[St. John's wort (Hypericum perforatum L.). A plant with relevance for dermatology]. / Johanniskraut (Hypericum perforatum L.). Eine Pflanze mit Relevanz für die Dermatologie.

Saint John's wort (Hypericum perforatum L.) is a herbal remedy that is effective in the treatment of mild to moderate depression. In traditional folk medicine, oily extracts of St. John's wort are used for topical treatment of wounds, burns and myalgia. The lipophilic phloroglucin-derivative hyperforin has antibacterial and antiinflammatory effects. These effects could be of relevance in topical treatment of infected wounds and other dermatoses, but no studies have been conducted so far. The naphtodianthrone hypericin is a photodtodynamic active substance that kills tumor cells via the induction of apoptosis. Hypericin also displays antiviral activity in vitro. In vivo, intravenous or oral treatment with hypericin of HIV-infected subjects did not result in a reduction of the virus load. Most of the patients treated with hypericin experienced phototoxicity. Similar phototoxic symptoms ("hypericism") have been observed in grazing animals ingesting large amounts of St. John's wort. In contrast, antidepressant medication with St. John's wort usually does not produce phototoxic symptoms. Recent pharmacokinetic studies suggest that the phototoxic threshold level of hypericin is not reached with dosages used for the oral treatment of depression. However, very recent reports demonstrated interactions of St. John's wort with other drugs such as digoxin, indinavir and cyclosporin. Blood levels of these drugs were dramatically decreased by St. John's wort. This should be considered in the treatment of skin conditions with antiviral drugs or cyclosporin.

[Plant-induced toxic and allergic dermatitis (phytodermatitis)]. / Durch Pflanzen ausgelöste toxische und allergische Dermatitis (Phytodermatitis).

Herbal products are being used increasingly for medical or cosmetic purposes. Many cosmetics contain plant extracts for fragrance. Sensitizing plants in cosmetics are tea tree oil, arnica, chamomile, yarrow, citrus extracts, common ivy, aloe, lavender, peppermint, and others. However, the sensitizing potential of these plants varies. Most of the sensitizing substances are sesquiterpene lactones or terpenes. The present paper reviews the various forms of phytodermatitis, including irritant plant dermatitis, phototoxic and photo-allergic dermatitis, allergic dermatitis, and airborne contact dermatitis.

[UVA1 phototherapy. Pilot study of dose finding in acute exacerbated atopic dermatitis]. / UVA1-Phototherapie. Pilotstudie zur Dosisfindung bei der bei akut exazerbierten atopischen Dermatitis.

BACKGROUND AND OBJECTIVE: UVA1 phototherapy is an new effective treatment modality for acute atopic dermatitis (AD). However there is still some controversy about the optimal UVA1 single and cumulative dose. PATIENTS/METHODS: We compared in a randomized, controlled, prospective pilot study the efficacy of a therapy with 15 treatments of a "high dose" (max. single dose of 130 J/cm2, max. cumulative dose 1840 J/cm2), "medium dose" (max. single dose of 65 J/cm2, max. cumulative dose 975 J/cm2) or "low dose" (max. single dose of 20 J/cm2, max. cumulative dose 300 J/cm2) UVA1 in patients with acutely exacerbated atopic dermatitis (SCORAD > 30). After determination of the IPD, patients randomized into one of the three treatment arms. The patients received 15 treatments (5 times per week) without any additional therapy except for topical skin care. RESULTS: After 15 treatments the "high dose" and "medium dose" groups showed a statistically significant reduction of the SCORAD. No significant reduction of the SCORAD was observed in the "low dose" group. All three treatment arms displayed no statistically significant changes in the IgE and ECP levels and in the number of eosinophils in the peripheral blood. The UVA1 therapy was well tolerated by all patients. No side effects were observed. CONCLUSIONS: This study suggests that both the "high dose" and the "medium dose" regimens are effective in the treatment of patients with acutely exacerbated atopic dermatitis.

Calcitriol 3 microg g-1 ointment in combination with ultraviolet B phototherapy for the treatment of plaque psoriasis: results of a comparative study.

BACKGROUND: Combinations of topical treatments and ultraviolet (UV) B phototherapy for plaque psoriasis may be more beneficial than either type of treatment used alone. OBJECTIVES: To determine the efficacy of calcitriol 3 microg g-1 ointment in combination with UVB phototherapy in treating plaque psoriasis. METHODS: Calcitriol ointment with UVB was compared with vehicle plus UVB in a randomized, double-blind study in 104 patients. RESULTS: Mean global improvement scores for both groups increased over the 8-week study period; there was a statistically significant difference (P < 0.05) in favour of the calcitriol/UVB combination from week 1. At end-point, 45% of the calcitriol/UVB group showed considerable improvement or clearing of psoriasis, compared with 21% of the control group. The superiority of calcitriol plus UVB was also reflected in the global severity and Psoriasis Area and Severity Index (PASI) scores; at end-point the mean percentage decrease in PASI score was 65% for the calcitriol/UVB group and 43% for vehicle/UVB (P = 0.0014). The incidence of skin-related adverse events was low (< 12%) and similar in the two treatment groups. No clinically significant changes in blood chemistry, in particular calcium levels, occurred. The greater efficacy of combined calcitriol and phototherapy allowed a 34% decrease in total UVB exposure. CONCLUSIONS: Calcitriol 3 microg g-1 ointment and UVB phototherapy in combination provides a promising therapy for managing chronic plaque psoriasis.

Recent advances in phototherapy.

This synopsis reviews recent developments in dermatological phototherapy. UVA1 phototherapy (340-400 nm) is effective in the treatment of inflammatory skin diseases such as acutely exacerbated atopic dermatitis, localized scleroderma, urticaria pigmentosa and disseminated granuloma annulare. Narrowband UVB radiation (311-313 nm) is used successfully as monotherapy or combined with dithranol, oral retinoids or 8-MOP in psoriasis, atopic dermatitis (AD) or photosensitivity disorders such as polymorphic light eruption. Bath water delivery of 8-methoxypsoralen and subsequent UVA-irradiation (PUVA bath therapy) for the treatment of psoriasis as well as for mycosis fungoides, localized scleroderma, urticaria pigmentosa or lichen planus is an effective alternative to its systemic application. The combination of salt water brine baths in different concentrations and subsequent UVA/B irradiation is used increasingly for the treatment of psoriasis or AD. Extracorporeal photopheresis (ECP) has proven to be a very effective treatment modality for cutaneous T cell lymphoma, chronic graft-versus-host disease and certain autoimmune diseases such as systemic scleroderma or pemphigus. However, despite the documented benefits of these new treatment modalities, little data exist as of yet on potential long-term side effects, thus the indications for these therapies should be considered carefully and patients should be followed up at regular intervals.

Topical application of St John's wort (Hypericum perforatum L.) and of its metabolite hyperforin inhibits the allostimulatory capacity of epidermal cells.

St John's wort (Hypericum perforatum) is a traditional herbal medicine that is used for the topical treatment of superficial wounds, burns and dermatitis. The characteristic metabolites of St John's wort are the photodynamic active plant pigment hypericin and the phloroglucin-derivative hyperforin. To date, no studies on immunomodulatory properties of topical preparations of St John's wort have been performed. Here, we investigated the alloantigen presenting function of human epidermal cells (EC) exposed to Hypericum ointment in vivo in a mixed EC lymphocyte reaction (MECLR). The effect of Hypericum ointment was compared with the immunosuppressive effect of solar-simulated radiation (SSR). Subsequently, we tested purified hyperforin in vivo and in vitro in a MECLR to evaluate its possible contribution to the effect of the Hypericum ointment. Furthermore, we assessed the effect of hyperforin on the proliferation of peripheral blood mononuclear cells (PBMC) in vitro. Compared with untreated skin, treatment with Hypericum ointment resulted in a significant suppression of the MECLR (P

[Comparison of balneophototherapy and UVA/B mono-phototherapy in patients with subacute atopic dermatitis]. / Vergleichsstudie Solebäder plus UVA/B versus UVA/B- Monotherapie bei Patienten mit subakuter atopischer Dermatitis.

In a controlled prospective study we compared the efficacy of combined salt water bath and UVA/B phototherapy to a UVA/B mono-phototherapy in patients with subacute atopic dermatitis (AD). The patients in the balneophototherapy group (n=16) were treated with baths containing 3-5% of the synthetic salt Psori-sal(trade mark), followed immediately by UVA/B irradiation, while the other treatment arm (n=12) received UVA/B phototherapy alone. After 20 treatments the balneophototherapy group showed a statistically significant (p

Hypericin levels in human serum and interstitial skin blister fluid after oral single-dose and steady-state administration of Hypericum perforatum extract (St. John's wort).

The photodynamically active plant pigment hypericin, a characteristic metabolite of Hypericum perforatum (St. John's wort), is widely used as an antidepressant. When administered orally, phototoxic symptoms may limit the therapeutic use of hypericin-containing drugs. Here we describe the high-performance liquid chromatographic (HPLC) detection of hypericin and semiquantitative detection of pseudohypericin in human serum and skin blister fluid after oral single-dose (1 x 6 tablets) or steady-state (3 x 1 tablet/day, for 7 days) administration of the Hypericum extract LI 160 in healthy volunteers (n = 12). Serum levels of hypericin and pseudohypericin were always significantly higher than skin levels (p 100 ng/ml).

[Psychological status and motivation for psychosocial intervention in patients with allergic disorders]. / Psychisches Befinden und Motivation zu psychosozialen Interventionen bei Patienten mit allergischen Erkrankungen.

The aim of this study was to compare the psychological stress of patients with different forms of immediate type hypersensitivity and urticaria. Moreover, the patients' motivation for different forms of psychological treatment was assessed and an indication for psychosocial support was defined. 228 consecutive inpatients with insect venom allergies (ins), food intolerance (food), drug hypersensitivities (dru) and urticaria (urt) were evaluated by validated questionnaires regarding psychological strain and motivation for psychosocial treatments. Patients with food intolerance and urticaria showed significantly elevated psychological stress and higher motivation for psychosocial support as compared to those with insect venom allergies and drug intolerance. Patient education was the favourite technique for the patients (food 78%, urt 57%, dru 24%, ins 17%), followed by relaxation treatment. The most important predictors for the motivation were the wish for self-responsibility, a feeling of helplessness and social limitations. If strong indication criteria are applied, psychosocial support is indicated in only small subgroups of each patient group. In spite of that, the management of allergic disease should consider the potential need for psychosocial support.

Effects of Mahonia aquifolium ointment on the expression of adhesion, proliferation, and activation markers in the skin of patients with psoriasis.

OBJECTIVE: To examine the effects of topical therapy with Mahonia aquifolium on the expression of pathogenetically relevant molecules in psoriatic skin by immunohistochemistry. STUDY DESIGN: Prospective-randomized, half-side comparison study with subsequent immunohistochemical assessment of biopsies. METHODS: The study areas were treated with Mahonia aquifolium ointment 3( daily and with dithranol in rising concentrations 1( daily, respectively. Biopsies of lesional skin from the test areas were carried out in 49 patients a) prior to therapy and b) 4 weeks after the start of therapy. Immunohistochemical stainings were performed with the following monoclonal antibodies: anti-ICAM-1, -CD3, -HLA-DR, -keratin 6, -keratin 16, -Ki-67. Evaluation of staining was made by two independent examiners using established semiquantitative scores. RESULTS: Marked staining with all of the cited monoclonal antibodies was observed in the lesional skin prior to therapy. After 4 weeks of therapy there was a marked reduction in the expressions of ICAM-1, CD 3, HLA-DR and keratin 6 and 16. There were significantly greater reductions of ICAM-1, CD3, and HLA-DR at sites treated with dithranol. The expression of Ki-67 was not reduced by either therapy. CONCLUSIONS: These results indicate efficacy of Mahonia aquifolium and dithranol in psoriatic skin both on cellular cutaneous immune mechanisms and on the hyperproliferation of keratinocytes. The effect of dithranol appears to be more potent than that of Mahonia aquifolium.

[Tumescent technique for local anesthesia. Use and prospectives of aa new anesthetic method]. / Die Tumeszenz-Lokalanästhesie. Entstehung, Anwendung und Perspektive eines neuen Anästhesieverfahrens.

The tumescent technique for local anesthesia (TLA) involves the infiltration of the subcutaneous fatty tissue with a large volume of a diluted local anesthetic. This large added volume increases the tension in the tissue, creating more favorable conditions for the action of the analgesic and for dermatological operative measures. Originally developed for use in the area of liposuction, TLA has since proved to have advantages over other forms of analgesia in numerous other dermatological indications. Overall, TLA is an effective and practical analgesic technique associated with comparatively few side effects that has been shown to be very useful in surgery of the skin.

Salt water bathing prior to UVB irradiation leads to a decrease of the minimal erythema dose and an increased erythema index without affecting skin pigmentation.

The combination of salt water baths and solar radiation is known as an effective treatment for patients with psoriasis and atopic dermatitis. To determine whether increased susceptibility to UVB radiation may contribute to this therapeutic effect we have studied the effect of bathing the skin in salt water prior to UVB irradiation. Twelve subjects were phototested on the volar aspects of their forearms with increasing doses of UVB radiation. One forearm was exposed to 5% salt water prior to irradiation. The minimal erythema dose (MED) was determined and the erythema index and skin pigmentation were assessed by photometric measurement. The combination of salt water bath and irradiation yielded a significant decrease of the MED when compared to UVB alone (median 90 mJ/cm2 vs 130 mJ/cm2, P < 0.01). Analysis of variance showed a significant influence of salt water bath on erythema (P < 0.05) but not on skin pigmentation. Within the MED test area the erythema index of the salt water exposed forearms was elevated significantly (P < 0.05) while skin pigmentation was not affected. Thus, bathing the skin in salt water leads to a decreased threshold level for the elicitation of UVB-induced erythema and a selective increase of the erythemal response. This sensitization to the effects of shortwave UVB radiation may increase immunosuppressive effects of UVB radiation and may lead to an increased efficacy of UVB phototherapy. However, there is also an increased sunburn risk when salt water baths are followed by exposure to UV radiation.

[Effect of various salt solutions on ultraviolet B-induced erythema and pigmentation]. / Der Einfluss verschiedener Salzlösungen auf die Ultraviolett-B-vermittelte Induktion von Erythem und Pigmentierung.

The combination of saltwater baths and subsequent ultraviolet irradiation is an effective treatment for psoriasis and atopic dermatitis. The aim of the present study was to determine the photosensitizing properties of two commercially available bath salts, original salt from the Dead Sea and sodium chloride. To address this issue, test areas on the volar aspects of the forearms were soaked with salt solutions for 15 minutes prior to ultraviolet-B (UVB) irradiation. The salt concentrations tested were 1%, 3% 5% and 15%. Tap water followed by UVB and UVB alone served as controls. Erythema was determined by visual and photometric measurement, and delayed tanning was assessed by colorimetry. Erythema obtained by wetting the skin prior to UVB irradiation was more pronounced than erythema induced by UVB alone. The most prominent erythema was yielded by tap water + UVB. The salts had a differing photosensitizing capacity and the strongest erythema was produced by the 5% solutions. There was only a moderate influence on delayed tanning by bathing the skin prior to irradiation. The results from the present study indicate that soaking the skin with salt solutions or tap water increases skin sensitivity to subsequent UVB irradiation. This may contribute to the effectiveness of salt water baths followed by UV irradiation and may account for an increased sunburn risk after bathing.

High-dose UVA1 therapy for atopic dermatitis: results of a multicenter trial.

BACKGROUND: The results of an open, single-center study suggested that phototherapy with high doses of UVA1 radiation (UVA1R; 340-400 nm) is effective for acute, severe exacerbations of atopic dermatitis (AD). OBJECTIVE: The purpose of this study was to assess the effectiveness of high-dose UVA1 phototherapy for acute, severe AD in a randomized multicenter trial in direct comparison with topical glucocorticoid therapy. METHODS: Patients were treated with high-dose UVA1R (10 days, 130 J/cm2/day; n = 20), topically with fluocortolone (10 days, 1 x daily; n = 17), or with UVA-UVB therapy (10 days, 1 x daily, minimal erythema dose-dependent; n = 16). RESULTS: With a clinical scoring system, significant differences in favor of high-dose UVA1R and fluocortolone therapy were observed (p < 0.0001), as compared with UVA-UVB therapy. At day 10, high-dose UVA1R was superior to fluocortolone (p < 0.002) therapy. Serum levels of eosinophil cationic protein and the blood eosinophil count were significantly reduced after high-dose UVA1 or fluocortolone, but not UVA-UVB therapy. CONCLUSION: This study confirms the therapeutic effectiveness of high-dose UVA1 monotherapy for treatment of severe exacerbations of AD.

The combination of oral acitretin and bath PUVA for the treatment of severe psoriasis.

We report four patients with severe erythrodermic, pustular psoriasis, or plaque-type psoriasis, who were treated with a combination of acitretin and bath PUVA. After 4 weeks out-patient treatment, the psoriasis in all patients had improved by > or = 90%. No patient had relapsed when reviewed at 3 months. No significant side-effects were seen with the combined retinoid/bath PUVA treatment. Acitretin and bath PUVA may be safely combined for the treatment of severe psoriasis.

Treatment of chronic palmoplantar eczema with local bath-PUVA therapy.

BACKGROUND: Systemic PUVA therapy may be useful in the treatment of chronic palmoplantar eczema. Topical PUVA-paint avoids some of the unwanted side effects of systemic psoralens and has been used successfully in the treatment of palmoplantar eczema and psoriasis. However, few data are available on the effectiveness of local bath-PUVA therapy in palmoplantar eczema. OBJECTIVE: Our purpose was to assess the effectiveness of local bath-PUVA therapy in 28 patients with chronic palmar or plantar eczema or both who were resistant to conventional topical treatment. METHODS: After fungal or bacterial infection had been excluded in all patients, hands or feet or both were soaked for 15 minutes in warm water containing 1 mg/L 8-methoxypsoralen. Immediately after, the skin was irradiated with increasing doses of UVA, starting with 0.5 J/cm2. PUVA-bath therapy was performed 4 times a week up to a total of 25 treatments. No additional therapy was allowed except emollients. RESULTS: Excellent or good effects were achieved in 93% of the patients with dyshidrotic and in 86% of the patients with hyperkeratotic eczema. In the patients with dyshidrotic eczema, the cumulative doses and the highest single doses of UVA were lower than those in the patients with hyperkeratotic eczema (21.4 vs 27.9 J/cm2 and 2.4 vs 3.0 J/cm2 of UVA), but this was not statistically significant. No phototoxic reactions were observed. CONCLUSION: Local bath-PUVA therapy is of value in the management of chronic palmoplantar eczema resistant to standard modes of topical treatment. Compared with topical PUVA-paint, local bath-PUVA therapy has several advantages, particularly the absence of phototoxic reactions, severe hyperpigmentation, and protracted photosensitivity.

[Bath additives in dermatologic balneotherapy. Indications and approaches in current research]. / Badezusätze in der Dermatologischen Balneotherapie. Indikationen und aktuelle Forschungsansätze.

Progress in dermatological research during the last years has provided new insights into the mode of action of additives to dermatological baths. The present paper reviews the pharmacokinetics of dermatological bath therapy additives such as sulfur, salts and trace elements, tars and ichthyol, lipids, antiseptics, astringents, plant extracts, surface-active agents and proteins.

Phototesting in bath-PUVA: marked reduction of 8-methoxypsoralen (8-MOP) activity within one hour after an 8-MOP bath.

It is not known how long after 8-MOP bath-PUVA administration erythema can be induced. Therefore, after determination of dose-dependence and kinetics of bath-PUVA erythema, we investigated the development of erythema using an erythematogenic UVA-dose (3 J/cm2) in time course experiments. Our results show that there is a loss of biological 8-MOP activity already 1 h after 8-MOP bath. This has important consequences for clinical practice with bath-PUVA, concerning the optimum time interval between the 8-MOP bath and irradiation as well as the persistence of photosensitivity in normal skin after bath-PUVA.