[Differential diagnosis of common nail disorders in childhood]. / Differenzialdiagnose häufiger Nagelveränderungen im Kindesalter.

BACKGROUND: Correct diagnosis of nail changes in childhood may be challenging. Knowing the anatomy of the nail apparatus and some pathophysiologic principles helps to categorize nail disorders correctly. OBJECTIVES: This article gives a structured overview of nail disorders in childhood, thus, facilitating correct diagnosis of nail abnormalities in childhood. MATERIALS AND METHODS: A review of literature and our own experience are presented. RESULTS: In the first part we present fundamental anatomical characteristics of the nail apparatus based on embryonal development of the nails. In the main part we categorize nail disorders according to clinical presentation: transient nail changes, congenital nail abnormalities, infectious diseases of the nails, nail changes in the context of chronic inflammatory skin diseases, pigmented nail changes, tumors and nail changes due to trauma.

[Atopic dermatitis in children. New aspects]. / Atopisches Ekzem bei Kindern. Aktuelle Aspekte.

Atopic dermatitis in childhood is controlled by adaequate topical treatment in the majority of cases. Severe manifestations, recurrent superinfections, associated food allergy and psychosocial aspects of a chronic disease in childhood need special consideration. Furthermore, prevention is an important issue in this age group. The following article focuses on new aspects with repercussions on the management of childhood atopic dermatitis and possible implications for the future.

[Selected bacterial infections of the skin in childhood]. / Ausgewählte bakterielle Infektionen der Haut im Kindesalter.

Bacterial infections of the skin are often seen by dermatologists. The majority of infections are caused by the gram-positive bacteria Staphylococcus aureus and Streptococcus pyogenes. These induce blistering/erosive (impetigo, ecthymata) and abceeding (folliculitis) infections of the skin, respectively. Owing to their differences in virulence factors and host immunity, these strains can lead to varying presentations and courses of the infections. This review focuses on impetigo, folliculitis, perianal streptococcal dermatitis, and ecthymata.

[Pediatric dermatology. New aspects of bacterial skin infections in children]. / Kinderdermatologie. Aktuelle Aspekte bakterieller Hautinfektionen im Kindesalter.

We review important aspects of bacterial skin diseases in children, most commonly caused by Staphylococcus aureus, group A beta-hemolytic streptococci (Streptococcus pyogenes) and Borrelia burgdorferi. For early diagnosis of Lyme borreliosis in children it is important to be familiar with the variable clinical presentation of erythema migrans and early hematogenic dissemination with multiple erythemata migrantia. Treatment of impetigo in children requires consideration of concomitant diseases, the specific pathogen as well as local resistance patterns. Recently retapamulin has been released as a new antibiotic for topical use in impetigo contagiosa. Perianal streptococcal disease has been underdiagnosed and is an important differential diagnosis of perianal skin disease in children. Diagnosis is made by culturing group A beta-hemolytic streptococci; a 2-week course of oral penicillin represents the treatment of choice.

[Reticular erythematous plaques]. / Netzförmig angeordnete erythematöse Plaques.

Reticular erythematous mucinosis (REM) syndrome primarily affects young women; the skin lesions usually appear on the chest and upper back. REM is diagnosed on the basis of the clinical picture and histological findings. REM syndrome is often associated with lupus erythematosus tumidus. Both diseases respond well to treatment with chloroquin. Topical tacrolimus and the use of a pulsed dye laser have fewer side effects and have also proved to be effective.

[Bullae and blisters--differential diagnosis]. / Impetigo--Mastozytosen--Epidermolysen. Differenzialdiagnose von Blasen, Bläschen und Pusteln.

Circumscribed collections of fluid in the skin are termed blisters or blebs (roughly up to 1 cm) or bullae (roughly upwards of 1 cm). They may be subcorneal (e.g. impetigo contagiosa, pemphigus foliaceus), intra-epidermal (e.g. pemphigus vulgaris, epidermolysis bullosa simplex), junctional (e.g. bullous pemphigoid) or subepidermal (epidermolysis bullosa dystrophica). Puss-filled vesicles are termed pustules. Impetigo contagiosa is by far the most common vesicle-forming disease seen in children. As a rule,the diagnosis and treatment are unproblematic. At the latest when suitable therapy fails to elicit a response and/or in the absence of pyogens, the less common differential diagnoses must be considered.

Role of Staphylococcus aureus surface-associated proteins in the attachment to cultured HaCaT keratinocytes in a new adhesion assay.

Colonization of human skin with Staphylococcus aureus is a common feature in a variety of dermatologic diseases. In order to reproducibly investigate the adherence of Staphylococcus aureus to human epidermal cells, an in vitro assay was established using the biotin/streptavidine labeling system and the HaCaT cell line. This assay was used to define the role of several Staphylococcus aureus surface proteins with regard to their function in the staphylococcal adhesion process. Our studies included the standard laboratory strain Newman as well as its genetically constructed mutants DU5873, DU5852, DU5854, and DU5886 generated by allele replacement or transposon mutagenesis, which are deficient in the elaboration of staphylococcal protein A (spa), clumping factor (clfA), coagulase (coa), and the fibronectin-binding proteins A and B (fnbA/B), respectively. In comparison with strain Newman all mutants showed remarkably reduced adherence to the HaCaT keratinocyte cell line in our assay, yielding only between 43% and 60% of the adherence capacity of strain Newman after 60 min. Bacterial adherence could be re-established by introducing the cloned wild-type genes for the surface proteins on shuttle plasmids into the chromosomally defective mutants, thus suggesting a pathogenetic role of these proteins in the attachment of Staphylococcus aureus to human keratinocytes. Bacterial adherence was additionally enhanced by alkaline pH-values that are characteristic for skin conditions with epidermal barrier dysfunction. The use of Staphylococcus aureus mutant strains, deficient in the elaboration of defined proteins, allows specific investigation of colonization and virulence factors of this dermatologic relevant microorganism.

Acne vulgaris in children and adolescents.

Acne vulgaris is a very common inflammatory skin disease originating from the pilosebaceous unit. Peak incidence is at puberty, but acne can affect all age groups. Prepubertal acne is rare, but important to recognize as diagnostic and therapeutic procedures differ from pubertal acne. Acne neonatorum is a mild, self-limiting disease, whereas acne infantum commonly presents with moderate to severe lesions and high risk of scarring thus requiring early intervention. Mid-childhood or prepubertal acne raises the suspicion of hyperandrogenemia, further investigations are indicated to rule out underlying disease. The same applies to any patient with very severe acne, acne not responding to therapy or unusual clinical presentation. Etiopathogenesis of acne is not yet fully understood. Familiy history is the most important risk factor to develop severe acne and scarring. The relevance of life style factors such as smoking or diet is controversial. Lately high carbohydrate diet and dairy products have been implicated as aggravating factors. Mild acne normally responds to topical monotherapy, in moderate disease combination of two synergistically acting substances (e.g. benzoyl peroxid plus antibiotic, benzoyl peroxid plus retinoid, retinoid plus antibiotic, benzoyl peroxid plus azelaic acid) will improve clinical response. Retinoids and/or benzoylperoxid have been shown to be effective in maintenance therapy. In patients with severe disease or high risk of scarring systemic therapy with antibiotics, oral contraceptives with antiandrogenic properties and in particularly isotretinoin as most effective acne treatment should be considered early to avoid physical and emotional scars.

Atopic eczema: what's new?

Atopic eczema (AE) is a chronic inflammatory skin disease characterized by recurrent intense pruritus and a typical age-related distribution of skin lesions. Several new aspects with regard to the pathogenetic background as well as strategies for prevention, diagnosis and treatment of AE have emerged. There are ongoing studies on genetic susceptibility loci, as well as environmental and nutritional factors associated with an increase or a decrease of AE lesions. The atopy patch test is now available for identification of allergens in aeroallergen-triggered AE. New topical therapies, such as the calcineurin inhibitors, have broadened the therapeutic armamentarium substantially. In order to increase knowledge and coping strategies, patient education programs have been launched. Learning objective Upon completing this paper, the reader should be aware of new developments in AE, especially on nomenclature, prevention strategies, diagnostic tests, as well as therapeutic options.

UVA1 phototherapy for disseminated granuloma annulare.

BACKGROUND/PURPOSE: Disseminated granuloma annulare is a benign granulomatous skin disease of unknown etiology. Recently, UVA1 (340-400 nm) phototherapy has been found effective in a small series of four patients. The purpose of this two-center study was to determine the rate and duration of clinical response to UVA1 phototherapy in a larger cohort of 20 patients with disseminated granuloma annulare. METHODS: Twenty patients with long-standing, stable disease (median 42 months, 95% CI 23-105) underwent UVA1 phototherapy. Sixteen patients were treated with a high-dose regimen (median single dose 110 J/cm2, 95% CI 103-121) and four patients with a medium-dose regimen (median single dose 50 J/cm2, CI 50-50). The clinical response was graded on a 5-point scale [0 = none, 1 = poor, 2 = moderate, 3 = substantial, 4 = (near) complete]. After cessation of therapy, patients with a clinical score of 3 or 4 were followed up to evaluate the duration of clinical improvement. RESULTS: At the end of treatment, five patients each had substantial improvement or (near) complete clearance. Another five patients had a moderate response, three patients were considered as poor responders and two patients as treatment failures. Out of the 10 patients with good or excellent response nine were available for follow up. Of these, two patients were still clear after 3 and 6 months, and seven patients relapsed after a median of 3 months (95% CI 1.68-6.46). CONCLUSIONS: UVA1 phototherapy provided good or excellent results in half of our 20 patients with disseminated granuloma annulare. In the majority of patients with a satisfactory response, however, discontinuation of treatment was followed by early recurrence of disease.

[Palmoplantar vesicular lesions in childhood]. / Vesikulöse Veränderungen in palmoplantarer Lokalisation im Kindesalter.

BACKGROUND AND OBJECTIVE: Palmoplantar vesicles in children have various underlying causes, requiring different therapies. We evaluated the most common underlying diseases and determined simple criteria for differentiation. PATIENTS/METHODS: Within a two years period all children up to 14 years of age who presented with acral vesicles were included in this study. RESULTS: The most common causes of acral vesicles in a group of 32 patients, were dyshidrotic eczema with (n=11) or without atopic diathesis (n=11) and scabies (n=7). Rarely, the cause of vesicular lesion was tinea (n=2) or infantile acropustulosis (n=1). While dyshidrotic eczema was a disease of late childhood, palmoplantar lesions caused by scabies developed in younger children up to the age of 4 years. Scabies in contrast to infantile acropustulosis tend to present with more generalized lesions, not being restricted to acral location. Dyshidrotic eczema revealed lesions bilaterally and in case of atopy, additional body areas were involved. Unilateral presentation was a clue for tinea. CONCLUSIONS: Acral vesicles in childhood can be diagnostically discriminated by the age of the patient and the distribution of the lesions.

[Contagious impetigo--pathogen spectrum and therapeutic consequences]. / Impetigo contagiosa--Erregerspektrum und therapeutische Konsequenzen.

OBJECTIVE: The aim of this prospective study was to compare the clinical picture of contagious impetigo (C.I.) with the causative organism and to generate data of the susceptibility of bacteria as the basis for adequate therapy. PATIENTS AND METHODS: In 126 patients with C.I. (86 children, 66 of them younger than 10 years) bacterial swabs were taken and antibiotic sensitivity testing for isolated organisms was tested. RESULTS: In all cases in which contents of vesicles or pustules were analysed, Staphylococcus aureus was the only pathogen isolated. In non-bullous variants of C.I. Staphylococcus aureus was the most often isolated organism as well. Both staphylococci and streptococci were isolated in 12 cases, whereas in just 9 cases streptococci were the only pathogen detected. All Staphylococcus aureus isolates were sensitive to flucloxacillin and cefotaxime. Erythromycin-resistance amounted to more than 20 percent. The percentage of resistant staphylococci against the predominantly topically applied antibiotics fusidinic acid and mupirocin was 2 and 0 per cent, respectively. CONCLUSION: For all manifestations of C.I. Staphylococcus aureus is at present the leading organism which has to be taken into consideration for treatment. If oral antibiotic therapy is indicated, penicillinase-stable penicillins or cephalosporins, preferably of the cefalexin-type, are the drugs of choice. Macrolides are no longer recommended for initiating of C.I. treatment.

[Confluent and reticulate papillomatosis. Successful therapy with azithromycin]. / Papillomatosis confluens et reticularis. Erfolgreiche Therapie mit Azithromycin.

Confluent and reticulated papillomatosis is a fairly rare dermatosis of still unknown origin affecting mostly female young adults. The lesions are mainly localized in the midline of the trunk. Systemic treatment is the treatment of choice because the disease is resistant to topical therapy and recurrences are often seen. In recent publications retinoids and minocycline have been reported as the favourite therapeutic approaches. We successfully treated a 19-year-old-girl with azithromycin resulting in a complete healing of all skin lesions. The patient has been free of disease for five months. Based on our own case and data in literature, azithromycin is an effective, reasonable and safe therapeutic alternative.

[Gianotti-Crosti syndrome following immunization]. / Gianotti-Crosti-Syndrom nach Impfung.

Four infants developed Gianotti-Crosti syndrome (GCS) 6 to 8 days after immunization. Subsequent booster vaccinations were well tolerated. Different types of viral infections have been implicated in the pathogenesis of GCS. The occurrence of GCS after vaccination is rarely described in literature. We suggest that vaccination may be a relevant etiologic factor and should be considered in infants presenting with GCS.