Sustainability of dermatological offices and clinics: challenges and potential solutions.

Ongoing high consumption of resources results in exceeding the planetary boundaries. Modern healthcare systems contribute to this problem. To address this issue, this article provides an overview of various aspects of sustainable actions in medical offices and clinics that can also be applied to dermatology. Specific fields of action include energy consumption, structural measures, traffic and mobility, organization including digitalization as well as personnel and evaluation. Moreover, we discuss specific topics such as hygiene and cleansing, dermatosurgery and prescription practices. External treatments and cosmetics are discussed separately as dermatological peculiarities. Finally, we provide information on established initiatives for more sustainable health care in Germany. We aim to encourage critical reappraisal of currently established practices and to stimulate the implementation of sustainable measures.

CTLA4 promoter methylation predicts response and progression-free survival in stage IV melanoma treated with anti-CTLA-4 immunotherapy (ipilimumab).

Anti-CTLA-4-antibodies can induce long-lasting tumor remissions. However, only a few patients respond, necessitating the development of predictive companion biomarkers. Increasing evidence suggests a major role of epigenetics, including DNA methylation, in immunology and resistance to immune checkpoint blockade. Here, we tested CTLA4 promoter methylation and CTLA-4 protein expression as predictive biomarkers for response to anti-CTLA-4 immunotherapy. We identified retrospectively N = 30 stage IV melanoma patients treated with single-agent anti-CTLA-4 immunotherapy (ipilimumab). We used quantitative methylation-specific PCR and immunohistochemistry to quantify CTLA4 methylation and protein expression in pre-treatment samples. CTLA4 methylation was significantly higher in progressive as compared to responding tumors and significantly associated with progression-free survival. A subset of infiltrating lymphocytes and tumor cells highly expressed CTLA-4. However, CTLA-4 protein expression did not predict response to treatment. We conclude that CTLA4 methylation is a predictive biomarker for response to anti-CTLA-4 immunotherapy.

Talimogene laherparepvec treatment to overcome loco-regional acquired resistance to immune checkpoint blockade in tumor stage IIIB-IV M1c melanoma patients.

BACKGROUND: Resistance to immune checkpoint blockade and targeted therapy in melanoma patients is currently one of the major clinical challenges. With the approval of talimogene laherparepvec (T-VEC), oncolytic viruses are now in clinical practice for locally advanced or non-resectable melanoma. Here, we describe the usage of T-VEC in stage IVM1b-M1c melanoma patients, who achieved complete remission or stable disease upon systemic treatment but suffered from a loco-regional recurrence. To our knowledge, there are no case reports so far describing T-VEC as a means to overcome acquired resistance to immune checkpoint blockade or targeted therapy. METHODS: All melanoma patients in our department treated with T-VEC in the period of 2016-2018 were evaluated retrospectively. Data on clinicopathological characteristics, treatment response, and toxicity were analyzed. RESULTS: Fourteen melanoma patients were treated with T-VEC in our center. Six patients (43%) received T-VEC first-line. In eight patients (57%), T-VEC followed a prior systemic therapy. Three patients with M1b stage and one patient with M1c stage melanoma were treated with T-VEC. These patients suffered from loco-regional progress, whilst distant metastases had regressed during prior systemic treatment. 64% of patients showed a benefit from therapy with T-VEC. The durable response rate was 36%. CONCLUSION: T-VEC represents an effective and tolerable treatment option. This is true not only for loco-regionally advanced melanoma patients, but also for patients with stable or regressive systemic metastases who develop loco-regionally acquired resistance upon treatment with immune checkpoint blockade or targeted therapy. A sensible selection of suitable patients seems to be crucial.

Unexpected Hair Regrowth in a Patient with Longstanding Alopecia Universalis During Treatment of Recalcitrant Dermatomyositis with the Janus Kinase Inhibitor Ruxolitinib.

is missing (Short communication).

[Facial necrosis caused by orthopoxvirus : Differential diagnosis and dermatohistopathological correlation of infectious facial ulcers]. / Faziale Nekrose durch Orthopoxviren : Differenzialdiagnosen und dermatohistopathologische Korrelation infektiöser fazialer Ulzera.

This article reports the remarkable course of a facial ulcer in a patient receiving prednisolone for Crohn's disease. Based on the initially unclear origin of the ulcer the patient received a triple anti-infective treatment (antiviral, antibiotic, antimycotic) but the lesion showed a rapid progression. An orthopoxvirus infection could be verified later by extensive diagnostics and relevant differential diagnoses could be ruled out. Extensive necrotic changes were observed in the first weeks resulting in cicatricial healing after months. Human cowpox infections have been repeatedly reported in Germany and are a relevant zoonosis. Cats and rodents are main carriers. The differential diagnoses include infections caused by other bacterial, mycobacterial, mycotic and parasitic agents that are thoroughly discussed here both clinically and histopathologically. Especially cutaneous leishmaniasis must be named as the incidence is continuously rising. With inadequate treatment infectious facial ulcers may give rise to life-threatening complications and extensive disfiguring scarring, therefore treatment must be initiated in a timely manner.

[Crisis resilience in medical practices and clinics]. / Krisenresilienz in Praxen und Kliniken.

BACKGROUND: Climate change because of anthropogenic greenhouse gas emissions increasingly triggers extreme weather events. Of all the continents, Europe is warming the fastest. Heat and drought, forest fires and floods will worsen in Europe even in optimistic global warming scenarios, affecting living conditions across the continent. Extreme weather events threaten energy and food security, ecosystems, infrastructure, water resources, financial stability, and people's healthcare. Many of these risks have already reached critical levels and could take on catastrophic proportions without immediate, decisive action. OBJECTIVES: This paper outlines current challenges for medical practices and clinics in the context of climate change and provides examples and guidance for strengthening crisis resilience. MATERIALS AND METHODS: Selective literature review on the different requirements for crisis resilience in practices and clinics was performed. RESULTS: Medical practices and clinics achieve crisis resilience by high degrees of adaptability and flexibility. They prepare for climate change-related challenges and are, therefore, able to protect themselves and maintain their function in the healthcare system. Recent weather events in Germany revealed insufficient resilience among the healthcare sector; hence, improvements are necessary. CONCLUSIONS: Changing environmental conditions urgently require the healthcare sector to adapt and effectively strengthen crisis resilience in order to ensure that critical infrastructure remains functional and the population has access to healthcare.

Hereditary epidermolytic palmoplantar keratosis due to a novel desmoglein-1 mutation: A case report.

Key Clinical Message: Keratosis palmoplantaris striata type I (SPPK-I) is a rare autosomal-dominant type of hereditary epidermolytic palmoplantar keratoderma, which can be caused by mutations in desmoglein-1 (DSG-1). Patients suffer from hyperkeratotic plaques and painful palmoplantar fissures. Unfortunately, treatment options including salicylic vaseline, topical corticosteroids, phototherapy, and retinoids are inefficient. Abstract: Hereditary palmoplantar keratodermas (PPKs) represent a heterogeneous group of rare skin disorders with epidermal palmoplantar hyperkeratosis. Mutations in the desmoglein 1 gene (DSG1), a transmembrane glycoprotein, have been reported primarily in striate PPKs. We report a patient with keratosis palmoplantaris striata type I (SPPK-I) with a specific pathogenic variant [c.349C>T, p.(Arg117*)] in DSG1. Despite increased understanding, effective treatment options for PPK, including SPPK-I, remain limited.

[Microplastic and dermatological care]. / Mikroplastik und dermatologische Versorgung.

BACKGROUND: Synthetic polymers (plastics) from fossil resources are produced in large quantities and reach the environment as microplastics due to improper disposal and via various entry routes. This may lead to implications on flora, fauna, and humans. OBJECTIVES: This article aims to provide a concise overview for dermatologists about this complex topic and how it relates to daily medical practice. MATERIALS AND METHODS: We performed a selective literature review regarding microplastics and sustainability in dermatology in liaison with the collaborative research center on microplastics at the University of Bayreuth. RESULTS: Primary and secondary microplastics are released into the environment on a large scale and accumulate in aquatic and terrestrial ecosystems. This may lead to their disruption and bears potential to create ecological niches for human pathogenic species. Humans and animals inhale and ingest microplastics, and the health consequences have not been sufficiently investigated. This is mainly because microplastics are not a homogenous group of substances, and potential effects depend on various properties (e.g., type of polymer, size, shape, additivation, surface charge). Dermatological care is resource intensive and contributes in various ways to this matter. CONCLUSION: Plastics are currently indispensable in many fields. Nevertheless, physicians have the responsibility to prevent negative consequences for the health of society (precautionary principle). Extensive efforts are thus necessary for better sustainability; this includes medical care.

[Sustainable transformation of practices and outpatient clinics]. / Nachhaltige Transformation von Praxen und Ambulanzen.

BACKGROUND: Climate change as a consequence of anthropogenic greenhouse gas emissions (CO2e) favors weather extremes. This challenges the healthcare system to cope with negative consequences and to remain functional at the same time. Despite rising costs and shortage of staff, sick people in an aging society must be increasingly cared for in a resource-efficient and climate-neutral manner without compromising the quality of care. AIM: This article summarizes current challenges for practices and outpatient clinics due to climate change and societal transformation. In addition, steps to implement transformative interventions are discussed. MATERIALS AND METHODS: Selective literature review in PubMed database was conducted on the impact of climate change on the healthcare system, crisis resilience, climate management, overprescription, and co-benefits. RESULTS: Crisis-resilient practices are attuned to challenges resulting from climate change. Communicating co-benefits in the physician-patient conversation can accelerate the transformation to a sustainable society. CONCLUSION: Rapidly changing environmental conditions require adaptation on the part of the healthcare system. Education and prevention are key to meet this challenge. Transformation to sustainable practices is an ongoing process and it represents a holistic concept that encompasses social, environmental, and economic aspects, which are interdependent and cannot be considered separately.

[Multilocular pyoderma gangrenosum : Association with primary manifestation of primary biliary cholangitis]. / Multilokuläres Pyoderma gangraenosum : Assoziation mit der Erstmanifestation einer primär biliären Cholangitis.

A 16-year-old female patient with previously diagnosed acne vulgaris was transferred to our clinic in reduced general condition with rapidly progressive and extremely painful ulcerations. In the laboratory exam, inflammatory parameters were highly elevated, but she was normothermic. Based on the findings, we diagnosed multilocular pyoderma gangrenosum. Further investigations established the diagnosis of primary biliary cholangitis as the underlying condition. Treatment with systemic corticosteroids was initiated and we started therapy with ursodeoxycholic acid. This led to improvement within a few days. PAPA-syndrome (pyogenic arthritis, pyoderma gangrenosum and acne vulgaris) could be ruled out by genetic analysis.