[Healing times and the need for hospitalization for leg ulcers of different etiologies]. / Unterschiedliche Abheilungsdauer und Häufigkeit der Hospitalisation bei Ulcus cruris verschiedener Ursachen.

BACKGROUND: Leg ulcers are a symptom of a heterogeneous group of diseases. Their treatment causes substantial costs due to the long healing times and extensive wound care measures. There is a paucity of information about healing times and the necessity of hospital treatment for leg ulcers of different etiologies. MATERIALS AND METHODS: In this retrospective study, healing times and the frequency of in-hospital treatment of 355 patients with leg ulcers attending a wound care clinic of a university hospital were examined. RESULTS: The proportion of healed ulcers was 32.0% after 3 months and 54.3% after 6 months with an average treatment duration of 6.1 months for all ulcers. This proportion of healed ulcers was higher for venous ulcers with 45.5% after 3 months and 63.0% after 6 months, whereas only 30.0% of mixed arterial-venous ulcers and 35.0% of hypertensive ischemic leg ulcers (HYTILU) were healed after 6 months. Of the latter group, 71% of patients were hospitalized at least once during the observation period as compared to 47% of patients with a venous ulcer. The duration of the hospital stay was longer for mixed ulcers and HYTILU with an average of 30 days vs. 23 days for venous ulcers. CONCLUSIONS: These data indicate that the healing times of ulcers of different etiologies differ substantially and that especially ulcers with arteriosclerosis as a causative factor have longer healing times. The fact that they require in-hospital treatment more frequently and for longer periods has significant socio-economic consequences.

[Extracorporeal shock wave therapy as a treatment of a non-healing chronic leg ulcer]. / Extrakorporale Stoßwellentherapie eines komplizierten chronischen Ulcus cruris venosum.

Extracorporeal shock waves are defined as a sequence of sonic pulses characterized by high peak pressure over 100 MPa, fast pressure rise, and short lifecycle. In the 1980s extracorporeal shock wave lithotripsy (ESWL) was first used for the treatment of urolithiasis. Orthopedic surgeons use extracorporeal shock wave therapy (ESWT) to treat non-union fractures, tendinopathies and osteonecrosis. The first application of ESWT in dermatology was for recalcitrant skin ulcers. Several studies in the last 10 years have shown that ESWT promotes angiogenesis, increases perfusion in ischemic tissues, decreases inflammation, enhances cell differentiation and accelerates wound healing. We successfully treated a non-healing chronic venous leg ulcer with ESWT. Furthermore we observed an improvement of the lymphatic drainage after application of ESWT. We are confident that ESWT is a non-invasive, practical, safe and efficient physical treatment modality for recalcitrant leg ulcers.

Post-surgical scalp wounds with exposed bone treated with a plant-derived wound therapeutic.

OBJECTIVE: To evaluate the efficacy of a plant-derived wound dressing, a mixture of hypericum oil (Hypericum perforatum) and neem oil (Azadirachta indica), in scalp wounds with exposed bone. METHOD: A retrospective review was conducted of all patients presenting with scalp wounds with exposed bone following the excision of skin tumours and treated with a plant-derived wound dressings (1 Primary Wound Dressing; Phytoceuticals AG), from January to July 2011. Time to healing, wound size, area of exposed bone, ease of handling, pain and complications were evaluated. RESULTS: Nine consecutive patients were analysed retrospectively. The patients' mean age was 81.2 ± 8.5 years (63-90 years), with a mean wound size of 13.2 ± 6.8cm(2) (0.4-22.6cm(2)) and 6.8 ± 6.5cm(2) (0.3-20.7cm(2)) of exposed bone. The time to complete healing by secondary intention was 4-20 weeks. A rapid induction of granulation tissue was observed, which covered the entire exposed bone surface in six out of nine cases (67%) after 4 weeks, and showed a reduction in the mean area of exposed bone of 95%. Dressing change was easy and without pain and there were no complications. CONCLUSION: This retrospective, non-controlled analysis suggests that ONE is a very simple to use, safe and potentially effective therapy for the treatment of scalp wounds with exposed bone. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflict of interest to declare.

Irradiation with water-filtered infrared A plus visible light improves cutaneous scleroderma lesions in a series of cases.

BACKGROUND: Cutaneous scleroderma is a chronic inflammatory disease of the dermal and subcutaneous connective tissue leading to sclerosis. Sclerosis of the skin can lead to dysmorphism, contractures and restrictions of movement. OBJECTIVE: The purpose of the study was to evaluate sclerosis in cutaneous scleroderma patients and to determine the efficacy of water-filtered infrared A plus visible light treatment, wIRA(+VIS), in 10 patients. METHODS: Hardness of the normal and diseased skin was measured by durometry in 10 controls and 8 patients. Moreover, circumscribed scleroderma (CS) was treated with wIRA(+VIS) irradiations in 10 patients who had not responded to conventional therapies. RESULTS: wIRA(+VIS) therapy led to a marked improvement, persistent even during long-term follow-up, in 7 out of 10 patients with CS. Of the other patients, 1 showed decreased sclerosis and disease activity and developed a worsening after cessation of therapy. In 2 further patients, where previous UVA1 treatment had failed to reduce disease activity, wIRA(+VIS) produced a slight decrease in sclerosis, but disease activity was still present. CONCLUSION: wIRA(+VIS) appears to be effective in the treatment of CS. Durometry proved to be helpful in assessing the degree of sclerosis and in documenting the response to therapy in these patients.

Recurrent non-melanoma skin cancer: remission of field cancerization after conversion from calcineurin inhibitor- to proliferation signal inhibitor-based immunosuppression in a cardiac transplant recipient.

Non-melanoma skin cancers (NMSCs) are the most common malignancies after solid organ transplantation. Their incidence increases with time after transplantation. Calcineurin-inhibitors (CNIs) and azathioprine are known as skin neoplasia-initiating and -enhancing immunosuppressants. In contrast, increasing clinical experience suggests a relevant antiproliferative effect of mammalian target of rapamycin inhibitors, also named proliferation signal inhibitors (PSIs). We report the case of a cardiac allograft recipient with an impressive and consolidated reduction of recurrent NMSC, observed after conversion from CNI-therapy to a PSI-based protocol.

[Acrodermatitis enteropathica-like skin lesions due to Crohn's disease-associated zinc deficiency]. / Acrodermatitis-enteropathica-ähnliche Hautveränderungen bei Morbus-Crohn-bedingtem Zinkmangel.

We report a case of acrodermatitis enteropathica-like skin eruptions presenting with alopecia, perlèche, glossitis, and genital erosions as well as multifocal eczematoid, psoriasiform, and bullous skin lesions due to zinc deficiency in Crohn's disease.

Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study.

BACKGROUND: Bullous pemphigoid (BP), pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are autoimmune bullous diseases characterized by the presence of tissue-bound and circulating autoantibodies directed against disease-specific target antigens of the skin. Although rare, these diseases run a chronic course and are associated with significant morbidity and mortality. There are few prospective data on gender- and age-specific incidence of these disorders. OBJECTIVES: Our aims were: (i) to evaluate the incidence of BP and PV/PF in Swiss patients, as the primary endpoint; and (ii) to assess the profile of the patients, particularly for comorbidities and medications, as the secondary endpoint. METHODS: The protocol of the study was distributed to all dermatology clinics, immunopathology laboratories and practising dermatologists in Switzerland. All newly diagnosed cases of BP and pemphigus occurring between 1 January 2001 and 31 December 2002 were collected. In total, 168 patients (73 men and 95 women) with these autoimmune bullous diseases, with a diagnosis based on clinical, histological and immunopathological criteria, were finally included. RESULTS: BP showed a mean incidence of 12.1 new cases per million people per year. Its incidence increased significantly after the age of 70 years, with a maximal value after the age of 90 years. The female/male ratio was 1.3. The age-standardized incidence of BP using the European population as reference was, however, lower, with 6.8 new cases per million people per year, reflecting the ageing of the Swiss population. In contrast, both PV and PF were less frequent. Their combined mean incidence was 0.6 new cases per million people per year. CONCLUSIONS; This is the first comprehensive prospective study analysing the incidence of autoimmune bullous diseases in an entire country. Our patient cohort is large enough to establish BP as the most frequent autoimmune bullous disease. Its incidence rate appears higher compared with other previous studies, most likely because of the demographic characteristics of the Swiss population. Nevertheless, based on its potentially misleading presentations, it is possible that the real incidence rate of BP is still underestimated. Based on its significant incidence in the elderly population, BP should deserve more public health concern.

Grover's disease induced by cetuximab.

A 71-year-old man exhibited an acute acneiform rash affecting the face and the upper trunk about 2 weeks after starting cetuximab, an epidermal growth factor (EGF) receptor antagonist treatment for metastatic colon cancer. The skin eruption faded after stopping cetuximab and applying topical corticosteroids. The reexposure to cetuximab 3 weeks later provoked a more extended relapse of the skin rash, which then clinically and histologically corresponded to transient acantholytic dermatosis . While the acneiform cutaneous side effects of the EGF receptor antagonists are interpreted as a result of the direct interference with pilosebaceous follicle homeostasis, in this case an acrosyringium-related pathogenesis might be postulated. Applying topical corticosteroids and emollients, the cetuximab therapy could be pursued.

[Pemphigoid nodularis triggered by hypereosinophilic syndrome?]. / Pemphigoid nodularis ausgehend von einem Hypereosinophilie-Syndrom?

Pemphigoid nodularis (PN) is a rare clinical variant of pemphigoid characterized by prurigo-like skin lesions and antibodies against BP180 and BP230 characteristic for bullous pemphigoid. Interestingly, most PN patients never develop blisters. This condition is often resistant to treatment. We describe a female patient who was initially diagnosed with hypereosinophilic dermatitis. Later on, in the presence of eosinophilic infiltrations in the gastrointestinal tract, obstructive ventilation disorder, pericardial and pleural effusions, the diagnosis of idiopathic hypereosinophilic syndrome was made. During the following 3 years she developed recalcitrant PN.

[Autologous cultured skin substitutes]. / Autologer kultivierter Hautersatz.

Progress in cell culture and biomaterial technologies has resulted in commercially available autologous and allogeneic skin substitutes that are composed of keratinocytes and/or fibroblats, in part combined with allogeneic (fibrin) or xenogeneic (collagen, hyaluronan) matrix substances. So far, clinical testing of tissue-engineered products focused on chronic wounds (vascular leg ulcers, diabetic foot ulcers); another major indication, however, is large acute skin defects (burns). During the last decade, partly-controlled clinical trials have been performed with several cultured skin substitutes, studying primarily vascular leg ulcers; a few of these products have been approved for defined indications by the regulatory authorities of various countries. To fulfill regulatory requirements and be eligible for reimbursement, safety as well as cost-effectiveness have to be documented for these novel therapies in contrast to established methods for clearly defined clinical settings; this, in combination with restricted health care resources, is actually hampering the clinical breakthrough of tissue engineering in the treatment of skin wounds, despite undiminished research activities.

Progressive respiratory failure in paraneoplastic pemphigus associated with chronic lymphocytic leukemia.

A 70-year-old Caucasian man with chronic lymphocytic leukemia suffered from widespread, histologically proven cutaneous lichen planus responding to topical corticosteroids. 2 years later, he presented with painful erosive stomatitis and increasing dyspnea. Histology, direct and indirect immunofluorescence were diagnostic for paraneoplastic pemphigus. A full diagnostic workup could not disclose the cause of the progressive respiratory insufficiency. Despite aggressive treatment of the lymphocytic leukemia and the paraneoplastic pemphigus, the patient died 3 months after diagnosis. Paraneoplastic pemphigus may lead to pulmonary failure which is refractory to treatment and has a fatal outcome.

Successful treatment of chemotherapy-refractory Sézary syndrome with alemtuzumab (Campath-1H).

INTRODUCTION: Sézary syndrome (SS) is a cutaneous T-cell lymphoma characterized by erythroderma, lymphadenopathy and circulating atypical T cells. Median survival after diagnosis is 10 yr, with chemotherapy resistance being a major problem in advanced disease. Alemtuzumab (Campath-1H) is a monoclonal antibody directed against the lymphocytic antigen CD52, expressed on B- and T-cells. Alemtuzumab is approved for relapsing chronic B-cell leukemia and seems to be active also in T-cell lymphomas such as T-cell prolymphocytic lymphoma, SS and mycosis fungiodes. CASE HISTORY: A 32-yr-old male patient presented with advanced stage, extensively pretreated SS with heavily itching erythroderma, peripheral lymphadenopathy, circulating Sézary cells and bone marrow infiltration. The disease had not responded to PUVA/interferon-alpha and progressed on chemotherapy with CHOP, 2-CDA, vinorelbine, etoposide and liposomal doxorubicin. Following treatment with alemtuzumab (30 mg i.v. three times per week for 10 wk), itching resolved rapidly and an almost complete remission was achieved within 3 months after starting this treatment. At 12-month follow up, no disease progression was present. CONCLUSION: In accordance with previous data, this single case underlines the potent activity of alemtuzumab in advanced, chemotherapy-refractory SS.

Elevated basal serum tryptase and hymenoptera venom allergy: relation to severity of sting reactions and to safety and efficacy of venom immunotherapy.

BACKGROUND: Mastocytosis and/or elevated basal serum tryptase may be associated with severe anaphylaxis. OBJECTIVE: To analyse Hymenoptera venom-allergic patients with regard to basal tryptase in relation to the severity of sting reactions and the safety and efficacy of venom immunotherapy. METHODS: Basal serum tryptase was measured in 259 Hymenoptera venom-allergic patients (158 honey bee, 101 Vespula). In 161 of these (104 honey bee, 57 Vespula), a sting challenge was performed during venom immunotherapy. RESULTS: Nineteen of the 259 patients had an elevated basal serum tryptase. Evidence of cutaneous mastocytosis as documented by skin biopsy was present in 3 of 16 patients (18.8%). There was a clear correlation of basal serum tryptase to the grade of the initial allergic reaction (P<0.0005). Forty-one of the 161 sting challenged patients reacted to the challenge, 34 to a bee sting and 7 to a Vespula sting. Thereof, 10 had an elevated basal serum tryptase, i.e. 1 (2.9%) of the reacting and 2 (2.9%) of the non-reacting bee venom (BV) allergic individuals, as compared to 3 (42.9%) of the reacting and 4 (8%) of the non-reacting Vespula venom-allergic patients. Thus, there was a significant association between a reaction to the sting challenge and an elevated basal serum tryptase in Vespula (chi2=6.926, P<0.01), but not in BV-allergic patients. Systemic allergic side-effects to venom immunotherapy were observed in 13.9% of patients with normal and in 10% of those with elevated basal serum tryptase. CONCLUSIONS: An elevated basal serum tryptase as well as mastocytosis are risk factors for severe or even fatal shock reactions to Hymenoptera stings. Although the efficacy of venom immunotherapy in these patients is slightly reduced, most of them can be treated successfully. Based on currently available data, lifelong treatment has to be discussed in this situation.

Monocyte selectivity and tissue localization suggests a role for breast and kidney-expressed chemokine (BRAK) in macrophage development.

Although numerous chemokines act on monocytes, none of them is specific for these cells. Here, we show that breast and kidney-expressed chemokine (BRAK) is a highly selective monocyte chemoattractant. Migration efficacy and Bordetella pertussis toxin-sensitive Ca(2+) mobilization responses to BRAK were strongly enhanced after treatment of monocytes with the cyclic AMP-elevating agents prostaglandin E(2) and forskolin. BRAK is the first monocyte-selective chemokine, as other types of blood leukocytes or monocyte-derived dendritic cells and macrophages did not respond. Expression in normal skin keratinocytes and dermal fibroblasts as well as lamina propria cells in normal intestinal tissues suggests a homeostatic rather than an inflammatory function for this chemokine. In addition, macrophages were frequently found to colocalize with BRAK-producing fibroblasts. We propose that BRAK is involved in the generation of tissue macrophages by recruiting extravasated precursors to fibroblasts, which are known to secrete essential cytokines for macrophage development.