Up-regulation of the chemokine CCL18 by macrophages is a potential immunomodulatory pathway in cutaneous T-cell lymphoma.

Mycosis fungoides (MF) is the most frequent form of cutaneous T-cell lymphoma (CTCL), which can deteriorate from patch stage to dermal-based tumors and systemic involvement in years. The interaction of chemokines in the skin with CTCL cells might have implications for the pathogenesis of the disease. In this study, we show by PCR analysis and immunofluorescence staining that the chemokine CCL18 is present in skin biopsy specimens of patients with MF and its precursor form parapsoriasis en plaque but not in healthy tissue. In addition, the serum levels of CCL18 were increased threefold in MF patients compared with those in healthy controls. In skin, CCL18 was specifically expressed by CD163(+) CD209(+) macrophages at the invasive margin of the tumor and not expressed by mature CD208(+) dendritic cells in the center of the tumor. The chemokine CCL17 was, by contrast, ubiquitously expressed. Furthermore, CCL18 promoted the chemotaxis but not the proliferation of CTCL cells. CCL18 inhibited proliferation of tumor cells and abolished the CXCL12-induced growth of a CTCL cell line. These data link the increased expression of CCL18 with CTCL and suggest an immunomodulatory effect of the chemokine in the pathogenesis of CTCL.

Definitions and outcome measures for bullous pemphigoid: recommendations by an international panel of experts.

Our scientific knowledge of bullous pemphigoid (BP) has dramatically progressed in recent years. However, despite the availability of various therapeutic options for the treatment of inflammatory diseases, only a few multicenter controlled trials have helped to define effective therapies in BP. A major obstacle in sharing multicenter-based evidences for therapeutic efforts is the lack of generally accepted definitions for the clinical evaluation of patients with BP. Common terms and end points of BP are needed so that experts in the field can accurately measure and assess disease extent, activity, severity, and therapeutic response, and thus facilitate and advance clinical trials. These recommendations from the International Pemphigoid Committee represent 2 years of collaborative efforts to attain mutually acceptable common definitions for BP and proposes a disease extent score, the BP Disease Area Index. These items should assist in the development of consistent reporting of outcomes in future BP reports and studies.

Human slan (6-sulfo LacNAc) dendritic cells are inflammatory dermal dendritic cells in psoriasis and drive strong TH17/TH1 T-cell responses.

BACKGROUND: Psoriasis is a chronic inflammatory skin disease that is considered to result from activated T cells stimulated by a population of inflammatory dermal dendritic cells (DCs). The origin and identity of these inflammatory dermal DCs are largely unknown. OBJECTIVE: We previously identified slanDCs (6-sulfo LacNAc) DCs as a rich source of TNF-α and as the early major source of IL-12. Here we studied the relevance of slanDCs as inflammatory dermal DCs in psoriasis. METHODS: Psoriasis skin samples were stained for the presence of activated slanDCs. Functional studies were carried out to determine the cytokine production of slanDCs, their T(h)17/T(h)1 T-cell programming, and their migration behavior. RESULTS: Large numbers of IL-23, TNF-α, and inducible nitric oxide synthase expressing slanDCs were found in psoriatic skin samples, which can be recruited by C5a, CX3CL1, and CXCL12. SlanDCs isolated from blood produced high levels of IL-1ß, IL-23, IL-12, and IL-6. Compared with classic CD1c(+) DCs, slanDCs were far more powerful in programming T(h)17/T(h)1 T cells that secrete IL-17, IL-22, TNF-α, and IFN-γ, yet CD1c(+) DCs induced a higher IL-10 production of T cells. Self-nucleic acids complexed to cathelicidin LL37 trigger endosomal Toll-like receptor (TLR) signaling (TLR7, TLR8, TLR9) and are key factors for the activation of DCs in psoriasis. We show that slanDCs respond particularly well to complexes formed of self-RNA and LL37. Similarly, slanDCs stimulated with a synthetic TLR7/8 ligand produced high levels of proinflammatory cytokines. CONCLUSION: Our study defines slanDCs as inflammatory dermal DCs in psoriasis and identifies their strong capacity to induce T(h)17/T(h)1 responses.

Efficacy and safety of omalizumab in patients with chronic urticaria who exhibit IgE against thyroperoxidase.

BACKGROUND: A subgroup of patients with chronic spontaneous urticaria (CU) exhibits IgE antibodies directed against autoantigens, such as thyroperoxidase (TPO). We conducted this study to investigate whether such patients with CU with IgE against TPO benefit from treatment with omalizumab, a humanized anti-IgE mAb licensed for the treatment of severe persistent allergic (IgE-mediated) asthma. OBJECTIVES: We sought to assess the efficacy of omalizumab treatment in patients with CU with IgE autoantibodies against TPO. METHODS: In this multicenter, randomized, double-blind, placebo-controlled study patients with CU (male/female, 18-70 years of age) with IgE autoantibodies against TPO who had persistent symptoms (wheals and pruritus) despite standard antihistamine therapy were randomized to receive either omalizumab (75-375 mg, dose determined by using the approved asthma dosing table) or placebo subcutaneously once every 2 or 4 weeks for 24 weeks. The primary end point was the change from baseline in mean weekly urticaria activity score after 24 weeks of treatment, as calculated from patients' diaries. The safety and tolerability of omalizumab were also assessed. RESULTS: Of the 49 randomized patients (omalizumab, n = 27; placebo, n = 22), 42 completed the study. At week 24, patients demonstrated a mean reduction in the weekly urticaria activity score from baseline of 17.8 with omalizumab and 7.9 with placebo (P = .0089). Complete protection from wheal development was observed in 19 (70.4%) patients in the omalizumab group compared with only 1 (4.5%) patient in the placebo group. The rate of adverse events was similar in both groups. CONCLUSIONS: The results of this study indicate that omalizumab is an effective treatment option for patients with CU with IgE autoantibodies against TPO who are refractory to conventional treatment.

Efficacy of pimecrolimus 1% cream in the long term management of atopic hand dermatitis. A double-blind RCT.

BACKGROUND: Efficacy and steroid sparing effects of pimecrolimus 1% cream in atopic dermatitis have been shown recently, but there is no data on efficacy in long term management of atopic hand dermatitis. This study aims to investigate the efficacy of pimecrolimus 1% cream as maintenance therapy in patients suffering from atopic hand dermatitis. PATIENTS AND METHODS: A double-blind vehicle controlled study in 40 adult patients with atopic hand dermatitis (IGA ≤ 3) comparing the efficacy of twice daily application of pimecrolimus 1% cream given as maintenance treatment versus vehicle over a 8 week period after clinical response (IGA ≤ 2) to a 1-3 week pre-treatment with mometasone fuorate 0.1% was performed. Primary endpoint was the time to relapse (IGA ≥ 3). RESULTS: Thirty-six out of 40 patients were randomised to receive either pimecrolimus 1% (P) or vehicle cream (V). The number of patients with stable remission in patients randomised to pimecrolimus (53.8%) and vehicle (43.8%) did not achieve statistical significance between the groups (p = 0.41). Subgroup analysis of patients with initially moderate dermatitis (IGA = 3, n = 20) showed a trend towards a better outcome for the pimecrolimus group (stable remission P = 81.8% versus V = 55.6%) (p = 0.244). CONCLUSIONS: Pimecrolimus 1% cream twice daily was not superior to vehicle in the sequential maintenance therapy of atopic hand dermatitis, but efficacy in moderate forms should be investigated in further studies.

Efficacy and safety of rituximab in pemphigus: experience of the German Registry of Autoimmune Diseases.

BACKGROUND: Rituximab has been reported to be effective in various small case series of patients with severe and/or refractory pemphigus. However, no systematic evaluation is available to corroborate this observation. The aim of this study was to systematically determine efficacy and safety of rituximab in treatment-resistant pemphigus. PATIENTS AND METHODS: Multicenter retrospective, observational study of 36 patients with severe pemphigus vulgaris (n = 33) and pemphigus foliaceus (n = 3) treated with rituximab before August 31(st) , 2008 and enrolled in a national observational registery between December 2008 and June 2009. RESULTS: Within a mean period of observation of 11 (1-37) months, 21 (58 %) pemphigus patients showed complete, 13 (36 %) partial, and 2 (6 %) no response to rituximab treatment. This correlates with a mean improvement of the visual analog scale for well-being of 34 (20-60) at baseline to 75 (40-95) at the last control visit. In 4 (11 %) patients, severe adverse events were recorded including 1 (3 %) serious infection. CONCLUSIONS: Data collected in this systematic registry indicate that rituximab is an effective and relatively safe adjuvant treatment option for refractory pemphigus. To further extend our knowledge on efficacy and safety of this drug, controlled prospective trials are required.

Evaluation of the atrophogenic potential of hydrocortisone 1% cream and pimecrolimus 1% cream in uninvolved forehead skin of patients with atopic dermatitis using optical coherence tomography.

Topical corticosteroids are widely used to treat atopic dermatitis (AD), but their anti-inflammatory mode of action can be accompanied by several unwanted side effects including skin atrophy and telangiectasia. In this 8-week, investigator-blinded, intraindividual right-left comparison study with patients with mild-to-moderate AD, hydrocortisone 1% cream (HCT) was applied twice daily for 4 weeks on one side of forehead skin without clinical signs of AD and pimecrolimus 1% cream (PIM) on the other. Epidermal and dermal thickness were assessed by optical coherence tomography (OCT) and high-frequency ultrasound, respectively. Skin atrophy and telangiectasia were assessed by contact dermatoscopic photography (Dermaphot(®)). Treatment with HCT leads to a significant decrease in epidermal thickness after only 2 weeks of treatment, while the decrease in PIM-treated sites was less pronounced and was not statistically significant. By 4 weeks after the end of treatment, epidermal thickness returned to baseline values. No dermal thinning or development of telangiectasia could be observed by means of ultrasound or Dermaphot(®), respectively. In summary, this study indicates that a 2-week single course of topical treatment with a mildly potent steroid can cause transient epidermal thinning, an effect not seen in the PIM group. The slight decrease with PIM - although not significant - could be due to normalization of the increased skin thickness caused by a subclinical inflammation in AD. This study suggests that PIM may be safer for treatment of AD in sensitive skin areas like the face, especially when repeated application is required.

Lipidome of narrow-band ultraviolet B irradiated keratinocytes shows apoptotic hallmarks.

BACKGROUND: UV light triggers a variety of biological responses in irradiated keratinocytes that might be associated with global perturbation of their lipidome. However, lipids that are specifically affected and the exact molecular mechanisms involved remain poorly understood. OBJECTIVES: To characterize time-dependent changes of the lipidome of cultured keratinocytes induced by narrow-band ultraviolet B (NB-UVB) irradiation. METHODS: Immortalized human keratinocytes (HaCaT) were cultured under standard conditions, irradiated with NB-UVB light (311 nm) at 400 and 800 mJ/cm(2) and collected 1, 2, 3, 6, 12 and 24 h later for lipid extraction. Lipid extracts were separated on silica plates in chloroform/ethanol/water/triethylamine (35:40:9:35) and in n-hexane/ethylacetate (5:1) followed by quantitative shotgun lipidomics analysis. RESULTS: Irradiation with 800 mJ/cm(2) of NB-UVB altered morphology and lipidome composition of HaCaT cells. Ceramide content increased two-fold 6- and 12-h postirradiation with 800 mJ/cm(2), followed by threefold increase in triacylglycerols (TAGs) that peaked at 24 h. In addition, we observed marked increase of various phosphatidylcholine and phosphatidylethanolamine ethers, whereas phosphatidylcholine-species with short-chain fatty acid moieties decreased. The abundance of other lipid species was altered to lesser extent or remained unchanged. CONCLUSIONS: NB-UVB affected the cellular lipidome of keratinocytes in strictly apoptosis-specific manner.

Early exposure to antibiotics and infections and the incidence of atopic eczema: a population-based cohort study.

It has been suggested that infants exposed to antibiotics are at increased risk for atopic eczema (AE), whereas the early exposure to infections might be protective. This study describes the complex relationship between early exposure to infections, anti-infectious treatment with antibiotics, and incident AE. Using a German population-based administrative health-care and prescription database, we established a cohort of 370 children not diagnosed as having AE during their first year of life. For each individual child we identified all infections and prescriptions of antibiotics within the first year as well as incident AE within the second year of life. Crude analyses suggested that early infections and exposure to antibiotics are risk factors for AE. However, stratified analyses indicated that early infections were only associated with a higher rate of AE when treated with broad-spectrum antibiotics such as cephalosporines or macrolides. The risk ratio (RR) of children with early respiratory tract infections not treated with antibiotics was 0.69 [95% confidence interval (95% CI) 0.39 to 1.24], whereas respiratory tract infections treated with macrolides (RR: 2.15, 95% CI: 1.18-3.91) or cephalosporines (RR: 1.93, 95% CI: 1.07-3.49) significantly increased the risk for AE. The results for other common childhood infections tended to be similar. Antibiotic treatment appears to modify the association between early infections and subsequent AE. We found no evidence that infections per se significantly alter the likelihood for subsequent AE.

Vitamin D metabolism.

Irradiation of human skin with ultraviolet B (280-320 nm) initiates the photochemical conversion of 7-dehydrocholesterol via previtamin D3 to vitamin D3. Vitamin D3 needs for its activation two hydroxylation steps in the liver and kidney. The final product, hormonally active 1alpha,25-dihydroxyvitamin D3 (calcitriol), arrives via the circulation to its target tissues and acts in a genomic or nongenomic manner. It has been found that human skin irradiated with ultraviolet B also is able to produce calcitriol in substantial amounts. This cutaneous vitamin D3 pathway is unique and, most likely, of considerable relevance for healthy and diseased skin. It is well known that topical application of calcitriol and its analogs can improve hyperproliferative skin diseases. Some studies have convincingly demonstrated that calcitriol and other vitamin D analogs may also be used for the treatment of immunological, inflammatory, and infectious skin diseases. More recently, it has been found that calcitriol or vitamin D analogs have photoprotective effects and can reduce UV-induced deoxyribonucleic acid damage.

Surface morphology and mechanical properties of fibroblasts from scleroderma patients.

Overproduction of extracellular matrix components by fibroblasts plays a key role in the pathogenesis of scleroderma. To investigate whether these functional alterations are accompanied by changes in the mechanical properties and morphology of fibroblast, atomic force microscopy was applied to dermal fibroblasts derived either from scleroderma patients or from healthy donors. No significant morphological differences could be observed among the different cell strains showing long cytoskeleton fibres similar in length and irregularly distributed protrusions on the cell surface. In contrast, significant differences in cellular stiffness of dermal fibroblasts derived from scleroderma lesions were detected. Compared to fibroblasts from healthy donors, diseased cells were characterized by a reduced elastic constant both when the global and local mechanical properties were probed. The altered stiffness of scleroderma fibroblasts may be important in the pathogenesis of the disease as it could lead to the abnormal response of fibroblasts to mechanical stimuli.

Skin physiological parameters confirm the therapeutic efficacy of pimecrolimus cream 1% in patients with mild-to-moderate atopic dermatitis.

In this double-blind, within-patient vehicle-controlled study, patients with mild-to-moderate atopic dermatitis (AD) were treated for 3 weeks twice daily with pimecrolimus cream 1% on one forearm and with vehicle cream on the other forearm. Efficacy of treatment was assessed clinically using the Atopic Dermatitis Severity Index (ADSI), the Investigators Global Assessment (IGA) and the pruritus visual analogue scale. In parallel, blood microcirculation in the skin was measured as an objective parameter for skin inflammation. Skin hydration and transepidermal water loss (TEWL) were monitored as parameter relevant for the barrier function. Treatment with pimecrolimus cream 1% resulted in a quick and marked improvement of signs and symptoms of AD and a significant reduction of microcirculation from 33.90 to 15.55 AU (P < 0.0001). Skin hydration increased continually from 42.86 to 52.69 AU (P = 0.002) and TEWL decreased from 35.30 to 21.50 g/m(2)/h (P = 0.001), indicating restoration of skin barrier. At vehicle-treated sites changes of skin physiological parameters were less pronounced and observed only initially with later plateau or even reversal. At the end of the study, there were significant differences for all measured skin physiological parameters between pimecrolimus cream 1% and vehicle: microcirculation 12.15 AU (P = 0.004), skin hydration 7.12 AU (P = 0.002), TEWL 11.38 g/m(2)/h (P = 0.004). Non-invasive evaluation of microcirculation and barrier functionality thus represent a valuable tool for the objective assessment of treatment response to pimecrolimus cream 1%.

Narrow-band UVB-induced externalization of selected nuclear antigens in keratinocytes: implications for lupus erythematosus pathogenesis.

The aim of this study was to analyze whether sera obtained from patients with lupus erythematosus (LE) react with membrane structures found on keratinocytes irradiated with narrow-band ultraviolet B (NB-UVB). We applied atomic force microscopy (AFM) to visualize cell surface structures expressing nuclear antigens upon apoptosis following NB-UVB irradiation. Immortalized human keratinocytes (HaCaT) were cultured under standard conditions, irradiated with 800 mJ cm(-2) NB-UVB light and imaged by AFM mounted on an inverted optical microscope. It was observed that NB-UVB irradiation provoked significant alterations of the keratinocyte morphology and led to the membrane expression of antigens recognized by anti-La and anti-Ro 60 kDa sera but not by antidouble-strand DNA sera. The presence of La and Ro 60 kDa antigens on keratinocyte surfaces after NB-UVB irradiation was limited mainly to the small bleb-like protrusions found on the keratinocytes by AFM. A closer investigation by AFM also revealed that some structures positively stained with anti-Ro 60 kDa serum were also located submembranously. We hypothesize that the externalization of some nuclear antigens because of NB-UVB exposure might be responsible for exacerbation of skin symptoms in patients suffering from LE.

Effects of the introduction of the German "Praxisgebühr" on outpatient care and treatment of patients with atopic eczema.

BACKGROUND: The introduction of a co-payment of 10 Euros per quarter and physician for adults (the so called "Praxisgebühr") as of January 01, 2004 was a significant health policy measure with unknown effects on medical care of patients with atopic eczema (AE). METHODS: Analysis of an administrative healthcare database from Saxony, Germany. Comparison of outpatient care and treatment of 11,036 patients with AE (6,696 adults) in the year before (2003) and after (2004) the introduction of the co-payment using descriptive statistics and logistic regression modeling. RESULTS: The proportion of adults with AE treated by dermatologists decreased from 52.8 % in 2003 to 42.3 % in the year after the co-payment was introduced. Consultations of general practitioners by adults and health services utilization by children/adolescents did not change. Treatment with topical calcineurin inhibitors in 2003 was an independent predictor for re-consultation in 2004 (p < 0.001). The proportion of adults receiving systemic steroids for AE significantly increased in 2004 (males: 2003: 5.9 %, 2004: 10.3 %, p < 0.001; females: 2003: 5.7 %, 2004: 8.2 %, p < 0.001). The risk for treatment with systemic steroids increased with the decrease in consulting frequency due to AE relative to 2003 (p = 0.006). CONCLUSIONS: After the introduction of the German "Praxisgebühr" fewer patients with AE received dermatological treatment. Simultaneously, an unexpectedly significant increase in the (non evidence-based) treatment of AE with systemic steroids was observed, of which patients with relatively lower consultation frequency after the introduction of the co-payment were particularly affected.

Outpatient care and medical treatment of children and adults with atopic eczema.

BACKGROUND: Despite the high prevalence, morbidity and economic burden of atopic eczema (AE), data on outpatient care of affected patients are missing. METHODS: Utilizing a population-based administrative health care database from Saxony, Germany, this study describes outpatient care and medical treatment of AE by different medical disciplines in 2003 and 2004 by means of a representative sample of 11,555 patients with AE. RESULTS: About 60% of all patients with AE seeking outpatient care were adults. Of the adults 66% and among children 51% consulted a dermatologist at least once within the study period. More than 50% of patients in all age groups received potent topical steroids. Of all patients 8% and 3% received topical pimecrolimus and topical tacrolimus, respectively. More than 10% of patients received systemic steroids, while less than 0.1% was given cyclosporine. The mean annual amount of topical anti-inflammatory treatment per patient was about 40 grams. CONCLUSIONS: Unexpectedly high proportions of patients with AE received potent topical and systemic steroids. The average total amount of prescribed medications was low. This study suggests insufficient care and medical treatment of patients with AE in routine practice.

Use of high-dose immunoglobulins in dermatology.

The treatment of severe autoimmune skin diseases and of toxic epidermal necrolysis (ICD: L51.2) with high-dose intravenous immunoglobulins (IVIg) is an established therapeutic procedure in dermatology. As IVIg are usually only administered in rare autoimmune diseases or in particularly severe disease courses, use of immunoglobulins in dermatology is commonly not based on experience from controlled and randomized studies typically demanded by evidence-based medicine. In face of the rarity of indications for IVIg it is improbable that such studies will be performed in the foreseeable future. Further, as the high costs of IVIg treatment limits its use as first-line therapy, no clear guidelines exist yet on IVIg use in skin diseases. The present recommendation is based on a consensus of the Working Group on European Guidelines of the EDF (European Dermatology Forum) and the EADV (European Association of Dermato-Venereology) and should provide aid in decision making for the use of IVIg in treating dermatologic diseases

Sporotrichoid atypical cutaneous infection caused by Mycobacterium marinum.

A case of a sporotrichoid cutaneous infection caused by Mycobacterium marinum is reported. A 53- year-old male patient presented with red, partly purulent nodular lesions on the back of his left hand, forearm, and upper medial arm that had developed consecutively during the past 4 weeks. A mycobacterial infection with M. marinum was confirmed by molecular methods in a lesional skin biopsy. The patient was treated systemically with rifampicin (750 mg/day) and clarithromycine (1,000 mg/day), and topically with sulmycin (gentamicin sulfate). After 12 weeks of treatment the nodules regressed, leaving behind erythematous patches. M. marinum is a waterborne mycobacterium that commonly infects fish and amphibians worldwide. Transmissions to humans occur occasionally, in most cases as a granulomatous infection localized to the skin, typically following minor trauma to the hands. For this reason, infections are especially common among aquarium keepers.

A randomized, double-blind, vehicle-controlled study of 1% pimecrolimus cream in adult patients with perioral dermatitis.

BACKGROUND: Perioral dermatitis (POD) is a common dermatosis without standard therapy. OBJECTIVE: We sought to evaluate pimecrolimus cream 1% in POD. METHODS: We conducted a multicenter, randomized, double-blind, parallel-group study in adult patients with POD treated twice daily with pimecrolimus cream 1% or vehicle until clearance for up to 4 weeks. Follow-up took place 4 and 8 weeks after treatment. RESULTS: Patients treated with pimecrolimus had an average POD Severity Index score of 2.6 compared with 3.5 for patients treated with vehicle. Both groups had baseline scores of 5.2. The between-group difference was 0.9 (95% confidence level 0.4, 1.4, P = .0011). Patients with history of topical corticosteroids benefited most. Pimecrolimus-treated patients reported greater improvement in quality of life. There were no group differences regarding safety. LIMITATIONS: Pimecrolimus vehicle is not a true placebo. CONCLUSIONS: Pimecrolimus rapidly improves clinical symptoms and quality of life of patients with POD, being most effective in corticosteroid-induced POD.

Treatment following an evidence-based algorithm versus individualised symptom-oriented treatment for atopic eczema. A randomised controlled trial.

BACKGROUND: Evidence-based treatment algorithms, successfully established for asthma, are missing for atopic eczema (AE). OBJECTIVES: To investigate whether treatment according to an evidence-based algorithm is an effective and applicable concept for the management of AE. METHODS: Based on a systematic literature review, we developed an evidence-based severity-score-oriented treatment algorithm for AE and compared its effectiveness to that of an individualised symptom-oriented treatment (individual therapy) in a randomised controlled trial. Sixty-three participants were randomised to algorithm (n = 32) or individual therapy (n = 31) and treated accordingly for 12 months. Study end points included difference between baseline SCORAD and mean SCORAD under treatment (primary end point), quality of life and treatment utilisation. Analysis was by intention to treat (registration: Clinical Trials.gov:NCT00148746). RESULTS: No statistically significant differences in clinical or subjective response were observed between groups. Treatment following the algorithm and individual treatment both effectively controlled AE. Mean SCORAD reductions were 47% (95% confidence interval, CI = 38-55; algorithm) and 42% (95% CI = 29-54; individual). Clinical response was paralleled by improved quality of life in both groups. Physicians adhered to the algorithm option in 93% of their treatment decisions. CONCLUSION: Treatment following an evidence-based algorithm is an effective and applicable concept for the management of AE but does not show clear advantages compared to individualised treatment in a dermatological setting.

Determinants of treatment goals and satisfaction of patients with atopic eczema.

BACKGROUND: Despite the high prevalence, morbidity, and economic burden of atopic eczema,data on patients' treatment goals and treatment satisfaction are missing. METHODS: A cross-sectional study was performed with standardized survey of all adult patients treated between 01/2004 and 03/2006 in the atopic eczema outpatient unit of the Department of Dermatology, TU Dresden, Germany. Assessed were disease-specific characteristics (age at onset, treatment, disease severity, quality of life impact), and aspects of health services research (treatment goals, patients' self-treatment competence, treatment satisfaction). Treatment satisfaction was assessed on a 100 mm visual analog scale with 0 reflecting "very dissatisfied", and 100 "highly satisfied". Based on an a priori model we analyzed the impact of sociodemographic and disease-specific factors on treatment satisfaction (primary endpoint) using multivariate regression modeling. RESULTS: Of the 267 patients asked to participate, 226 (85 %) agreed. Mean treatment satisfaction was 59.6 (+/- 30.8). Age and sex were not significantly associated with treatment satisfaction. Professional competence of the treating physician was the most important determinant of treatment satisfaction, followed by physician's sensitivity, disease severity, education about the condition, and patient's competence to adjust treatment to disease activity. Reduction of itching and burning, as well as complete clearing of all skin changes, were the most important treatment goals. CONCLUSIONS: For adult patients with atopic eczema the impression of professional competence of the treating physician has highest priority. Disease severity only explains 20 % of the total variance of treatment satisfaction. Comprehensive information about the condition and reinforcement of patients' treatment competence should be better integrated in clinical practice.