Atopic dermatitis: disease characteristics and comorbidities in smoking and non-smoking patients from the TREATgermany registry.

BACKGROUND: Atopic dermatitis (AD) is a chronic inflammatory skin disease with a multifactorial genesis including genetic predispositions and environmental risk and trigger factors. One of the latter possibly is smoking, indicated by an increased prevalence of AD in adults and children that are actively or passively exposed to cigarette smoke. OBJECTIVES: In this study, AD characteristics and its atopic comorbidities are compared in smoking and non-smoking AD patients. METHODS: TREATgermany is a non-interventional clinical registry which includes patients with moderate to severe AD in Germany. Baseline data of patients included in TREATgermany from inception in June 2016 to April 2020 in 39 sites across Germany was analysed comparing AD disease characteristics and comorbidities in smokers vs. non-smokers. RESULTS: Of 921 patients, 908 (male: 58.7%) with a mean age of 41.9 ± 14.4 reported their smoking status. The objective Scoring of Atopic Dermatitis (oSCORAD) did not differ between smokers (n = 352; 38.8%) and non-smokers, however, lesions' intensity of oozing/crusts and excoriations as well as patient global assessment scores (PGA) of AD severity were higher in smoking as opposed to non-smoking patients. Smokers reported a lower number of weeks with well-controlled AD and more severe pruritus than non-smokers. Total IgE levels were more elevated in smokers and they displayed a younger age at the initial diagnosis of bronchial asthma. After adjustment for potential confounders, the increased intensity of oozing/crusts, the reduced number of weeks with well-controlled AD and the greater pruritus remained different in smokers compared to non-smokers. In addition, smoking patients with adult-onset AD showed a 2.5 times higher chance of involvement of the feet. CONCLUSIONS: German registry data indicate that AD patients who smoke have a higher disease burden with a different distribution pattern of lesions in adult-onset AD.

[Treatment of hand eczema]. / Therapie des Handekzems.

The treatment of hand eczema represents a great challenge in the daily clinical practice for dermatologists. There are various forms of local, physical and systemic treatment, such as alitretinoin which is the only registered systemic treatment option for severe chronic hand eczema. In 2017 dupilumab was approved for the treatment of moderate to severe atopic dermatitis and can theoretically also be applied for atopic hand eczema. The first and most important step in treatment is to identify the underlying etiology of the hand eczema with the appropriate diagnostic measures, ranging from skin biopsy to allergy testing including occupational products. An important component of treatment is the basic treatment in the form of consistent and stage-adapted skin care. Treatment of hand eczema should follow a step by step procedure whereby the basic treatment should be maintained and, depending on the etiology and clinical type, should be supplemented by topical, systemic and physical treatment forms, also often used in parallel. Mild to moderate forms of hand eczema are usually treated with the basic treatment, emollients and topical glucocorticoids according to various guidelines. In moderate to severe forms of hand eczema UV phototherapy and systemic treatment should be implemented. This article summarizes the most important treatment modalities based on case reports and series, clinical studies, guidelines and expert recommendations.

[Pruritus in elderly people-an interdisciplinary challenge]. / Pruritus im Alter ­ eine interdisziplinäre Herausforderung.

Due to demographic change, especially in Western countries with increasing life expectancy and a continuously increasing number of elderly, chronic pruritus (CP) is more and more observed in clinical practice. CP in elderly may present with specific pruritic skin diseases, as chronic prurigo (nodular form) and can also occur in unaffected, normal looking skin. CP in elderly remains a challenge. Especially CP without any skin lesions is a major diagnostic and therapeutic challenge. Due to the increasing prevalence of malignant diseases in elderlies, paraneoplastic pruritus is also an important differential diagnosis. Treatment depends on the mobility of the patient which determines if and which topical agents can be used and if ultraviolet phototherapy can be administered. There are a number of topical and systemic medications, which must be selected according to existing comorbidities, possible drug interactions, and the patient's compliance as well as possible side effects such as cognition and sedation. All this may hamper treatment of CP in elderly.

[Individual in-patient and out-patient prevention in occupational skin diseases]. / Individuell ambulante und stationäre Prävention bei Berufsdermatosen.

Concerning all occupation-related diseases, one-third of those reported in Germany are skin diseases. Among them, contact dermatitis is the most frequent skin disease. It usually presents as hand eczema leading to a loss of function and ability to work as well as reduced quality of life. Due to the high demand a number of prevention programmes were introduced. They comprise measures of secondary (out-patient) and tertiary (in-patient) prevention. Out-patient prevention measures include dermatologist's report and occupation-tailored teaching and prevention programmes. If the occupational skin disease is severe, therapy is not successful or the diagnosis is not clear measures of tertiary prevention can be offered as an in-patient treatment and prevention programme. All this aims to prevent the job loss of the patient. Preventive measures in occupational dermatology have proven to be very effective in recent years, especially measures of individual in-patient and out-patient prevention as components of a complex hierarchical prevention concept. This integrated concept of an in-patient/out-patient disease management reveals remarkable pertinent effectivity for patients with severe occupational dermatoses in risk professions.

Association between tobacco smoking and prognosis of occupational hand eczema: a prospective cohort study.

BACKGROUND: Hand eczema (HE) is a common occupational skin disease. Tobacco smoking is known to be associated with adverse cutaneous effects. However, its influence on the prognosis of occupational HE has not yet been studied. OBJECTIVES: To evaluate relations between smoking status, severity and prognosis of occupational HE in patients taking part in an interdisciplinary tertiary individual prevention programme (TIP). METHODS: In a prospective, multicentre, cohort study 1608 patients with occupational HE taking part in a TIP were recruited and followed up for 3 years. The clinical and self-reported outcome data of smokers and nonsmokers were compared. RESULTS: Nonsmokers and smokers were equally distributed. During the TIP, the average self-reported daily cigarette consumption and the severity of HE decreased significantly (P < 0·01). However, at all time points HE was significantly more severe in smokers than in nonsmokers. This association was not dependent on the self-reported number of cigarettes smoked daily. Smokers had significantly more days of absence from work due to occupational HE than nonsmokers in the year before the TIP (P < 0·01) and in the following year (P = 0·02). After the TIP, smokers reported significantly more often that they had to give up their occupation (P = 0·02) than nonsmokers. CONCLUSIONS: The severity of occupational HE is increased in smokers. Tobacco smoking is associated with a higher number of days of absence from work and with not staying in the workforce owing to occupational HE. Thus, smoking confers a worse prognosis and interferes with the outcome of prevention programmes.

[Drug-induced pruritus]. / Arzneimittelinduzierter Pruritus.

BACKGROUND: Pruritus, especially chronic pruritus, has long been underestimated and leads to high psychological strain in the affected patients. Even today, in spite of receiving increased attention, the underlying etiology cannot always be identified. METHODS: We review potential underlying pathologic mechanisms of drug-induced pruritus, focusing among others on current dermato-oncological medications in terms of their pruritogenic risks. RESULTS: Acute pruritus must be distinguished from chronic pruritus which lasts for a minimum of 6 weeks. There are various therapeutic approaches for drug-induced pruritus. As a first step, the drug causing the pruritus has to be identified; then the intake of that drug has to be ceased or modified. This may not always be possible, as in the case of chemotherapy agents. CONCLUSIONS: With regard to the demographic development of the population with increasing life expectancy and the resulting increasing polypharmacy, drugs will have to be taken into account as a possible cause for pruritus more often in the future. It would be desirable to routinely assess pruritus as a possible adverse effect in regulatory drug studies.

[Pruritus, erythema and others. Dermatology of the ear]. / Pruritus, Erytheme & Co. Das Ohr aus dermatologischer Sicht.

Dermatological diseases of the ear are frequent and diverse. Specific skin diseases including tumours of the skin, specific diseases of the ear with manifestation on the skin, metabolic diseases and hereditary diseases belong to this field. Pruritus of the acoustic meatus is particularly challenging in daily clinical practice and requires accurate diagnosis. Depending on the clinical findings, laboratory examinations, bacteriological and mycological smear, histology and allergological tests are needed. Therapy comprises treatment of the underlying disease and symptomatic anti-pruritic treatment.

Differential effects of a tertiary individual prevention programme for patients with occupational skin disease depending on diagnosis.

BACKGROUND: Occupational skin disease (OSD) is common. Tertiary individual prevention programmes (TIP) aim at helping individuals with refractory OSD to remain active in the workforce. Evidence exists that these interventions improve skin protection behaviour related cognitions. However, it is not clear whether these effects generalize to all types of OSD. OBJECTIVE: To evaluate whether effects on socio-cognitive determinants of skin protection behaviour vary between patients with work related atopic dermatitis (AD) and other work related skin diseases. METHODS: A total of 14 inpatients with work related AD and 87 inpatients with other work related skin diseases completed measures on socio-cognitive determinants of skin protection behaviour before and after a 3-week inpatient TIP. Mixed model analyses, using maximum-likelihood estimation tested whether there were differential effects of the intervention on socio-cognitive determinants of skin protection behaviour. RESULTS: Although patients with AD reported more favourable cognitions towards skin protection behaviour than patients with other skin diseases at admission, these cognitions deteriorated or remained on the same level. Patients with other forms of OSD on the other hand developed more favourable cognitions during the intervention. CONCLUSION: Professionals working in the field of OSD should not cease to assist AD patients in achieving optimal skin protection behaviour. Tertiary individual prevention measures may need to pay more attention to the needs of individuals with an occupationally relevant AD. This may contribute to their being able to remain active in the workforce. The alternative would entail regular sick leave, poorer quality of life and economic hardship for the AD patient.

[Medical information systems in the internet : current data about the dermatologic web site www.dermis.net]. / Medizinische Informationssysteme im Internet : Aktuelle Daten zum dermatologischen Informationsportal http://www.dermis.net.

www.dermis.net was established in 1994 as a dermatological information system with now more than 4,000 pages and over 7,500 dermatological images in an atlas. 1,200 dermatological diagnoses and medical information with 1,100 synonyms can be searched by body location and in alphabetical order. Additionally, there are seven information modules about skin cancer, atopic dermatitis, rosacea, skin care, eczema, fungal diseases and hemorrhoids with links to other medical pages like Cochrane Library. Pediatric skin diseases are covered in PeDOIA. www.dermis.net is meanwhile available in German, English, Spanish, Portuguese, French and Turkish language. Current contents of this information system and user behavior are presented in this paper.

[Evidence-based evaluation of the effect of Type IV Allergies on the reduction of fitness for work. Survey of occupational skin diseases]. / Evidenzbasierte Beurteilung der Auswirkung von Typ-IV-Allergien bei der Minderung der Erwerbsfähigkeit. Begutachtung berufsbedingter Hautkrankheiten.

Evidence-based guidelines about the distribution of type IV allergens of the European standard series in different professions and its occupational relevance are missing. Based on published data, epidemiological investigations, work related knowledge about industrial processes, and allergen specific properties, recommendations are given about the clinical impact in the working environment for the following allergens: acrylates/methacrylates, epoxy resins, dichromate, cobalt, nickel, formaldehyde, (chlor-)methylisothiazolone, p-phenylendiamine, colophony, thiurame, mercaptobenzothiazole, dithiocarbamate, n-isopropyl-n'-phenyl-p-phenylendiamine, fragrance mix, composite mix, and neomycinsulfate. These recommendations might improve the clearance rate and allergological evaluation of the occupational relevance of different delayed type sensitizations or allergens.

[Pruritus in childhood. A diagnostic and therapeutic challenge]. / Pruritus im Kindesalter. Eine diagnostische und therapeutische Herausforderung.

From the clinician's point of view, pruritus in children is quite frequent. It mainly occurs along with dermatoses but rarely with systemic diseases such as renal and liver failure or with genetic disorders. Mostly, it appears in the setting of atopic dermatitis (AD). Other frequent differential diagnoses comprise e.g. scabies, impetigo, varicella, tinea, urticaria, mastocytosis and psoriasis. In children, pruritus is most often associated with severe scratching leading to artefacts. This group of patients requires a therapeutical regimen of its own. The use of topical and systemic treatments depends on the underlying aetiology of pruritus and the stage and status of the skin. The physician has to consider that topically applied drugs may cause intoxication due to the different body volume/body surface proportion, especially in newborns and infants. The dosages of systemic drugs need to be adapted in children and UV phototherapy should be performed with caution due to possible longterm photo damage of the skin. Physicians feel more insecurity treating pruritus in children, especially when systemic treatments are taken into consideration. We want to highlight the major aetiologies of pruritus in children and point out the cornerstones of antipruritic therapy in this challenging group of patients in recognition of our own clinical experiences and the current literature.

[Hydroxyethyl starch-(HES)-induced pruritus as secondary complication of an occupational accident]. / Hydroxyethylstärke- (HES-)induzierter Pruritus als sekundäre Folge eines Arbeitsunfalls.

A 29-year old employee (controller in the textile industry) had an occupational accident leading to a femoral fracture. After surgery, he developed acute respiratory distress syndrome (ARDS) necessitating intensive care treatment. Three weeks after the accident, he developed generalized severe itching on a daily basis unresponsive to systemic and topical treatments. After one year, the itching had decreased to approximately 50% of its initial intensity. Hydroxyethyl starch (HES)-induced pruritus was diagnosed, based on the typical history and clinical features, the proven administration of HES and its cutaneous tissue storage by electron microscopy. Drug-induced pruritus caused by the plasma expander hydroxyethyl starch can be a secondary consequence of an occupational accident and thus an issue in accident compensation claims.

Coincidence of multiple, disseminated, tardive-eruptive blue nevi with cutis marmorata teleangiectatica congenita.

A 71-year-old woman reported a slow progression of multiple bluish dark asymptomatic macules and papules on the pretibial region of both lower legs for over 30 years. At birth a left-sided hypoplasia of the leg including the buttock accompanied by a connatal vascular nevus had been diagnosed. The ipsilateral deep veins of the pelvis and leg had a normal anlage. Histopathological examination revealed multiple blue nevi of the common type. The association of multiple blue nevi and cutis marmorata teleangiectatica congenita with limb hypoplasia has not previously been reported and is discussed in this paper. One could speculate whether these symptoms represent a new syndrome, because by thorough examination the NAME syndrome could be ruled out.

Atrial myxoma syndrome mimicking Ehrmann-Sneddon syndrome.

Livedo racemosa with cerebrovascular lesions has been described as Ehrmann-Sneddon syndrome. The etiopathogenetic factors provoking the vascular lesions, however, are of high diversity reaching from mechanical to autoimmune causes. We present a male patient with typical livedo racemosa, muscle pain and feeling of coldness of the forearms. By dermatohistopathology and magnetic resonance tomography of the brain, Ehrmann-Sneddon syndrome could be confirmed. At this time a chronic streptococcal infection could be diagnosed. Antibiotics, anticoagulants and vascularity-supplying therapy improved the clinical and subjective symptoms. Six months later, the patient developed dizziness, vision disorder, hypesthesia of the right forehead, malaise and weight loss. A further diagnostic workup including echocardiography revealed a myxoma of the left atrium. This report illustrates the association of Ehrmann-Sneddon syndrome with cardiac myxoma and points out that cardiac diagnostic examination should be included when dealing with small-vessel involvement of the brain.