Combination of 308-nm xenon chloride excimer laser and topical calcipotriol in vitiligo.

BACKGROUND: A large variety of therapeutic agents are being used for the treatment of vitiligo, but treatment remains a challenge. Recently, monochromatic phototherapies such as 311-nm narrowband ultraviolet B therapy and 308-nm xenon chloride excimer laser have been reported to be an effective and safe therapeutic option in children and adult patients with vitiligo. Single reports stipulate that the addition of topically applied calcipotriol to phototherapy increases its effectiveness. OBJECTIVE: The purpose of the present pilot study was to determine if the addition of topical calcipotriol increases the efficacy of the 308-nm xenon chloride excimer in the treatment of vitiligo. METHODS: Ten patients with vitiligo with essentially bilateral symmetrical lesions were enrolled in this prospective right/left comparative, single-blinded trial conducted over a 15-month period. All patients received 308-nm XeCl excimer laser therapy three times weekly. Calcipotriol ointment (Daivonex) was applied to lesions on one side of the body twice daily. RESULTS: After 24 treatments (8 weeks), nine patients were evaluated. Eight patients showed evidence of repigmentation on both body sides, with no significant difference between the body side treated with calcipotriol and excimer laser and the side treated with excimer laser alone. The mean repigmentation rate was 22.4% (1-37%). CONCLUSION: The addition of calcipotriol ointment to 308-nm xenon chloride excimer laser phototherapy does not significantly enhance its efficacy. Small additive effects must be investigated in a larger trial.

[Cutaneous neoplasms]. / Neoplasien der Haut.

The skin is the organ most commonly affected by malignancies. Various cancers of the skin show a dramatic increase in incidence over the last decades. Epithelial skin tumors are most frequently, e.g., basal cell carcinoma and the squamous cell carcinoma with its precursors, the actinic keratoses. Melanoma, which is extremely difficult to treat in advanced tumor stages, is dreaded. Besides that, there are other epithelial malignant diseases, e.g. Morbus Bowen and adnexal tumors originating from the skin appendices. Mesenchymal malignant neoplasias such as Morbus Kaposi, angiosarcomas and other dermal sarcomas, are rare. Since the majority of malignant neoplasms is removable and curable by a simple surgical intervention, the knowledge of the different skin tumors is essential for non-dermatologist.

[Granulomatous slack skin: partial remission following intralesional administration of interferon-alpha and PUVA]. / Granulomatous slack skin. Partielle Remission unter intraläsionärer Gabe von Interferon-alpha und PUVA.

Granulomatous slack skin (GSS) is a rare cutaneous T-cell lymphoma which typically runs a protracted and indolent course. On histopathological assessment lymphoid infiltrates with multinucleated giant cells in the dermis and subcutis with elastophagocytosis can be observed. Skin lesions are characterized by pendulous folds. We report on the successful response of the lesions to intralesional interferon alpha combined with PUVA.

[Allergic contact dermatitis to cosmetics containing Melaleuca alternifolia (tea tree oil)]. / Dermatite de contact allergique aux cosmétiques à base de Melaleuca alternifolia (tea tree oil).

INTRODUCTION: Melaleuca alternifolia is a coniferous tree found in tropical regions, the needles contain an essential oil that is used in medical and cosmetic products. The essential oil contains turpentines (limonene, alpha-pinene, phellandrene) that are potentially allergenic. PATIENTS AND METHODS: In 1997, 1216 patients were patch tested in our dermatoligic unit. Fourteen of them tested because of eczema used products containing tea tree oil. The patients used creams, hair products and essential oils containing Melaleuca alternifolia for cosmetic reasons and to treat skin affections. They were patch tested for a standard panel of allergens, topical emulgators, perfumes, plants, topical medications, metal, gloves, topical disinfectants and preservatives, dental products and rubber derivatives. Products containing Melaleuca alternifolia were tested concentrated or diluted. RESULTS: We report on 7 cases of patients with an allergic contact dermatitis due to tea tree oil. Two of them also exhibited from a delayed type IV hypersensitivity towards fragrance-mix or colophony suggesting the possibility of cross reaction or an allergic group reaction caused by contamination of the colophony with the volatile fraction of turpentines. DISCUSSION: The allergic potential of low concentrations of Melaleuca alternifolia is presumed to be low on healthy skin. Photoaged Melaleuca alternifolia must be considered to be a stronger sensitizer.

[Type A botulinum toxin: a new methods in treating focal hyperhidrosis. A summary of various possibilities in hyperhidrosis therapy with special emphasis type A botulinum toxin injections]. / Botulinumtoxin A: Ein neuer Weg in der Behandlung der fokalen Hyperhidrose. Eine Zusammenstellung der verschiedenen Möglichkeiten in der Hyperhidrose-Therapie unter spezieller Gewichtung von Botulinumtoxin A-Injektionen.

Hyperhidrosis is defined as an excess of sweating over the amount necessary for thermoregulation. Essential focal hyperhidrosis is a overactivity of the sweat glands of the axilla, palms and soles probably due to a disorder of the sympathetic nervous system. The therapy is difficult, even though there are many therapeutic options. Beside the effort to treat the psychovegetative disorder (autogenic training or acupuncture), there are efforts to seal the lumen of terminal sweat ducts using aluminiumchlorhydroxide application or iontophoresis. Surgery has the aim to eliminate sweat glands either by excision or by denervation. It is also possible to use chemical denervation with systemic anticholinergics. Only recently the local chemodenervation with injections of botulinum toxin (BTX) was added to the therapeutic tools of focal hyperhidrosis. We present an overview of several therapeutic options in consideration of BTX.

Clinical efficacy of narrow-band UVB (311 nm) combined with dithranol in psoriasis. An open pilot study.

BACKGROUND: For UVB, the most effective wavelength in clearing psoriatic lesions was found to be of 313 nm. The efficacy of whole body exposure to narrow-band UVB (311 nm) combined with dithranol in psoriasis has not been evaluated to date. OBJECTIVE: Evaluation of the clinical efficacy of phototherapy with narrow-band UVB (311 nm) and dithranol for psoriasis by means of whole body exposures and analysis of the mean cumulative irradiation dose. METHODS: In this open pilot study, 13 patients were treated for 4-5 weeks. Evaluation of the therapeutic efficacy was performed by comparing the Psoriasis Area and Severity Index (PASI) scores at baseline and after 4 weeks of treatment. The cumulative irradiation dose was also calculated. RESULTS: Evaluation of the PASI scores showed a significant overall reduction of psoriatic lesions after 4 weeks of treatment. The cumulative irradiation dose was similar or lower to those found for phototherapy with narrow-band UVB alone. DISCUSSION: In patients with widespread psoriasis, treatment with narrow-band UVB (311 nm) combined with dithranol is safe and effective, allowing reduction of the cumulative irradiation dose.

Measurement of 5-methoxypsoralen and 8-methoxypsoralen in saliva of PUVA patients as a noninvasive, clinically relevant alternative to monitoring in blood.

BACKGROUND: Monitoring of psoralen concentration and time-course in PUVA patients is vital for efficient PUVA therapy. Blood sampling is invasive and labour-intensive and thus unsuited for routine use and repeat measurements over the course of therapy. OBJECTIVE: Psoralen pharmacokinetics in saliva were investigated and validated as a noninvasive, simple and biologically relevant alternative to measurements in blood. METHODS: The time-course of psoralen concentration was measured in saliva and serum of volunteers and patients receiving PUVA or extracorporeal photopheresis therapy. The samples were analysed by high-performance liquid chromatography. Three commonly used oral psoralen preparations were tested: Psoraderm5 (5-methoxypsoralen; 5-MOP), Meladinine and Oxsoralen (both 8-methoxypsoralen; 8-MOP). RESULTS: The pharmacokinetic parameter Cmax in saliva averaged 10% (range 6-20%) of the serum values for 8-MOP, and < or = 4% for 5-MOP. These concentrations correspond to the therapeutically relevant, non-albumin-bound fraction of psoralen in serum that is available to diffuse into the tissues. The parameter tmax in saliva and serum coincided, indicating that psoralens diffuse rapidly between the two compartments. CONCLUSION: Monitoring of psoralens in saliva is a valuable, noninvasive alternative to measurements in serum, suitable for routine use. A series of five or six saliva samples is sufficient to determine tmax in a patient beginning photochemotherapy. To determine Cmax, three independent saliva measurements at t = tmax are recommended.

Incidence and in-vivo relevance of anti-interferon antibodies during treatment of low-grade cutaneous T-cell lymphomas with interferon alpha-2a combined with acitretin or PUVA.

Interferon-alpha combined with retinoid or PUVA is used for the treatment of cutaneous T-cell lymphoma. Anti-IFN-alpha antibodies (IFN ab) occur regularly during IFN-alpha treatment. We investigated the incidence of neutralizing and binding IFN ab and analysed their relationship with clinical and immunological parameters. A group of 17 CTCL patients were treated with IFN alpha-2a three times weekly subcutaneously at a dose of 3 Mill. I.U. combined either with retinoid (acitretin, Neotigason; 0.5 mg/kg bodyweight) daily or with 5-methoxypsoralen (1.2 mg/kg bodyweight) plus UVA radiation three times weekly. Prior to and during treatment we monitored stage, skin involvement by a tumour burden index, serum levels of beta 2-microglobulin, neopterin, binding and neutralizing IFN ab, Interleukin-6 (IL-6), soluble IL-2 receptors (sIL-2r) and the CD4/CD8 ratio of peripheral blood mononuclear cells. We observed two complete, two partial and six minor responses, four patients with stable disease and three patients with progressive disease. Of the 17 patients, 7 developed binding IFN ab, but only 2 had neutralizing IFN ab which were associated with high titres of binding IFN ab. IFN ab formation was more frequent in patients with normal CD4/CD8 ratios and a high tumour burden index and showed a trend to be more frequent in PUVA-cotreated patients than in retinoid-cotreated patients. Responses were more frequently seen in IFN ab-negative patients. IFN ab developed in patients treated with PUVA or retinoid combined with IFN. Binding as well as neutralizing IFN ab may have an impact on the treatment success in CTCL patients.

Therapeutic approaches in cutaneous lymphoma.

Standard therapy of the CTCL MF and SS consists of topical glucocorticosteroids, PUVA, topical chemotherapy, and total skin electron beam irradiation in stages Ia and IIa; local radiation or total skin electron beam irradiation in stage IIb; and systemic chemotherapy in stages III and IV. The experimental treatment modalities, interferon-alpha and retinoids, especially arotinoid, are most effective in early stages of CTCL; in advanced stages, the effectiveness can be increased by combination regimens. Up to now, the most promising results are obtained by combination therapy of interferon and PUVA. When serotherapy is considered as a therapeutic alternative for patients in stage IIb to IVb, the benefit/risk ratio must be carefully analyzed. Anti-thymocyte-globulin and monoclonal antibodies, either alone or conjugated to radioisotopes or toxin, have shown some therapeutic effect but are still under investigation. Extracorporal photopheresis is well established in erythrodermic patients. Initial reports also have shown encouraging results with this treatment for stage Ib and in combination with methotrexate or interferon. Hexadecylphosphocholine, a new, well-tolerated topical agent, induced a remission rate of 50%, with 25% complete remission in CTCL patients of stage Ia to IIb.

Cutaneous ossification in Albright's hereditary osteodystrophy.

A 23-year-old woman presented with subcutaneous ossification, which together with short stature, stocky physique, round face and brachydactyly suggested Albright's hereditary osteodystrophy (AHO). Serum calcium and phosphorus levels were normal. AHO refers to the phenotype of the syndromes of pseudo-hypoparathyroidism (PHP) type Ia and pseudopseudohypoparathyroidism (PPHP), both considered genetically related variants with a defect of the alpha subunit of the stimulatory G protein of adenylate cyclase, necessary for the action of parathyroid and other hormones using cyclic AMP as an intracellular second messenger. PPHP differs from PHP in that it lacks parathyroid hormone resistance manifesting itself as hypocalcemia. Other endocrine end organ unresponsiveness, e.g. hypothyroidism and hypogonadism, may also be found with PHP. Both PHP and PPHP usually exhibit characteristic phenotypic abnormalities, of which subcutaneous ossification may be a presenting feature. The differential diagnosis of cutaneous calcification and ossification is outlined.