Improvement of early recognition of lentigo maligna using dermatoscopy.

BACKGROUND: The clinical differentiation between lentigo senilis/initial seborrheic keratosis and lentigo maligna on the face can be difficult. OBJECTIVE: Our purpose was to determine whether dermatoscopy (eg, skin surface microscopy at 10x magnification) can reliably differentiate between these entities. METHODS: Dermatoscopic slides of 87 consecutive patients presenting 37 malignant and 50 benign pigmented skin lesions on the face were analyzed with the use of 27 dermatoscopic criteria. RESULTS: Univariate analysis selected two criteria specific for lentigo maligna: asymmetric pigmented follicular openings and dark (brown or black) rhomboidal structures. Location-specific importance in relation to facial location was attributed to the color "slate-gray, " especially in combination with structures such as dots, globules, streaks, and homogeneous areas. Multivariate analysis (logistic regression model) revealed the 4 most important features to be asymmetric pigmented follicular openings, dark rhomboidal structures, slate-gray globules, and slate-gray dots with a sensitivity of 89% and a specificity of 96%. CONCLUSION: Three conclusions can be drawn from our study: With a set of 4 dermatoscopic features, early lentigo maligna can be detected with high accuracy; dermatoscopic features on the face differ from criteria used in other locations; and our progression growth model for lentigo maligna delineates the different steps of malignant growth in lentigo maligna.

Epidermodysplasia verruciformis treated using topical 5-aminolaevulinic acid photodynamic therapy.

We describe a 65-year-old woman who had had wart-like lesions on the hands, lower arms and forehead for about 45 years. She had already had several basal cell carcinomas excised. Histological study, electron microscopy and in situ hybridization [human papilloma virus (HPV)-types 5/8/12/14/19-23/25/36] of skin biopsies confirmed a diagnosis of epidermodysplasia verruciformis (EV). Photodynamic therapy (PDT) was performed using a 20% 5-aminolaevulinic acid ointment applied for 6 h to the lesions and irradiating using an incoherent light source (lambda = 580-740 nm, 160 mW/cm2, 160 J/cm2). Following PDT, blistering and crusting of the lesions occurred, but these healed completely within 2-3 weeks without scarring, and the cosmetic result was excellent. Six months after PDT a skin biopsy was taken. In situ hybridization was positive for HPV type 8 in skin which was clinically and histologically normal. Twelve months after PDT a few lesions had recurred on the hands. Although permanent cure of EV cannot be achieved by any therapy at present and single lesions continue to appear in this patient, topical PDT might result in better control of HPV-induced lesions.

[Laser and cryotherapy of hemangioma in infants in a direct comparison]. / Laser- und Kryotherapie der Säuglingshämangiome im direkten Vergleich.

In our comparative study, 40 infants ranging in age from 1 week to six months, were treated for their hemangiomas. Cryosurgery was performed on 20 hemangiomas whereas the others were treated with flash lamp-pumped pulsed dye laser (FPDL). In 72% of initial macular, flat-topped, superficial hemangiomas a predominant (> 75%) or complete regression could be achieved. In 68% of cutaneous-exophytic lesions, both therapeutical modalities showed a sufficient regression (> 50%) or marked growth inhibition after two sessions with further improvement after additional treatment. Cutaneous hemangiomas and the cutaneous part of combined hemangiomas responded well to both therapies whereas subcutaneous hemangiomas were predominantly influenced by cryotherapy. Our data emphasise the efficiency of early treatment of childhood hemangiomas. Since FPDL therapy is easy to perform, less time-consuming and reduces post-therapeutic exsudation, this treatment is preferable in initial macular, flat-topped and superficial lesions while cryotherapy is considered to be superior in lesions with marked elevated and/or subcutaneous parts.

[On the color black]. / Uber die Farbe Schwarz.

The colour black often has a negative symbolic connotation. However, our synopsis of its occurrence in dermatology, and the historical changes and sociocultural differences in the way it is viewed, highlight the diversity of its potential meaning. Unlike any other colour, black requires personal confrontation.

[Prosthesis edge nodule and verrucous hyperplasia in leg amputees]. / Prosthesenrandknoten und Verruköse Hyperplasie des Beinamputierten.

Dermatologic problems in leg amputees mainly result from their specific prosthetic supply. As this relationship is not well documented in the German language literature, we try to illustrate important pathophysiologic aspects of lower and upper limb prostheses in two highly characteristic dermatoses, epidermoid cysts and verrucous hyperplasia (papillomatosis cutis lymphostatica). Their management includes improvements in prostheses' workmanship and conceptional changes (e.g. CAT-CAM-technique). Interdisciplinar diagnostic and therapeutic efforts particularly between orthopedic surgeons, prosthetists and dermatologists should prevent immobility of the amputee at an early stage.

[Steroid-induced scabies norvegica]. / Steroidinduzierte Scabies norvegica.

Two patients aged 50 and 84 years presented with generalized itching eczema that has been treated with external and internal steroids for months. Despite therapy, the condition worsened continuously. Examination of skin scrapings revealed numerous mites, so Norwegian scabies was diagnosed. General examinations excluded underlying diseases. Treatment with steroids over months most likely led via immunosuppression to the exacerbation of the disease.

[Elastolysis of the mid-dermis and annular elastolytic giant cell granuloma: different stages in the clinical spectrum of dermal elastolysis? Case report and review of the literature]. / Elastolyse der mittleren Dermis und anuläres elastolytisches Riesenzellgranulom: Unterschiedliche Stadien im klinischen Spektrum der dermalen Elastolyse? Fallbericht und Literaturübersicht.

In recent years there has been increased interest in diseases showing degeneration of dermal elastic tissue. Mid dermal elastolysis is a rare dermatosis, which is histopathologically characterized by mid dermal loss of elastic tissue. Both papular and patchy forms, as well as inflammatory and non-inflammatory variants, have been described. A 70-year-old woman had annular patches. In their center the clinical and histopathological findings suggested non-inflammatory mid dermal elastolysis whereas the red and slightly elevated margins showed clinical and histopathological features of annular elastolytic giant cell granuloma. Based on our case and a review of the literature, we discuss the differential diagnosis of dermal elastolysis and hypothesize that a number of lesions histologically showing mid dermal elastolysis may represent different inflammatory or non-inflammatory stages of one disease which may overlap or change from one form into another.

[Dermatoses in leg amputees]. / Dermatosen bei Bein-Amputierten.

Dermatologic disorders of the stump in patients with a leg amputation may have characteristic pathophysiologic and clinical features. A knowledge of these factors may lead to earlier diagnosis and avoid immobilization. There ist no German language review of this aspect of dermatology. After providing an overview of the problem, including a discussion of prostheses, we review the following problems: mechanically induced blisters, follicular keratoses, epidermoid cysts, stump edema syndrome, acroangiodermatitis (pseudo-kaposi sarcoma) and verrucous hyperplasia.

Side-effects and complications of flashlamp-pumped pulsed dye laser therapy of port-wine stains. A prospective study.

The flashlamp-pumped pulsed dye laser (FPDL) was the first laser system specifically developed for the treatment of cutaneous vascular lesions such as port-wine stains (PWS), telangiectases and haemangiomas. Its theoretical advantages have been verified by numerous excellent clinical results. As there are few systematic studies on the adverse effects of this laser system, we investigated 100 consecutive patients who received FPDL therapy of PWS. Pain during and after laser therapy was a common complaint. Post-treatment erythema occurred in 29%, oedema in 73%, formation of bullae in 1%, and serous crusting in 46-83% of patients (based on our observations and the patients histories, respectively), all of which lasted for a maximum of 7 days. Furthermore, complications such as impetigo-like crusting occurred in 25%, bleeding in 12%, a pyogenic granuloma in 1%, hyperpigmentation in 27%, hypopigmentation in 1%, atrophic scarring in 3%, and an hypertrophic scar in 1%. Although most of these changes were only focal, and were predominantly transient, our results indicate that the incidence of side-effects and complications produced by the FPDL (wavelength 585 nm, pulsewidth 450 microseconds) may be higher than previously documented in the literature.

[Malignant infiltrating blue nevus of the plaque type. Case report and literature review]. / Maligner infiltrierender blauer Nävus vom Plaque-Typ. Fallbericht und Ubersicht.

We present, to the best of our knowledge, the first case of a malignant, primary plaque-type blue naevus in a 61-year-old male. Two biopsy specimens had been examined within 13 years, and revealed a common and cellular blue variant as a precursor. Locally invasive growth and regional lymph node swelling were present, but these alone could not confirm malignancy before evaluation of all clinical and histopathological features, as they are known to occur with benign cellular blue naevi. The recent literature and our case indicate that there is a malignant potential in every histological and clinical variant of blue naevus.

Epidermal damage and limited coagulation depth with the flashlamp-pumped pulsed dye laser: a histochemical study.

To investigate vessel coagulation depth and tissue damage in therapy with the flashlamp-pumped pulsed dye laser (585 nm, 5 mm spot size, 450 microsecond pulse duration, 6-8 J/cm2), we used the nitroblue-tetrazolium chloride stain in 22 post-treatment biopsy specimens from patients with port wine stain. With this method, thermally damaged tissue can be easily differentiated from unchanged tissue to the level of single cells. The results showed that in superficial port wine stain vessels up to 150 microns in diameter, vessel coagulation was complete and selective without further dermal damage. With the increase of vessel diameter, strong superficial hemoglobin absorption led to only partial vessel-wall coagulation and, in some cases, to superficial dermal damage. Likewise, deeper vessels were not coagulated because of shadow effects by superficial vessel layers. Thus, the overall vessel-wall coagulation depth of the flashlamp-pumped dye laser was limited to a maximum of 0.65 mm (mean 0.37 mm). In addition, some degree of epidermal damage was present in most specimens, which significantly increased with epidermal melanin content and resulted in epidermal coagulation and blistering in pigmented skin. Our results explain the occurrence of crusting, hyperpigmentation, and hypopigmentation in therapy with the flashlamp-pumped dye laser and its limited effect on dark or hypertrophic port wine stains in adults featuring large vessel diameters or multiple vessel layers.

[Nevi flammei in childhood and adolescence. Treatment with the flashlamp-pumped pulsed dye laser]. / Nävi flammei im Kindes- und Jugendalter. Die Behandlung mit dem blitzlampengepumpten Farbstofflaser.

In 77 patients with port-wine stain under 18 years of age we performed 100 test treatments with the flashlamp-pumped pulsed dye laser (585 nm, 450 microseconds, 5 mm beam diameter). In 54% of cases we could obtain excellent or good lightening with one test treatment. In only 9% of cases did the patients show bad or no response to laser therapy. In the following treatment of larger areas (n = 125), the rate of good or excellent lightening was even higher (60%). Side effects were infrequent and consisted mostly of transient hyperpigmentation. In contrast to argon laser therapy, the flashlamp-pumped pulsed dye laser is safe and effective for treatment of port-wine stains in childhood and adolescence. Our results and the good results reported in the literature confirm the flashlamp-pumped pulsed dye laser as the laser of choice for port-wine stain treatment in young patients.

Carbon dioxide laser therapy of a widespread epidermal nevus.

BACKGROUND AND OBJECTIVE: The treatment of epidermal nevi is difficult and often unsatisfactory. Many therapeutic approaches have been tried, of which the surgical methods including lasers aim to avoid recurrences and hypertrophic scarring. Here we report the case of a widespread, life-impairing epidermal nevus, summarize the available treatment modalities, and discuss CO2 laser therapy with respect to the clinically soft variants of these developmental defects. STUDY DESIGN/PATIENTS AND METHODS: A patient with a widespread, recurrent, biopsy-proven epidermal nevus was treated with a 10,600-nm CO2 laser. After test treatments in local anaesthesia, four sessions were performed under general anaesthesia each with a follow-up time of 4 years to date. RESULTS: CO2 laser vaporization resulted in complete removal of the treated nevus without any obvious scarring. The patient is free of recurrence 4 years postoperatively. CONCLUSION: CO2 laser treatment of epidermal nevi is a useful modality in selected variants.

Successful treatment of hydroxyethyl starch-induced pruritus with topical capsaicin.

We report a case of recalcitrant pruritus after infusion therapy with hydroxyethyl starch (HES) for sudden deafness. The diagnosis was confirmed by detection of typical HES storage vacuoles within dermal macrophages and perineural cells. Treatment with antihistamines and antipruritic agents, UVB irradiation, and neuroleptic drugs, was ineffective. Topical capsaicin (0.05%) twice daily produced excellent symptomatic relief, without side-effects.

[The interdisciplinary aspects of notalgia paraesthetica]. / Interdisziplinäre Aspekte der Notalgia paraesthetica.

For 3 years a 75-year-old man with type II diabetes had been suffering from paroxysmal pruritus in a circumscribed area of brown discoloration of the skin over the left should blade. This condition, also known as notalgia paraesthetica, is a rare, but perhaps underdiagnosed, neurocutaneous entity, a largely sensory neuropathy due to a muscular compression phenomenon. In this case histological examination of a biopsy specimen showed focal acanthosis, obvious basal hyperpigmentation and discrete perivascular lymphocytic infiltration with numerous melanophages. At first, glucocorticoids were administered unsuccessfully against the distressing pruritus. Purely symptomatic local capsaicin treatment decreased the pruritus temporarily. Endocrinological diagnosis failed to demonstrate multiple endocrine neoplasia (MEN) syndrome 2A, which has been frequently described in association with notalgia paraesthetica.

[Scabies norvegica sive crustosa in a patient with AIDS]. / Scabies norvegica sive crustosa bei einem Patienten mit AIDS.

We report the case of a 20-year-old homosexual man with HIV-1 infection presenting with AIDS. An erythemato-squamous, papulo-crustous, non-itching dermatosis of 4 months duration was finally diagnosed as Norwegian scabies in the immunosuppressed. For clinical and epidemiological reasons the high contagiosity of this rare entity requires an appropriate therapy without delay.