[Zoster disease after Shingrix vaccination]. / Zostererkrankung nach Shingrix-Impfung.

Shingrix is a recombinant adjuvant subunit vaccine. The vaccine is approved in Germany for prevention of zoster manifestation and postherpetic neuralgia in adults aged ≥60 years. In the case of bullous skin lesions after vaccination with Shingrix a zoster disease should be considered. Unexpected side effects associated with the vaccination should be reported to the Drug Commission of the German Medical Association.

[Pityriasis rubra pilaris : Successful treatment with ixekizumab]. / Pityriasis rubra pilaris : Eine erfolgreiche Therapie mit Ixekizumab.

Pityriasis rubra pilaris is a rare papulosquamous chronic skin disease. The disease often exists for years and is difficult to treat. Not only is it clinically similar to psoriasis vulgaris, but both diseases also have a similar cytokine profile. The successful use of biologicals is frequently reported in case reports. Studies with large numbers of cases are lacking.

Prospective multicentre cohort study on 9154 surgical procedures to assess the risk of postoperative bleeding - a DESSI study.

BACKGROUND: To date, there is still a debate how to deal with patients receiving antithrombotic agents prior to surgical procedures on the skin. OBJECTIVE: To prospectively assess complications after dermatosurgical interventions, especially bleeding, depending on anticoagulation therapy. METHODS: Patients underwent surgery consecutively as scheduled, without randomization, whether or not they were currently taking anticoagulants. Nine institutions of the DESSI (DErmatoSurgical Study Initiative) working group documented patient data prospectively on a standardized study sheet prior to and after 9154 dermatosurgical interventions. RESULTS: Bleeding complications were observed in 7.14% of cases (654/9154 surgeries). A severe bleed requiring intervention by a physician occurred in 83 surgeries (0.91%). In multivariate analysis, INR, length of the defect, perioperative antibiotic treatment, current treatment with anticoagulation therapy, age and surgery on hidradenitis suppurativa/acne inversa (HS/AI) were significant parameters independently influencing the risk of bleeding. Discontinuation of phenprocoumon therapy and subsequent switching to low molecular weight heparin was associated with the highest risk of bleeding (9.26%). CONCLUSION: Bleeding complications in skin surgery are generally rare. Even if slightly increased complication rates are found in patients taking anticoagulants during skin surgery, platelet inhibitors should not be stopped prior to surgery. If a surgical procedure in patients on a combination therapy of 2 or more antiplatelet cannot be postponed, it should be conducted with the patient remaining on combination therapy. Discontinuation of DOACs is recommended 24 h prior to surgery. Bridging of phenprocoumon should be terminated. In patients with a bleeding history, the INR value should be within the therapeutic range.

Sex steroid hormones are not altered in great saphenous veins after varicose vein treatment in male patients.

OBJECTIVE: The objective of this study was to assess differences in blood samples (sex steroid hormone levels and blood counts) before and after surgical treatment of incompetent great saphenous veins (GSV) in males. METHODS: Antecubital vein and GSV blood samples were taken from 11 men with varicose veins and GSV reflux before and after treatment. Six patients were treated with high ligation, stripping and phlebectomy. Five patients were treated with endoluminal radiofrequency ablation and phlebectomy. After a four-year follow-up period (FU) cubital vein and GSV blood samples were taken again. RESULTS: In men with varicose veins, significantly higher (P < 0.05) serum testosterone (median 25.18 nmol/L, range 8.82-225.1) and oestradiol (median 179 pmol/L, range 79-941) levels were found in the saphenous vein samples before and after the FU (testosterone 18.8 nmol/L, range 7.96-83.1, oestradiol 171 pmol/L range 125-304) compared with the cubital vein samples before therapy (testosterone 15.72 nmol/L, range 8.36-23.29; oestradiol 84 pmol/L, range 41-147) and after the FU (testosterone 14.5 nmol/L, range 6.10-22.2, oestradiol 117 pmol/L, range 95-165). After the FU, one patient demonstrated recurrent varicose veins with groin neovascularization. Another presented with axial reflux of the anterior accessory saphenous vein. Further differences in blood counts and serum androstenedione levels between the upper and lower extremities were not detected. CONCLUSION: The differences between testosterone and oestradiol levels in the leg veins compared with the cubital veins persist after treating men with refluxing saphenous veins. These results suggest that local hormone regulation may be different between leg and arm veins in men with varicose veins.

Reconstruction of nasal defects with forehead flaps in patients older than 75 years of age.

BACKGROUND: As the number of elderly patients diagnosed with non-melanoma skin cancer (NMSC) increases, the number of patients receiving dermatologic surgery also increases. Multimorbidity in this patient group is common. OBJECTIVE: The aim of this study is to assess the aesthetic and functional outcomes and complications of forehead flap (FHF) in elderly patients with NMSC. METHODS: Between 2006 and 2011, data for 28 patients 75 years of age or older who had been treated with FHFs under tumescent local anaesthesia were analysed. RESULTS: The median age of the study participants was 81 years (range, 75-95 years). Of the 28 total patients, 16 (57%) were female and 12 (43%) were male. The average defect size was 11 cm(2) (5-30 cm(2)). Cartilage grafts were used in four patients (14%). The average time to takedown was 25 days (17-45). The median follow-up for the patients was 10 months (1-60 months). There were seven treatment-related complications due to infectious causes (2), epidermal necrotic tissue (2), bleeding (1), hair on the flap (1) and alar rim notching (1). No life-threatening complications were detected. CONCLUSIONS: The FHF procedure is a safe and low-risk procedure in patients 75 years of age or older with advanced skin defects. If a defect requires an FHF to obtain a normal and aesthetic appearance, this procedure should be performed. However, dermatologists must weigh the safety of the procedure in relation to the clinical benefits when managing this patient group.

New rhinophyma severity index and mid-term results following shave excision of rhinophyma.

BACKGROUND: Rhinophyma is a progressive nasal deformity resulting from hyperplasia of the sebaceous glands and connective tissue, with a negative effect on quality of life. Partial-thickness shave excision has been used for the treatment of rhinophyma, but the mid- and long-term efficacy of the treatment is unknown. OBJECTIVES: We analysed the clinical outcomes of shave excision in patients with rhinophyma in our centre between 2005 and 2009. METHODS: The entire nose was shaved using a scalpel while under tumescent anaesthesia. The clinical assessment was scored using a novel Rhinophyma Severity Index. RESULTS: Thirty-three patients with rhinophyma and shave excision were recruited for the study. A mid-term follow-up examination was possible in 23/33 (69.7%) patients. After a mean follow-up of 37.4 ± 13.2 months, 21 (91.3%) patients showed an improved Rhinophyma Severity Index (3.3 ± 1.1 to 1.7 ± 0.9, p < 0.0001). All patients reported a high level of satisfaction after surgery (excellent or good result). Eleven (47.8%) patients developed rhinophyma recurrence. CONCLUSION: Shave excision under tumescent anaesthesia is an effective treatment for rhinophyma. The treatment is associated with high patient satisfaction and minimal side effects. A possible recurrence of rhinophyma must be addressed, however, while obtaining informed consent.

UVA (UVA-1) therapy for the treatment of acute GVHD of the skin.

Long-wavelength UVA (340-400 nm UVA-1) phototherapy has been reported to be effective in atopic dermatitis, localized scleroderma and T-cell-derived skin diseases. We retrospectively investigated 70 patients with acute cutaneous GVHD after allogeneic haematopoietic cell transplantation or donor lymphocyte infusion. Complete and partial responses with a median duration of 10 months were achieved in 49 (70%) and 17 (24.3%) patients, respectively. Overall, 47 (67.1%) patients were not treated with systemic steroids. Furthermore, immunosuppression could be tapered in 24 (34.3%) patients while they were receiving UVA-1 treatment. Responses were seen irrespective of age or type of conditioning. Treatment was very well tolerated. After a median follow-up of 18 (range 10-60) months, three patients developed epithelial skin neoplasia. We conclude that UVA-1 therapy is feasible, well tolerated and can be an effective treatment for acute GVHD of the skin, thereby avoiding the use of systemic steroids and/or allowing a more rapid tapering of systemic immunosuppression in a substantial number of patients. The results of this retrospective analysis warrant larger, prospective studies and the effectiveness of UVA-1 therapy should be compared with other established treatment modalities.

Surgical excision of basal cell carcinoma with complete margin control: outcome at 5-year follow-up.

BACKGROUND: The incidence of skin cancer and especially basal cell carcinoma (BCC) has increased in the last few decades. The gold standard of care is usually a surgical excision, but it also has the risk of local recurrence depending on tumor characteristics. OBJECTIVES: We analyzed the 5-year cure rates after surgical excision of BCC with complete margin control using paraffin-embedded sections. METHODS: A retrospective analysis of 671 patients (45.3% male, 54.7% female) with 777 primary and 85 with recurrent BCC were collected during 2001-2003. All patients underwent surgery with complete margin control using paraffin-embedded sections. When the histological examination revealed a positive margin, another surgical step was performed in the area of residual tumor. RESULTS: Five-year follow-up examinations were possible in 630/862 (73.1%) of patients with BCC. In the group with primary BCC (n = 562), 3 tumor recurrences (0.5%) were identified; in the group with recurrent BCC (n = 68), 2 tumor recurrences (2.9%) were seen, resulting in an overall 5-year recurrence rate of 0.8% for all patients with BCC. The mean tumor recurrence time after surgery was 36.6 months. CONCLUSION: Local complete tumor resection confirmed by complete margin control using paraffin-embedded sections can achieve excellent cure rates for both primary and recurrent BCC.

No clinical benefit of preoperative fluorescence diagnosis of basal cell carcinoma localized in the H-zone of the face.

BACKGROUND: Basal cell carcinoma (BCC) is the most common malignant skin carcinoma. Fluorescence diagnosis (FD) has been suggested as a promising method for noninvasive detection of subclinical tumour cell dissemination in BCC. OBJECTIVES: In this prospective study, we evaluated the clinical performance of a preoperative definition of the lateral borders of BCC by FD in comparison with its definition by purely clinical diagnosis (CD). The fluorescence intensity on the skin was recorded using a digital light-emitting diode-based fluorescence imaging system. METHODS: Twenty-six patients with BCC (22 with nodular subtype) of the H-zone were included. The tumour area was determined 3 h after application of methyl aminolaevulinate by inspection and photographic documentation (CD) and FD. Subsequently, BCCs were excised according to the complete area defined by CD and FD with a security margin of 3 mm; surgical specimens were sectioned horizontally and subjected to meticulous histological mapping. The tumour areas as determined by FD, CD and histology were superimposed to map the entire lateral tumour margin. RESULTS: The tumour area could be visualized by FD in 24 of 26 patients. The mean tumour area as determined by FD was significantly smaller than the tumour area as determined by CD [80 mm(2) , 95% confidence interval (CI) 50-110 mm(2) vs. 101 mm(2) , 95% CI 76-125 mm(2) ; P < 0·012]. The superimposition of FD and histology showed in 10 of 26 patients a complete detection of the tumour margin by FD; thus sensitivity of FD was calculated as 38·5%. In only three of 26 patients FD revealed a tumour extent greater than determined by CD. Specificity of FD was calculated as 88·4%. CONCLUSIONS: On aggregate, this study suggests that preoperative FD of nodular BCC localized in the H-zone offers no additional benefit to define subclinical tumour infiltration compared with CD alone.

[Desmoplastic fibroma on arm of 22-year-old woman]. / Desmoplastisches Fibroblastom bei einer 22-jährigen Patientin im Bereich des Oberarms.

Desmoplastic fibroblastoma ("collagenous fibroma") is a rare benign, slowly progressive fibrous soft tissue tumor that ranges 1-20 cm in size. The tumor occurs in all ages, predominantly in the upper part of the body. Children are rarely affected. The tumor often infiltrates the subcutis; less often it invades the fascia and skeletal muscle or causes bone erosions. Histologically, the tumor is composed of spindle-shaped cells embedded in a densely collagenous stroma, sometimes forming a pseudo-capsule. Magnetic resonance imaging and computed tomography as well as ultrasonography are used to define the extensions of the tumor. Because it is clinically extremely difficult to determine if soft tissue tumors are benign or malignant, all should be excised with a margin of safety and examined histologically. We report a 22-year old woman with desmoplastic fibroblastoma located on the upper arm. Clinical and histopathological findings and treatment options are discussed.

[Tumescent anaesthesia for dermatological surgery. Plasma concentrations of lidocaine and prilocaine]. / Tumeszenzlokalanästhesie bei dermatologischen Eingriffen. Plasmakonzentrationen von Lidocain und Prilocain.

BACKGROUND: Tumescent anaesthesia is currently used for several dermatological procedures. The objective of this study was to determine the plasma concentrations of local anaesthetics under real operating conditions with this anaesthetic technique. METHODS: A total of 31 patients received 3 different anaesthetic solutions with prilocaine and lidocaine for several surgical procedures. The concentrations of local anaesthetics, methemoglobin, epinephrine as well as the occurrence of adverse reactions were determined 30 min, 1 h, 3 h, 6 h, 12 h and 24 h after administration RESULTS: Maximum plasma concentrations of prilocaine were measured predominantly after 3 and 6 h, for lidocaine after 6 h. In two patients maximum plasma levels occurred 24 h after infiltration. Although toxic concentrations were not exceeded, side-effects could be observed in four patients. CONCLUSIONS: Even if the measured concentrations of local anaesthetics appeared to be safe, slight and moderate side-effects could be observed in 12.9% of cases. Maximum plasma levels of local anaesthetics may still occur 24 h after administration.

[Mycosis fungoides and B-cell chronic lymphocytic leukemia: an extremely rare coincidence]. / Mycosis fungoides und chronisch lymphatische B-zell-leukämie: eine äusserst seltene koinzidenz.

The simultaneous appearance of mycosis fungoides (MF) and B-cell chronic lymphocytic leukemia (B-CLL) in the same patient is extremely rare. Only seven cases have been described in literature. A 72-year-old patient was diagnosed with coincident MF, stage Ib, and B-CLL, Binet stage A. Hypotheses on simultaneous occurrence of B- and T-cell malignancies as well as a new therapeutic option are discussed.

[Reactions of the skin to solar radiation]. / Von der Verbrennung bis zum Melanom. Sonnenbad mit bösen Folgen.

When spending time out of doors in summer, certain rules of behavior need to be observed. Environmental factors such as, for example, water, the beach and the midday sun all have a major influence on the UV radiation burden to which people may be subjected. In addition, the sun's rays can interact with certain medications, alcohol and drugs, as also cosmetics, and trigger pathological skin reactions. A permanently sun-damaged skin is not only very difficult to treat, but is also frequently associated with malignant changes. Moderate exposure to the sun after prior gradual acclimatization is to be recommended. Patients with increased photosensitivity require special photoprotective agents.