aim has been to optimize bed capacity, decrease the duration of inpatient stay and provide good follow-up medical care. This confronts hospitals with the need for closely cooperating with the referring general practitioners or specialists. METHOD: A specially structured questionnaire was sent to all those general practitioners and specialists (n=890) who had referred patients to a university department of dermatology. The response rate was 23%. The completed questionnaires were analysed with respect to criteria judged to be important in determining referral for inpatient care and the quality of medical and related service provisions. RESULTS: Especially important to the referring doctors were optimal competence of patient care, the degree of cooperation and prompt, detailed information after the patients have been discharged. CONCLUSION: This type of analysis can serve to optimize the course of diagnosis/treatment and to utilize fully the available hospital resources. Also considered are various ways in which a hospital department can, by networking with general practitioners and specialists, become a centre for providing optimal services.

Anorectal melanoma: surgical management guidelines according to tumour thickness.

Management of patients with anorectal melanoma is still controversial. To reach a rationale therapeutic approach, we reviewed our experience obtained over the past decade. In all, 19 consecutive patients with the diagnosis of anorectal melanoma were included in this retrospective survey. Details of the patients' presentation, symptoms, tumour size and histology and tumour state were recorded, and the primary therapeutic procedures were evaluated in detail. The size of the tumours ranged between 0.5 and 7 cm in diameter. The median tumour thickness was 10 mm (range 0.6-40 mm). At diagnosis, six of 19 patients already presented with either regional or distant metastases. The remaining 13 patients were treated with curative intend, either by abdomino-perineal resection (APR) or wide local excision (WLE). The form of operative therapy, however, had no impact on overall survival. Nevertheless, the incidence of local recurrences was lower after APR even for patients with less favourable tumours. In conclusion, WLE alone is not sufficient for local tumour control of thick anorectal melanoma.