Laser treatment of vascular dermatological diseases using a pulsed dye laser (595 nm) in combination with a Neodym:YAG-laser (1064 nm).

There are many vascular anomalies which are often a diagnostic and therapeutic challenge. They are classified in vascular tumors (e.g. infantile hemangioma) or vascular malformations (e.g. port-wine-stain). Moreover there are several other and rare vascular disregulations and diseases in the field of dermatology. Many laser systems focus on the therapy of vascular pathologies. We use a pulsed dye laser (595 nm) on its own or in combination with a Neodym:YAG-laser (1064 nm) to treat those vascular diseases. This paper points out the advantages and side effects of these two laser systems and describes the limitations of those.

CD8-positive pseudolymphoma in lues maligna and human immunodeficiency virus with monoclonal T-cell receptor-beta rearrangement.

A 42-year-old Caucasian man suffered from disseminated plaques and ulcerated nodules for 6 weeks. He had weight loss and generalized lymphadenopathy. Underlying diseases were not known up till then. Based on a skin biopsy, the diagnosis of CD8-positive cutaneous T-cell lymphoma, type mycosis fungoides was made in a pathological reference center for lymphoma. A reproducible T-cell receptor (TCR)-beta rearrangement was detectable. Before starting therapy, a new biopsy was taken and the previous diagnosis was re-evaluated taking clinical images and symptoms into account. Based on both, the diagnosis of a CD8+ pseudolymphoma in lues maligna and human immunodeficiency virus was made. We highlight histopathologic clues for the correct diagnosis, and we emphasize the indispensability of clinical-pathological correlation. Furthermore, we discuss the differential diagnosis of CD8+ lymphoproliferative disorders.

Combination therapy of infantile hemangiomas with pulsed dye laser and Nd:YAG laser is effective and safe.

BACKGROUND: Infantile hemangiomas (IH) can cause severe complications such as obstruction, ulceration or heart failure. Therefore, in certain difficult-to-treat areas, or when there is no sign of involution, early and effective therapy is required. In rare instances, systemic treatments, like the beta-blocker propranolol and oral corticosteroids, can cause serious side effects. Effective and well-tolerated local treatment options are thus desirable as additive or alternative methods. PATIENTS AND METHODS: In this retrospective interdisciplinary study, 38 children with 77 IH were treated with pulsed dye laser (PDL) (595 nm) and Nd:YAG laser (1,064 nm). The treatment success and side effects were evaluated according to objective and subjective parameters, including hemangioma thickness measured by ultrasound and the parents' evaluation of treatment. RESULTS: All 77 treated IH responded to the therapy, of which 52.8 % healed after the end of treatment and 47.2 % had only minimum residual components. The success of treatment was assessed by the parents in 92.6 % as very good or good. Transient blistering occurred as the main side effect in 45.9 %. CONCLUSIONS: Combination therapy with PDL and Nd:YAG laser represents an effective local method for IH with minimal side effects.

Limited diagnostic value of Wells-score and D-dimer testing in hospitalized dermatologic patients with symptoms of deep vein thrombosis.

BACKGROUND: D-dimer analysis and clinical probability scoring (Wells-score) show a high sensitivity and negative predictive value for the exclusion of deep vein thrombosis (DVT). OBJECTIVE: To identify the diagnostic performance of D-dimer testing and Wells-score in hospitalized patients with dermatologic conditions. METHODS: In this retrospective cohort study, 109 examinations in 102 patients were performed by Wells-score, Tina-quant D-dimer testing and whole-leg duplex ultrasonography or phlebography. RESULTS: DVT was confirmed in 14 patients. The Wells-score alone allowed no discrimination of DVT and non-DVT patients. D-dimer testing identified all cases of DVT (100% sensitivity). Only 16 patients showed D-dimers within normal limits and none was diagnosed with DVT (100% negative predictive value). A high rate of false-positive D-dimer results (72%) led to a low specificity (17%). The number needed-to-test to exclude one DVT was 6.8. Based on multivariate statistical analysis, increased D-dimer levels were significantly associated with the dermatologic main diagnosis (p = 0.008), age (p = 0.001) and with the presence of DVT (p = 0.011). The highest D-dimer values were found in non-DVT patients with metastasized or systemic malignancies (median 2.48 mg/L) or inflammatory skin conditions (e.g., generalized psoriasis, median 2.22 mg/L). CONCLUSIONS: Wells-score and D-Dimer testing were of limited diagnostic value because of many false-positive results. Required imaging procedures were reduced by only 16 cases (15%). Therefore, we suggest directly investigating hospitalized dermatologic patients with suspected DVT and skin diseases associated with high D-Dimer levels, by whole-leg compression ultrasonography.

Associated factors and comorbidities in patients with pyoderma gangrenosum in Germany: a retrospective multicentric analysis in 259 patients.

BACKGROUND: Pyoderma gangrenosum (PG) is a rarely diagnosed ulcerative neutrophilic dermatosis with unknown origin that has been poorly characterized in clinical studies so far. Consequently there have been significant discussions about its associated factors and comorbidities. The aim of our multicenter study was to analyze current data from patients in dermatologic wound care centers in Germany in order to describe associated factors and comorbidities in patients with PG. METHODS: Retrospective clinical investigation of patients with PG from dermatologic wound care centers in Germany. RESULTS: We received data from 259 patients with PG from 20 different dermatologic wound care centers in Germany. Of these 142 (54.8%) patients were female, 117 (45.2%) were male; with an age range of 21 to 95 years, and a mean of 58 years. In our patient population we found 45.6% with anemia, 44.8% with endocrine diseases, 12.4% with internal malignancies, 9.3% with chronic inflammatory bowel diseases and 4.3% with elevated creatinine levels. Moreover 25.5% of all patients had a diabetes mellitus with some aspects of potential association with the metabolic syndrome. CONCLUSIONS: Our study describes one of the world's largest populations with PG. Beside the well-known association with chronic bowel diseases and neoplasms, a potentially relevant new aspect is an association with endocrine diseases, in particular the metabolic syndrome, thyroid dysfunctions and renal disorders. Our findings represent clinically relevant new aspects. This may help to describe the patients' characteristics and help to understand the underlying pathophysiology in these often misdiagnosed patients.

Atypical location of lymphocytoma cutis in a child.

Lyme borreliosis is a common infectious disease that can affect myocardial muscle or the central nervous system if not treated at an early stage. Here we report a unique case of an atypical location of lymphocytoma cutis in a 3-year-old boy. Histologic and immunohistochemical analysis revealed the correct diagnosis.

Successful Nd:YAG laser therapy for hair removal in the oral cavity after plastic reconstruction using hairy donor sites.

BACKGROUND: Concepts of reconstruction of intraoral structures may often include the transfer of flaps composed of external skin with hairs. Given that intraoral hair growth following myocutaneous flaps can cause discomfort, there is a need for effective treatments to relieve cancer patients of these symptoms. OBJECTIVE: To describe the successful epilation of hairy intraoral flaps using Nd:YAG laser emitting a wavelength of 1,064 nm. METHODS: We performed an interdisciplinary prospective clinical study with 9 patients suffering from intraoral hair growth after plastic reconstruction of a hairy donor site due to cancer. Eight male and one female patients were treated with 1-4 sessions of Nd:YAG laser at 5-15-week intervals. RESULTS: Laser treatment resulted in effective hair reduction in 8/9 patients regardless of flap type. In 5/9 patients a hair clearance of >90% could be achieved, whereas laser treatment was ineffective in one male with white hair. Patients were very satisfied with the outcome and no side effects could be observed. CONCLUSION: Nd:YAG laser therapy appears to be a successful therapeutic option for patients suffering from growth of dark hair in the oral cavity after plastic reconstruction using a hairy donor site.

Postzygotic HRAS and KRAS mutations cause nevus sebaceous and Schimmelpenning syndrome.

Nevus sebaceous is a common congenital cutaneous malformation. Affected individuals may develop benign and malignant secondary tumors in the nevi during life. Schimmelpenning syndrome is characterized by the association of nevus sebaceous with extracutaneous abnormalities. We report that of 65 sebaceous nevi studied, 62 (95%) had mutations in the HRAS gene and 3 (5%) had mutations in the KRAS gene. The HRAS c.37G>C mutation, which results in a p.Gly13Arg substitution, was present in 91% of lesions. Nonlesional tissues from 18 individuals had a wild-type sequence, confirming genetic mosaicism. The HRAS c.37G>C mutation was also found in 8 of 8 associated secondary tumors. Mosaicism for HRAS c.37G>C and KRAS c.35G>A mutations was found in two individuals with Schimmelpenning syndrome. Functional analysis of HRAS c.37G>C mutant cells showed constitutive activation of the MAPK and PI3K-Akt signaling pathways. Our results indicate that nevus sebaceous and Schimmelpenning syndrome are caused by postzygotic HRAS and KRAS mutations. These mutations may predispose individuals to the development of secondary tumors in nevus sebaceous.

Lymph node ultrasound during melanoma follow-up significantly improves metastasis detection compared with clinical examination alone: a study on 433 patients.

Early detection of melanoma metastases is essential for effective treatment and may be crucial for the prevention of systemic metastases and patient survival. However, data demonstrating the reliability and accuracy of ultrasound examination for the detection of lymph node metastases, in addition to clinical examination, are rare. We have examined 433 melanoma patients with stage-dependent follow-up intervals of 3 to 12 months. One thousand three hundred and thirty-two paired clinical and nonblinded sonographic tests of the locoregional lymph node areas were performed. Lesions suspicious of melanoma metastases were examined histopathologically. Of note, sensitivity [0.9394 (95% confidence interval: 0.7977-0.9926)] and specificity [0.9808 (95% confidence interval: 0.9717-0.9875)] of combined clinical and sonographic investigations were significantly (P<0.0001) higher than clinical results alone. Significant differences between clinical follow-up and sonographically assisted follow-up were found for American Joint Committee on Cancer 2002 melanoma stages I (P=0.0389), III (P=0.0101), and IV (P=0.0016). For stage II melanoma, a trend was detected (P=0.0821). Lymph node metastases were detected sonographically in 1.73% of clinically metastasis-free investigations (n=22). Our data suggest that high-frequency sonography should be part of all melanoma follow-up investigations, independent of melanoma type, melanoma stage, or lymph node biopsy status.

Hyperkalemia complicating propranolol treatment of an infantile hemangioma.

Propranolol treatment was recently reported to be successful for the management of severe infantile hemangioma. Known adverse effects of propranolol treatment include transient bradycardia, hypotension, hypoglycemia, and bronchospasm (in patients with underlying spastic respiratory illnesses), which led to a general recommendation to gradually increase propranolol dosage and closely monitor patients' hemodynamics at the onset of therapy. To date, no serious or unexpected adverse effects that required specific intervention have been reported. In this report, we describe the case of a 17-week-old female preterm infant who presented with a large, ulcerated, cutaneous-subcutaneous hemangioma of the right lateral thoracic wall, which we treated successfully with propranolol. A few days into therapy, a potentially life-threatening adverse effect, severe hyperkalemia, was observed and required treatment with loop diuretics, fluids, and nebulized salbutamol to normalize her serum potassium levels. This therapy could be gradually tapered and finally discontinued only after several weeks of propranolol treatment. Our case report indicates that, at least during the initial phase of the propranolol treatment of infantile hemangioma, close monitoring of serum electrolytes, besides the monitoring of hemodynamics and blood glucose, is necessary.