[Initially undetected de novo psoriasis triggered by nivolumab for metastatic base of the tongue carcinoma]. / Initial nicht erkannte De-novo-Psoriasis getriggert durch Nivolumab bei metastasiertem Zungengrundkarzinom.

Nivolumab is a monoclonal antibody that binds to the PD-1 receptor on T cells and inhibits the interaction with the PD-L1 and PD-L2 ligands on cancer cells. Thus, nivolumab has immunostimulatory properties. The known side effects of this therapy include fatigue, skin rash, dysfunction of the thyroid gland and colitis, which are explained by the immunoregulatory mechanisms of the drug. Here we report on the case of a 58-year-old man with metastatic base of tongue carcinoma who developed de novo psoriasis triggered by nivolumab. The patient was treated for months with the diagnosis of a generalized mycosis. This case highlights the importance of vigilance for unexpected cutaneous side effects during immune stimulating therapy with checkpoint inhibitors.

[Partial response of solar urticaria to omalizumab therapy]. / Partielles Ansprechen einer Lichturtikaria auf Omalizumab.

The treatment of solar urticaria is regarded as difficult. In some cases good responses to the anti-IgE antibody omalizumab (Xolair®), approved for treatment of chronic spontaneous urticaria, have been reported. We report on a 50-year-old Caucasian woman who for the last 5 years has developed localized itching and stinging erythemas following exposure to sunlight accompanied sometimes by anaphylactic reactions. Oral antihistamines in three- to four-fold doses and a topical sun screen had been only partially effective in long-term use. Positive immediate-type reactions with whealing appeared in phototesting with low doses of UVB and UVA. Three weeks after s. c. injection of 300 mg omalizumab, the minimal urticarial dose (MUD) for UVB was increased at least 20-fold (from <0.001 to 0.02 J/cm2) and for UVA four-fold (from 0.1 to 0.4 J/cm2) and the patient reported no itching at the test area. On the other hand, MUD for UVA1 remained unchanged (5.0 J/cm2). The weekly urticarial activity score (UAS7) was reduced from 30 points before omalizumab administration to 14 points in weeks two and three. Overall, a partial response of solar urticaria to omalizumab therapy could be observed in the present case.

[Phlebology in German departments of dermatology. An analysis on behalf of the German Society of Phlebology]. / Phlebologie an deutschen Hautkliniken. Eine Bestandsaufnahme im Auftrag der Deutschen Gesellschaft für Phlebologie.

BACKGROUND: Phlebologic diseases have become extremely common and have major socio-economic impact. However, the percentage of dermatologists working in phlebology appears to be decreasing according to the data of the German Society of Phlebology (DGP). METHODS: To investigate the reasons for this development, we--on behalf of the DGP--sent a questionnaire to 120 German Departments of Dermatology in autumn 2012. RESULTS: In 76 returned questionnaires, the number of physicians with additional fellowship training in phlebology averaged 1.5; the average number of those who fulfill the criteria for training fellows in phlebology was 0.9. In 71.1 % of the departments there was a phlebologist. A special phlebologic outpatient clinic existed in 73.7 % of the departments. Sonography with Doppler (89.5 %) and duplex (86.8 %) was used as the most frequent diagnostic tool. For therapy, compression (94.7 %), sclerotherapy (liquid 78.9 %, foam 63.2 %, catheter 18.4 %), endoluminal thermic procedures (radio wave 28.9 %, laser 17.1 %) and surgery (especially crossectomy and stripping 67.1 %, phlebectomy of tributaries 75 %) were used. The average number of treatments was very heterogenous in the different departments. CONCLUSIONS: Phlebology definitely plays an important role in dermatology. Most departments fulfill the formal criteria for the license to conduct advanced training in phlebology. A wide spectrum of phlebological diagnostic and therapeutic procedures is available.

[Long term treatment of psoriasis with TNF-alpha antagonists. Occurrence of malignant melanoma]. / Prolongierte Psoriasistherapie mit TNF-alpha-Antagonisten. Entwicklung des malignen Melanoms.

A 51-year-old white man developed de novo a cutaneous malignant melanoma (Stage Ia) after a 30-month treatment period with TNF-alpha-antagonists, consecutively using infliximab, adalimumab and etanercept because of a recalcitrant moderate to severe plaque psoriasis. The patient previously had been treated fumarates for 4 years, cyclosporine A for 2 months and methotrexate for 5 weeks. He also received cycles of cream PUVA and UVB before and then between systemic medications. A possible causal connection between development of melanoma and immunosuppressive treatment is discussed in the light of recent literature. The termination of TNF-alpha-antagonist therapy following development of melanoma is recommended.

Photoallergic contact dermatitis from topical diclofenac in Solaraze gel.

Solaraze gel (Shire Deutschland GmbH & Co. KG, Cologne, Germany) containing 3% diclofenac has been licensed in 2001 as a topical treatment for actinic keratoses. It is commonly used in dermatological practice. Undesirable effects are believed to be rare but include pruritus, paresthesia and application-site reactions (dry skin, rash, erythema, contact dermatitis and vesicobullous eruptions). Recently, a few cases of contact dermatitis due to three different allergens including diclofenac have been reported (1,2).

[Granuloma annulare]. / Granuloma anulare.

Granuloma annulare is a benign self-limiting disease of unknown origin, characterized by dermal papules tending to form annular shapes. It belongs to the granulomatous inflammatory skin diseases characterized by histomorphologically detectable granulomas. In addition to localized variants, generalized or disseminated variants also exist. The disease is often asymptomatic and does not require therapy in every case. Established therapies for localized forms of granuloma annulare are glucocorticosteroids, cream PUVA and cryosurgery. Antimalarials, antileprotics, retinoids, fumarates, UVA1 phototherapy and photochemotherapy are of value in disseminated cases. Recent case reports demonstrate the successful treatment of granuloma annulare with topical calcineurin antagonists or imiquimod and with the systemic administration of biologicals.

[Sarcoidal allergic contact dermatitis due to palladium following ear piercing]. / Sarkoidale allergische Kontaktdermatitis auf Palladium nach Ohrpiercing.

Granulomatous tissue reactions due to jewelry made of gold, silver, nickel and palladium are rare but nevertheless have been known for a long time. A female patient developed nodular infiltrates after having been pierced with ear stickers containing palladium. A contact allergic reaction could be demonstrated as the underlying cause by inducing similar histological changes following patch testing with palladium.

[Sporotrichosis as the cause of a leg ulcer]. / Sporotrichose als Ursache eines Ulcus cruris.

A young man presented at Lugala Lutheran Hospital (Tanzania) with an ulcer on his lower leg which had developed over the past 9 weeks. Subcutaneous nodules and plaques were found all the way up to his groin; this observation prompted a strong suspicion that the patient had the lymphocutaneous form of sporotrichosis which had not been seen at this hospital before. The diagnosis was confirmed histopathologically. The patient was then treated with saturated solution of potassium iodide.

Clinical experience with topical calcitriol (1,25-dihydroxyvitamin D3) in psoriasis.

The use of vitamin D analogues for the treatment of chronic plaque psoriasis is well documented. Of importance now is their comparability and compatibility with other established treatments for psoriasis. This paper reviews five studies with calcitriol 3 microg g(-1) ointment (Silkis ointment, Galderma Laboratories). Calcitriol applied twice daily was found to be as effective as short-contact dithranol in terms of global improvement and PASI scores. However, patients favoured calcitriol over dithranol when both quality of life and treatment acceptability were assessed. Two studies provide evidence of the benefit of combining calcitriol with other antipsoriatic therapies. Combination with ultraviolet (UV) B phototherapy proved as effective as UVB alone over an 8-week period; however, the combination had a radiation dose-sparing effect, thus reducing the risk of adverse events. Likewise, calcitriol combined with betamethasone valerate (each applied separately, once daily) was as efficacious as twice-daily betamethasone, thereby achieving a corticosteroid-sparing effect. Finally, two studies confirm that calcitriol 3 microg g(-1) ointment can be used safely in patients with psoriasis of the head and confirm the high level of clinical efficacy achieved with this compound.

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.

[Therapy of lymphomatoid papulosis with balneo-PUVA-photochemotherapy]]. / Therapie der lymphomatoiden Papulose mit Bade-PUVA-(Balneo-) Photochemotherapie.

Lymphomatoid papulosis is a rare lymphoproliferative disorder of the skin. The standard therapeutic regimen is systemic (oral) photochemotherapy (PUVA). We examined the efficacy of PUVA-bath photochemotherapy in a patient requiring heart transplantation because of idiopathic dilatated cardiomyopathy and a relative contraindication against systemic 8-methoxypsoralen. The 42-years old male patient had suffered for 15 years with itching papules and plaques which clinically, immunohistochemically and molecular biologically were diagnosed as lymphomatoid papulosis. PUVA-bath photochemotherapy with 8-MOP was initiated. After 29 treatments the plaques disappeared completely. After 44 sessions (cumulative UV-A dose 206 J/cm2) the patient's skin almost was clear. PUVA-bath photochemotherapy proved to be a therapeutic alternative to systemic PUVA-treatment in this case of lymphomatoid papulosis.

[Pruritus of dark skin in hookworm infection]. / Pruritus auf dunkler Haut bei Hakenwurminfektion.

Using the example of a young man from Senegal we would like to point out that in cases of pruritus without an underlying skin disease an intestinal parasitosis might be the cause of the pruritus should the patient come from the tropics. However, it is important to use concentration methods when examining stool specimens so as to be able to diagnose the parasitosis. The causal connection between a pruritus and an intestinal parasitosis needs to be confirmed by a successful treatment.

Detection of HHV-8 DNA in a German patient with classical Kaposi's sarcoma may allow an estimation of the incubation period.

DNA of HHV-8 (Kaposi's sarcoma-associated Herpes virus [KSHV]) was detected in a biopsy of a Kaposi's sarcoma in an elderly male patient from Saxony (East Germany). The diagnosis of classical Kaposi's sarcoma was first made in 1986. During World War II, the patient had been on active service on the Greek Islands of Crete and Rhodes only, he did not travel outside East Germany after the war. It is assumed that the patient was infected during his stay on the islands of Crete or Rhodes, where classical Kaposi's sarcoma is endemic. If so, the incubation period of classical Kaposi's sarcoma could be as long as 40 years.

Fotemustine and interferon alpha2b in metastatic malignant melanoma.

The efficacy of treatment with fotemustine and interferon (IFN) alpha was evaluated in metastatic melanoma. A group of 50 patients with metastatic malignant melanoma were treated with a combination of IFNalpha2b and the nitrosourea fotemustine. The patients received 10 MU IFN three times weekly for 3 weeks and fotemustine at a dose of 100 mg/m2 on days 8, 15 and 22. After a 5-week rest period, patients with stabilized or responding disease received a maintenance therapy consisting of 10 MU IFN three times a week for 1 week followed by administration of fotemustine (100 mg/m2) on day 8. This cycle was repeated every 4 weeks until progression occurred. If there was complete remission (CR), treatment was stopped after an additional three cycles. Toxicity and clinical response were scored according to WHO criteria. Objective response was seen in 14 patients (28%; 95% confidence interval 15.6%-40.4%) with four CR and ten partial responses (PR). The median duration of CR was 73 weeks, that of PR 26 weeks. Toxicity was acceptable, enabling treatment on an outpatient basis. The combination of fotemustine with IFNalpha is effective and well tolerated, but there is no evident advantage over fotemustine monotherapy in the treatment of metastatic melanoma.

[Herpes gestationis--oral corticosteroids cannot be avoided]. / Herpes gestationis--an internen Kortikosteroiden führt kein Weg vorbei.

An immunpathologically proven gestational herpes case is presented. Herpes gestationis may begin at any stage of pregnancy but it is usually seen during the second trimester. As a rule oral prednisolone therapy is required. We report on a patient who initially insisted on local therapy only. However this local treatment with steroids proved to be insufficient.

[Responders and nonresponders of ultraviolet A-1 therapy of acute exacerbated atopic eczema]. / Responder und Nonresponder bei der UV-A-1-Therapie des akut exazerbierten atopischen Ekzems.

Of 46 patients with severe atopic eczema treated with UVA-1, 14 were evaluated as non-responders and 32 as responders. Responding patients significantly had (p < 0.05) more severe skin involvement before onset of treatment (clinical severity score SCORAD 62.7 +/- 12.4 points) compared to non-responders (53.0 +/- 10.6 points). Serum levels of total IgE, ECP and sIL2R before treatment did not show any significant differences between the two groups. The data confirm the efficacy of UVA-1 treatment in severe cases of atopic eczema.

[Cutaneous reactions in Crohn disease. Vasculitis in various skin segments]. / Kutane Reaktionen bei Morbus Crohn. Vaskulitiden verschiedener Etagen des Hautorgans.

Two young female patients presented with recurrent erythema and Henoch-Schönlein purpura respectively. In both cases clinical, histological and radiological showed relatively mild, but previously undiagnosed Crohn's disease as a trigger. We describe the treatment of the underlying disease and the symptomatic treatment of skin lesions. Categories of specific and unspecific skin lesions associated with Crohn's disease, as described in the literature, are presented. Vasculitic changes of the deep versus the superficial dermal plexus are discussed.