Ulcus vulvae acutum Lipschütz: a systematic literature review and a diagnostic and therapeutic algorithm.

The case report literature on ulcus vulvae acutum Lipschütz (UVAL) is scant, and specific guidelines on its diagnosis and treatment are lacking. Our study's aim was to perform a systematic literature review of UVAL in order to formulate a diagnostic and therapeutic algorithm. Using the PRISMA criteria, we searched PubMed and MEDLINE for the terms 'ulcus vulvae acutum', 'Lipschütz ulcer' and 'acute genital ulcer AND vulva'. We extracted relevant data on 'type of article', 'patients' age', 'amount and localization of ulcers', 'presence of flu-like symptoms', 'prior sexual contacts', 'diagnostic workup' (including histology, blood count and serology such as Epstein-Barr virus testing) and 'treatment/outcome'. Data were meta-analysed and comparative analyses were discussed in order to create a diagnostic algorithm and recommendations for management. Twenty-one publications reporting a total of 60 cases of UVAL were included for analysis. On this basis, we formulated a diagnostic and therapeutic algorithm defined by two major and four minor criteria. The major criteria were (i) acute onset of one or more painful ulcerous lesions in the vulvar region and (ii) exclusion of infectious and non-infectious causes for the ulcer. The minor criteria were (i) localization of ulcer at vestibule or labia minora, (ii) no sexual intercourse ever (i.e. patient was a virgin) or within the last 3 months, (iii) flu-like symptoms and/or (iv) systemic infection within 2-4 weeks prior to onset of vulvar ulcer. Use of a symptom-based treatment algorithm based on our proposed major and minor criteria will improve the diagnosis and management of UVAL.

Mobile teledermatology helping patients control high-need acne: a randomized controlled trial.

BACKGROUND: Acne is an important health issue with a major psychological impact in addition to the physical problems it causes. OBJECTIVES: To investigate the superiority of mobile teledermatology in the care of patients with high-need facial acne in comparison to outpatient services with particular attention to treatment efficacy, safety, and patient compliance. Further, patient satisfaction with remote care was evaluated. METHODS: Sixty-nine consecutive patients (f: 25, m: 44, median age: 19 years, range: 13-37 years) were randomly allocated to either the teleconsultation (TCA) or the outpatient consultation (OCA) arm of the trial to receive isotretinoin treatment in weight and severity-dependent dosages over 24 weeks. Acne grading was performed by one examiner using the Global Acne Severity Scale (GEA) and the total lesion counting (TLC). RESULTS: Due to noncompliance issues, 17 of 69 (24.6%) patients were excluded from the study, of who 10 had been assigned to the TCA (10/34; 29.4%) and 7 to the OCA (7/35; 20%). Both, in the TCA (GEA-score: ∆ = 2.25; TLC: ∆ = 89.08) and in the OCA (GEA-score: ∆ = 2.0; TLC: ∆ = 91.21) excellent and almost equivalent therapeutic outcomes were achieved. In the TCA, however, less patients experienced adverse reactions (P = 0.55). Even though additional live supervision would have been appreciated in some teledermatology cases, patients were satisfied with the mobile service and no consultation request was created. CONCLUSION: Mobile teledermatology is an efficient, safe and well-accepted tool among patients with high-need acne constituting at least a valuable adjunct to outpatient care services. Further larger studies would be useful to confirm our findings.

A multicenter prospective trial to asses a new real-time polymerase chain reaction for detection of Treponema pallidum, herpes simplex-1/2 and Haemophilus ducreyi in genital, anal and oropharyngeal ulcers.

Treponema pallidum, herpes simplex virus types 1 or 2 (HSV-1/2) and Haemophilus ducreyi are sexually transmitted pathogens that can cause genital, anal and oropharyngeal ulcers. Laboratory evaluation of these pathogens in ulcers requires different types of specimens and tests, increasing the risk of improper specimen handling and time lapse until analysis. We sought to develop a new real-time PCR (TP-HD-HSV1/2 PCR) to facilitate the detection of T. pallidum, HSV-1/2 and H. ducreyi in ulcers. The TP-HD-HSV1/2 PCR was tested (i) in a retrospective study on 193 specimens of various clinical origin and (ii) in a prospective study on 36 patients with genital, anal or oropharyngeal ulcers (ClinicalTrials.gov # NCT01688258). The results of the TP-HD-HSV1/2 PCR were compared with standard diagnostic methods (T. pallidum: serology, dark field microscopy; HSV-1/2: PCR; H. ducreyi: cultivation). Sensitivity and specificity of the TP-HD-HSV1/2 PCR for T. pallidum were both 100%, for HSV-1 100% and 98%, and for HSV-2 100% and 98%, respectively. T. pallidum and HSV-1/2 were detected in 53% and 22% of patients in the prospective study; H. ducreyi was not detected. In the prospective study, 5/19 (26%) specimens were true positive for T. pallidum in the TP-HD-HSV1/2 PCR but non-reactive in the VDRL. The TP-HD-HSV1/2 PCR is sensitive and specific for the detection of T. pallidum and HSV-1/2 in routine clinical practice and it appears superior to serology in early T. pallidum infections.

Near-fatal anaphylaxis caused by human serum albumin in fibrinogen and erythrocyte concentrates.

A 40-year-old man developed anaphylactic shock during surgical replacement of a prolapsed mitral valve during general anaesthesia and an attenuated reaction (Grade 2), three days later during a blood transfusion. Human serum albumin, a component of the fibrinogen concentrate used postoperatively with the erythrocyte concentrate, was identified as the trigger, confirmed by positive skin prick and intradermal tests. Any anaphylaxis during the peri-operative period should cause the clinician to perform allergy tests for identification of the culprit drug and, sometimes, culprit additive. Testing of human serum albumin, acting as hidden allergen, should be included, especially where there has been a blood transfusion.

Determination of sIgE to rPhl p 1 is sufficient to diagnose grass pollen allergy.

BACKGROUND: New diagnostic tools such as the basophil activation test (BAT) and component-resolved diagnosis (CRD) are promising for Hymenoptera venom or food allergy. A clear benefit for inhalant allergens has not yet been shown. Our aim was to compare new and established tests for grass pollen allergy. METHODS: Forty-nine patients with grass pollen allergy and 47 controls were prospectively enrolled in the study. A symptom score was calculated for each patient. Conjunctival provocation tests (CPT), skin prick tests (SPT), BAT, and sIgE determination including CRD were performed. Sensitivity and specificity were compared and results were correlated with the symptom score. RESULTS: Single determination of sIgE to rPhl p 1 showed the best balance between sensitivity (98%) and specificity (92%). Use of additional components, such as rPhl p 2 and 5, did not increase sensitivity. Generally, sensitivity of tests was high: SPT 100%, ISAC-112 100%, sIgE to timothy grass 98%, BAT 98%, ISAC-103 84%, and CPT 83%. Specificity ranged from 79% (SPT) to 96% (CPT). All test results and calculated values (e.g. ratio sIgE/tIgE) did not correlate with symptom severity. Asymptomatic sensitization to timothy grass in controls was rare in the CAP (11%) and predominantly due to Phl p 1 sensitization. CONCLUSION: rPhl p 1 was sufficient to diagnose grass pollen allergy, and sIgE patterns were the same in symptomatically and asymptomatically sensitized subjects. The testing of multiple components was of minor importance, and no test correlated with symptom severity.

Simultaneous intradermal testing with hymenoptera venoms is safe and more efficient than sequential testing.

BACKGROUND: According to current guidelines, skin testing for hymenoptera venom allergy should be performed in a stepwise manner, maintaining 15- to 20-min intervals between the injections of venom. Given the long-winded procedure of sequential skin testing, we retrospectively explored the safety of simultaneous intradermal testing. METHODS: Four hundred and seventy-eight consecutive patients with a convincing history of an anaphylactic reaction after a hymenoptera sting were tested. All venom concentrations (0.02 ml of 0.001, 0.01, 0.1, and 1.0 µg/ml of honey bee and wasp venom) were administered simultaneously to the skin. RESULTS: Four hundred and seventy-two (98.7%) patients tolerated the simultaneous intradermal test without any side-effects. Only three subjects (0.6%) had a presumed allergic reaction during the test; another three reactions were considered vasovagal. CONCLUSION: Our skin test protocol with four simultaneously injected concentrations of two hymenoptera venoms is safe and permits the investigator to draw rapid conclusions about the individual's sensitization pattern.

Oral xylose isomerase decreases breath hydrogen excretion and improves gastrointestinal symptoms in fructose malabsorption - a double-blind, placebo-controlled study.

BACKGROUND: Incomplete resorption of fructose results in increased colonic hydrogen production and is a frequent cause of abdominal symptoms. The only treatment available is diet. AIM: To study whether orally administered xylose isomerase (XI), an enzyme that catalyses the reversible isomerisation of glucose and fructose, can decrease breath hydrogen excretion in patients with fructose malabsorption. METHODS: Patients received 25 g fructose in 100 mL water together with either placebo or XI capsules. Primary endpoint was the reduction in breath hydrogen excretion, as assessed by the area under the breath hydrogen curve over 4 h (AUC). A secondary endpoint was the reduction in abdominal pain, bloating and nausea assessed on a visual analogue scale (VAS, range: 0-10). A P value <0.05 was considered statistically significant. RESULTS: Sixty-five patients in whom fructose malabsorption had been diagnosed by positive breath hydrogen test within the previous year, were included in the study [15 males, 50 females; mean age 43.3 (s.d. = 14.4), range: 21-73 years]. The median AUC was 885 ppm/240 min in the XI group compared to 2071 ppm/240 min in the placebo group (P = 0.00). Median scores for abdominal pain (0.7 vs. 1.3) and nausea (0.2 vs. 0.6), but not for bloating (P = 0.053), were significantly improved after XI (P = 0.009 and P = 0.005) as compared with placebo. CONCLUSIONS: Oral administration of xylose isomerase significantly decreased breath hydrogen excretion after ingestion of a watery fructose solution. Nausea and abdominal pain were significantly improved by xylose isomerase.

Ratio of marked and excised sentinel lymph nodes and scintigraphic appearance time in melanoma patients with negative sentinel lymph node.

AIM: Metastases can occur in up to 15% of all melanoma patients with negative sentinel lymph node examination (SN -). We retrospectively investigated the number of preoperatively marked sentinel lymph nodes (SNs) with lymphoscintigraphy and effectively surgically removed SNs in SN--patients with cutaneous melanoma >or=0.5 mm. Ratio of these parameters was calculated and impact of this ratio as well as impact of scintigraphic appearance time (SAT) on disease progression was studied. MATERIALS AND METHODS: Data on 122 SN--patients--70 women (58%), mean age 56.5 years--were analyzed. Mean follow-up time was 58 months. RESULTS: Mean tumour thickness of all patients was 2.3 mm. In 51 patients (42%) the number of SNs marked in lymphoscintigraphy was higher than excised in surgery, in 47 patients (38%) the same number as marked was excised and in 24 patients (20%) a lower number was marked than excised. Metastases occurred in 17 patients (14%) after a mean time of 24.8 months. Mean tumour thickness (5.4 mm) was significantly higher in these patients than in the other patients (p = 0.000). Ratio of marked and excised SNs had no influence on disease progression; the only parameter influencing outcome was tumour thickness (p = 0.000). Short SAT was significantly associated with higher tumour thickness (p = 0.004). CONCLUSION: Our study indicates that, in routine clinical practice, it suffices to harvest the first SN, as the ratio of marked and excised SNs has no impact on disease progression.

Tryptase as severity marker in drug provocation tests.

BACKGROUND: In the absence of objective symptoms, it is difficult to assess an adverse reaction during drug provocation testing. We evaluated the value of serum tryptase levels to distinguish between positive, negative and, even more important, so-called 'hysterical' reactions (conversion symptoms). The latter are occasionally observed in drug provocation tests when the patient experiences ambiguous subjective symptoms. METHODS: In a prospective single-center study, 303 patients underwent 785 drug provocation tests. Blood was taken for tryptase measurement on each test day before and after drug challenge, and the changes in serum tryptase levels in patients with no reactions were compared with those who experienced immediate reactions to a drug. RESULTS: Thirty-four of 785 drug provocations were clinically judged as being positive. Despite objective symptoms, median serum tryptase values in the afternoon were even lower than baseline levels. However, this decrease was not statistically significant. In the 751 patients suffering no objective reactions, the median values of post-testing tryptase values were statistically significantly decreased as compared with pretesting values. CONCLUSIONS: The measurement of serum tryptase levels does not appear to be helpful to differentiate mild allergic or nonallergic reactions from 'hysterical' ones. The milder decrease in the group with objective drug reactions might indicate slight mast cell activation in some patients. More severe clinical drug reactions led to stronger mast cell degranulation. Mild reactions did not increase the tryptase levels consistently.

[ABO blood group expression in corneal allograft failures]. / ABO-Blutgruppenexpression in Hornhäuten mit Transplantatversagen.

BACKGROUND: ABO blood group antigens are only expressed by the epithelial cells of normal human corneas. Since AB0 blood group antigens are also known to be expressed on stromal and endothelial cells of inflamed corneas, this study aimed to investigate the extend of ABO blood group antigen expression in corneal allograft failures. MATERIAL AND METHODS: Twenty-two failed corneal allografts of 22 patients were examined. In 12 cases the patients had clinically proven corneal allograft rejection. In 10 cases there was no evident history of allograft rejection and the diagnosis graft failure due to chronic endothelial cell loss was made. Immunohistochemical staining of paraffin embedded sections was performed with monoclonal mouse antibodies to human blood group antigen A or B using the streptavidin-biotin-peroxidase complex technique. RESULTS: Blood group antigens A or B were expressed by stromal keratocytes in 5 out of 12 and by endothelial cells in 7 out of 12 corneas with clinically proven immunologic graft rejection. Corneal transplants with chronic endothelial cell loss expressed blood group antigens A and/or B on the endothelial cells in three out of ten cases. CONCLUSION: The results of this study show that ABO blood group antigens can be up-regulated in cases of corneal allograft failure, especially in cases of immune mediated graft rejection. This phenomenon might play a role in corneal allograft rejection.

[Epidemiologic surveillance of contact allergens. The "monitoring series" of IVDK (Information Network ofDermatologic Clinics for Detection and Scientific Evaluation of Contact Allergy]. / Epidemiologische Uberwachung von Kontaktallergenen. Der "Monitorblock" des IVDK.

The selection of the most important contact allergens is subject to a continuous change. Several factors may influence the sensitization rates and thus the decision, which substances to include in the standard series of the most frequent allergens. The Information Network of Departments of Dermatology adds substances of interest for a certain time period to the standard series in order to evaluate parameters such as sensitization rate, grade of reaction, and clinical relevance of positive reactions. In 6 testing periods starting in 1996, 13 test substances were evaluated. Due to the results, propolis, compositae mix, and bufexamac were included in the standard series in 1999, while lyral was added in 2002. Sorbitansesquioleat, dispers blue mix, and iodopropynyl butylcarbamate are under further discussion. Substances such as glutaraldehyde and p-aminoazobenzole should be tested in certain risk groups only, whereas the steroids budesonide and tixocortol should be tested when clinically suspected.

The seamy side of natural medicines: contact sensitization to arnica (Arnica montana L.) and marigold (Calendula officinalis L.).

Medical remedies of plant origin have gained increasing popularity in recent years. Both anaphylactic and eczematous allergic reactions are on the rise, accordingly. Arnica and marigold, both of the Compositae family, are in widespread use, but only limited data are available on their allergenic potential. We tested 443 consecutive patients, in addition to the European standard and other series, with Compositae mix, sesquiterpene lactone mix, arnica, marigold, and propolis. 5 subjects ( approximately 1.13%) reacted to arnica, 9 ( approximately 2.03%) to marigold. The Compositae mix was positive in 18 cases ( approximately 4.06%). Among them were 3 out of 5 individuals with a sensitization to arnica, and 4 out of 9 who reacted to marigold. Sensitization to arnica and marigold was often accompanied by reactions to nickel, Myroxylon Pereirae resin, fragrance mix, propolis, and colophonium. We conclude that Compositae allergy contributes significantly to the epidemiology of contact dermatitis and that sensitization to arnica and marigold cannot be assessed by testing with the Compositae or sesquiterpene mix alone. As extracts of these plants are frequently used in occupational and cosmetic products, patch testing with additional plant extracts or adjustment of the commercial Compositae mix to regional conditions is recommended.

Pigmented purpuric contact dermatitis from Disperse Blue 106 and 124 dyes.

The diagnosis of purpura pigmentosa progressiva in a female patient had to be changed to purpuric contact dermatitis after patch testing with textile dyes. A modified patch test performed in the area in which most of her skin lesions were located revealed a petechial reaction to the azo dye Disperse Blue 124/106. For evaluation of purpura pigmentosa progressiva we suggest a patch test with potential allergens, and, especially for textile dyes, a patch test at the lesion site may be helpful.