[Hedgehog fungi in a dermatological office in Munich : Case reports and review]. / Igelpilze in einer Münchner Hautarztpraxis : Fallbeschreibungen und Übersicht.

Patient 1: After contact to a central European hedgehog (Erinaceus europaeus), a 50-year-old female with atopy developed erythrosquamous tinea manus on the thumb and thenar eminence of the right hand. The patient had previously been scalded by hot steam at the affected site. The zoophilic dermatophyte Trichophyton erinacei could be cultured from the hedgehog as well as from scrapings from the woman's skin. Antifungal treatment of the hedgehog was initiated using 2 weekly cycles of itraconazole solution (0.1 ml/kg body weight, BW). In addition, every other day enilconazole solution was used for topical treatment. The patient was treated with ciclopirox olamine cream and oral terbinafine 250 mg daily for 2 weeks, which led to healing of the Tinea manus .Patient 2: An 18-year-old woman presented for emergency consultation with rimmed, papulous, vesicular and erosive crusted skin lesions of the index finger, and an erythematous dry scaling round lesion on the thigh. The patient worked at an animal care facility, specifically caring for hedgehogs. One of the hedgehogs suffered from a substantial loss of spines. Fungal cultures from skin scrapings of both lesions yielded T. erinacei. Treatment with ciclopirox olamine cream and oral terbinafine 250 mg for 14 days was initiated which led to healing of the lesions. Identification of all three T. erinacei isolates from both patients and from the hedgehog was confirmed by sequencing of the internal transcribed spacer (ITS) region of the ribosomal DNA, and of the translation elongation factor (TEF)-1-alpha gene. Using ITS sequencing discrimination between T. erinacei strains from European and from African hedgehogs is possible. T. erinacei should be considered a so-called emerging pathogen. In Germany the zoophilic dermatophyte T. erinacei should be taken into account as causative agent of dermatomycoses in humans after contact to hedgehogs.

[Requirements for mycological diagnostics in accordance with the guideline of the German Medical Association for quality assurance of medical laboratory tests]. / Anforderungen für die mykologische Diagnostik entsprechend der Richtlinie der Bundesärztekammer (Rili-BÄK) zur Qualitätssicherung laboratoriumsmedizinischer Untersuchungen.

The ability of recognizing various clinical manifestations of mucocutaneous mycosis, making a diagnosis, and establishing a treatment is part of a dermatologist's daily routine. However, due to the fact that clinical manifestations, laboratory diagnostics, and treatment are performed in one hand, laboratory findings are properly classified and interpreted. Since new binding guidelines of the German Medical Association on quality assurance measures in medical laboratory testing came into force, there is much concern among dermatologists of how to comply with these new regulations. It is the intention of the authors to help our readers to implement these new rules in order to make sure that mycological diagnostics continue to be part of a dermatologist's professional work.

[Treatment of hyperfunctional facial lines with botulinum toxin]. / Behandlung hyperfunktioneller Gesichtslinien mit Botulinumtoxin.

Lines and wrinkles in the face are not only due to intrinsic and photoaging, but are also caused by lines of facial expression due to muscular action. Botulinum toxin A, which blocks the cholinergic transmission resulting in flaccid paralysis, is a powerful therapeutic tool in the treatment of frown lines, glabellar lines, crow-feet and platysma-bands. It has to be kept in mind, however, that the benefits of this treatment are transient and repeated injections are necessary. A treatment guide with injection sides and concentration of the toxin is presented in the context of the current literature.

Subfascial endoscopic perforator surgery with tumescent local anesthesia.

BACKGROUND: Subfascial endoscopic perforator surgery (SEPS) has become an established procedure. OBJECTIVE: To evaluate SEPS with tumescent local anesthesia (TLA) using an single-port device originally designed for that purpose. METHODS: Patients selected for SEPS received subcutaneous infiltration of TLA into the medial aspect of the calf 20 minutes before surgery. Bipolar coagulation and dissection were used to treat incompetent perforators. RESULTS: Fifty-one patients with 67 legs of CEAP stages C3-C6 underwent SEPS with TLA. In 40 patients or 53 legs (79.1%) TLA alone allowed successful completion of the SEPS procedure. Five patients with 7 legs (10.4%) required additional intravenous analgesics during surgery. In 4 patients or 4 legs (6.0%) with marked dermatoliposclerosis, pain control with TLA was so inadequate that SEPS had to be stopped. CONCLUSION: SEPS with TLA is feasible in patients with CEAP stage C3-C6. However, patients with pronounced dermatoliposclerosis are likely to need more invasive analgesic measures.

Infrequent early recanalization of greater saphenous vein after endovenous laser treatment.

OBJECTIVE: The frequency of recanalization of the greater saphenous vein (GSV) after endovenous laser treatment (ELT) is unclear. This study was undertaken to establish the incidence of early recanalization after ELT and to study the histopathologic features of reperfused and excised GSV. METHODS: One hundred nine GSV in 85 consecutive patients with clinical stage C(2-6) E(P,S) A(S,P,D) P(R) disease were treated with ELT. Twelve months of follow-up with duplex scanning at regular intervals was possible in 104 treated veins (95.4%) in 82 patients (96.5%). Recanalized vessels were removed surgically and examined at histopathology. RESULTS: ELT-induced occlusion proved permanent at duplex scanning over 12 months of follow-up in 94 of 104 GSV (90.4%) in 73 patients. In 4 patients, 5 GSV (4.8%) were recanalized completely after 1 week, after 3 months (n = 3), or after 12 months. Another 5 GSV (4.8%) in 5 patients exhibited incomplete proximal recanalization over the 12 months of follow-up. Finally, 9 recanalized vessels (8.6%) required further treatment with high ligation and stripping. Histopathologic analysis of recanalized GSV revealed a multiluminal pattern, as commonly noted in reperfusion after spontaneous thromboplebotic occlusion of the GSV. During follow-up, secondary incompetency of untreated lateral accessory saphenous veins was observed in two legs (1.9%). CONCLUSION: Early recanalization requiring retreatment is observed in less than 10% of GSV after ELT. The histopathologic pattern mimics recanalization after thrombophlebotic occlusion.

Thermal damage of the inner vein wall during endovenous laser treatment: key role of energy absorption by intravascular blood.

BACKGROUND: Despite the clinical efficacy of endovenous laser treatment (EVLT), its mode of action is incompletely understood. OBJECTIVE: To evaluate the role of intravascular blood for the effective transfer of thermal damage to the vein wall through absorption of laser energy. METHODS: Laser energy (15 J/pulse, 940 nm) was endovenously administered to explanted greater saphenous vein (GSV) segments filled with blood (n = 5) or normal saline (n = 5) in addition to GSVs under in vivo conditions immediately prior to stripping. Histopathology was performed on serial sections to examine specific patterns of damage. Furthermore, in vitro generation of steam bubbles by different diode lasers (810, 940, and 980 nm) was examined in saline, plasma, and hemolytic blood. RESULTS: In saline-filled veins, EVLT-induced vessel wall injury was confined to the site of direct laser impact. In contrast, blood-filled veins exhibited thermal damage in more remote areas including the vein wall opposite to the laser impact. Steam bubbles were generated in hemolytic blood by all three lasers, while no bubbles could be produced in normal saline or plasma. CONCLUSION: Intravascular blood plays a key role for homogeneously distributed thermal damage of the inner vein wall during EVLT.

Endovenous treatment of the greater saphenous vein with a 940-nm diode laser: thrombotic occlusion after endoluminal thermal damage by laser-generated steam bubbles.

PURPOSE: Despite a rapid spread of the technique, very little is known about the laser-tissue interaction in endovenous laser treatment (EVLT). We evaluated EVLT of the incompetent greater saphenous vein (GSV) for efficacy, treatment-related adverse effects, and putative mechanisms of action. METHODS: Twenty-six patients with 31 limbs of clinical stages C(2-6), E(P), A(S,P), P(R) with incompetent GSV proven by means of duplex scanning were selected for EVLT in an outpatient setting. A 600-microm fiber was entered into the GSV via an 18-gauge needle below the knee and proceeded to the saphenofemoral junction (SFJ). After infiltration of tumescent local anesthesia, multiple laser pulses of 15 J energy and a wavelength of 940 nm were administered along the vein in a standardized fashion. D-dimers were determined in peripheral blood samples 30 minutes after completion of EVLT in 16 patients and on postoperative day 1 in 20 patients. One GSV that was surgically removed after EVLT was examined by means of histopathology. Additionally, an experimental in vitro set-up was constructed as a means of investigating the mechanism of laser action within a blood-filled tube. RESULTS: A median of 80 laser pulses (range, 22-116 laser pulses) were applied along the treated veins. On days 1, 7, and 28, all limbs except one (97%) showed a thrombotically occluded GSV. In one patient, the vessel showed incomplete occlusion. The distance of the proximal end of the thrombus to the SFJ was a median 1.1 cm (range, 0.2-5.9 cm) in the remaining patients. Adverse effects in all 26 patients were ecchymoses and palpable induration along the thrombotically occluded GSV that lasted for 2 to 3 weeks. In two limbs (6%), thrombophlebitis of a varicose tributary required oral treatment with diclofenac. D-dimers in peripheral blood were tested with normal results in 14 of 16 patients 30 minutes after completion of the procedure and elevated results in 7 of 20 patients at day 1 after EVLT. However, an increase of D-dimers from day 0 to day 1 was observed in 15 of the 16 patients undergoing tests 30 minutes after EVLT and on day 1. The 940-nm laser was demonstrated by means of in vitro experiments and the histopathological examination of one explanted GSV to act by means of indirect heat damage of the inner vein wall. CONCLUSION: EVLT of the GSV with a 940-nm diode laser is effective in inducing thrombotic vessel occlusion and is associated with only minor adverse effects. Laser-induced indirect local heat injury of the inner vein wall by steam bubbles originating from boiling blood is proposed as the pathophysiological mechanism of action of EVLT.