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CME Dermatology 24: Porokeratosis Abstract. Porokeratoses are a heterogeneous group of cornification disorders with the characteristic histological feature of the cornoid lamellae in the area of the marginal ridge. It is a rare but characteristic disease that occurs primarily in adulthood. Men are slightly more likely to be affected. The etiopathogenesis that leads to the transformation of the keratinocytes remains unclear; associations with genetic mutations and trigger factors such as UV rays and immunosuppression were observed. Due to the risk of malignant degeneration, consistent sun protection and regular clinical controls should take place. Cryotherapy, ablative laser therapy, curettage, photodynamic therapy or topical application of fluorouracil (5-FU), imiquimod and retinoids can be used to treat itchy, painful or cosmetically disturbing porokeratoses, depending on the location and severity.

CME Dermatology 23/Answers: Hidradenitis suppurativa Abstract. Hidradenitis suppurativa (Acne inversa) is a chronic skin disease characterized by recurrent inflammatory nodules, abscesses, and scarring mainly in the intertriginous areas. The prevalence is estimated to be 0.05 to 4.1 % worldwide, with women being more commonly affected. The exact pathogenesis remains unknown, but hair follicle occlusion and inflammation seem to be the initiating events. Several epidemiological correlations with smoking and obesity as well as mutations in gamma secretase genes were described. The therapy depends on the extension of the disorder and should respect the current guidelines. Topical clindamycin is suitable for mild forms of the disease whereas moderate to severe disease requires systemic anti-inflammatory treatment. Surgical intervention is currently the only definitive treatment for hidradenitis suppurativa.

CME Dermatology 22/Answers: Measles - Empidemiology and Clinical Manifestations Abstract. Measles is a highly contagious, acute and febrile illness that results from infection with measles virus. The World Health Organization (WHO) estimates a worldwide prevalence of ten million patients per year, leading to approximately 142 000 deaths (case fatality rate 1.4 %). The illness begins with fever, malaise and typically with at least one of the following signs: cough, coryza and/or conjunctivitis. Three to four days later, the characteristical rash appears. The primary clinical diagnosis needs to be confirmed by detection of specific IgM antibodies in serum or viral RNA by a throat swap. The management mainly consists of supportive therapy, a specific antiviral treatment does not exist. Therefore, prevention by widespread measles vaccination has absolute priority.

CME Dermatology 21: Scabies - Clinical Manifestation, Diagnosis and Therapy Abstract. Scabies is a common contagious skin infestation found in all parts of the world affecting individuals of all ages. Its worldwide prevalence is estimated at about 200 million people at any one time. Typical manifestations consist of severe itch that is aggravated at night, and disseminated, excoriated, erythematous papules on the trunk and limbs. Diagnosis can be confirmed by microscopic examination of skin scrapings taken from skin lesions. Recommended treatments consist of Permethrin 5 % cream applied once with repetition after 7-14 days or oral ivermectin 200 µg/kg as two doses 1 week apart. Additionally, written instructions on how to behave, decontaminate textiles and apply medications should be provided to suspected cases, and all the patient's close personal contacts should be treated simultaneously. As the disease can be sexually transmitted, screening for sexually transmitted diseases is recommended in sexually active patients.

Skin changes as a characteristic of internal diseases Abstract. Numerous skin changes are of great importance, as they can be groundbreaking for basic internal diseases or indicate associated complications or side effects of therapies. The early detection of such marker manifestations allows immediate action to prevent potentially serious consequences. For example, specific skin changes in limited forms of collagenosis may not only be diagnostically significant, but also prognostically significant, which allows gentler therapies if the course of the disease is more favourable. The most important prerequisite for a correct diagnosis of cutaneous lesions is a careful and complete skin status with additional consideration of the adjacent mucous membranes and skin appendages. In a first step, the primary anatomical site, morphology and lesion location should be identified and then the distribution assessed. This article describes more frequent skin manifestations in diseases of different organ systems (with the exception of infections, less frequent metabolic disorders and drug side effects).

CME Dermatology 16/Answer: Fever, Pustules and Joint Pain as Vacation Mementoes.

CME Dermatology 16: Fever, Pustules and Joint Pain as a Vacation Mementoes.

The incidence of sexually transmitted infections is rising in Europe and in Switzerland since the beginning of the third millenium. Many organisms may affect the perianal skin and the anorectum. While some of these infections are a result of contigous spread from genital infection, most result from receptive anal intercourse affecting males who have sex with males but is seen increasingly in females as well since there is evidence of the increasing popularity of anal sex among heterosexuals. The symptoms of specific infections are largely dependent on the route and site of inoculation. Organisms that cause typical genital symptoms - such as syphilis, chancroid, herpes simplex or HPV-infection - result in similar symptoms when the perianal skin, the anoderm or the distal anal canal are the site of infection. Patients with proctitis may have unspecific signs in various degrees including mucous discharge, rectal bleeding, anorectal pain, superficial ulcers and sometimes generalized lymphadenopathy and fever. It is of utmost importance to include STIs (e. g. lymphogranuloma venereum, gonorrhea, non-LGV-chlamydia and herpes simplex) in the differential diagnosis in these patients. Unfortunately rectal infection with chlamydia and gonorrhea is asymptomatic in the majority of cases of men having sex with men and in high-risk females. A careful history and physical examination is essential in establishing a correct diagnosis, usually supported by proctoscopy, culture, PCR, serology and histology. Certain organisms, more commonly thought of as food- or water-borne disease may be sexually transmitted by direct or indirect fecal-oral contact from various sexual practices.

Although there have been significant advances in diagnosis, treatment, and education, the occurence of STI continues to increase worldwide as well as in Switzerland. The most common STI include human papillomavirus (HPV), chlamydia, herpes, simplex virus types 1 and 2, gonorrhea, syphilis, hepatitis B and trichomoniasis. Diagnosis and treatment continue to be major public health challenges because of the asymptomatic nature of many of these infections. Recent studies showed favorable epidemiologic trends for HPV infection in vaccinated females as well as in some males. On the other hand we are confronted with rising incidences e.g. in urethritis with various causative agents and in syphilis cases. Alarmingly during the last 3 years gonococci have become less susceptible to our remaining antibiotics, necessitating strict adherence to updated treatment guidelines. Other trends in STIs and their consequences are discussed.

Herpes simplex virus (HSV) and varicella-zoster virus (VZV) are both human alpha-herpes viruses. They are capable of establishing latent infections in neural tissues and to reactive from these sites, determining the clinical features of the disease (primary infection versus recurrences). Infections with these viruses are common; an increased number of elderly and immunocompromised individuals will likely lead to an even higher prevalence. HSV infection--in its typical form characterized by grouped vesicles--is frequently inapparent or atypical in both primary and recurrent disease. The clinical spectrum is wide, ranging from trivial labial blisters to the most severe fatal sporadic encephalitis and neonatal infection. Seroprevalence studies in the Western world demonstrate a much higher percentage of people infected with HSV-2 than are currently identified by clinical studies. Since undiagnosed genital herpes infections are the major factor in fueling the genital herpes epidemic, awareness and more accurate diagnosis followed by therapy and counseling are mandatory. Primary VZV infection and herpes zoster are usually diagnosed clinically, but can be confirmed by virus detection methods from swabs of lesions or antibody tests. Antiviral therapy should be considered in varicella if the disease is complicated. In herpes zoster antiviral therapy should be given within 72 hours in immunocompromised patients and those at risk of postherpetic neuralgia. The availability of effective antiviral therapy makes early diagnosis most important.

A thorough dermatologic examination permits early identification of an increased risk for ulceration. This is of central importance in any plan to prevent amputation. Investigation should focus on the color of the skin, alteration of the texture, temperature and presence of swelling. Attention should be paid to callosities, indicating increased foot pressures, and to breaks in the skin, which may be followed by bacterial penetration. In addition, a variety of nail changes exists associated with diabetes mellitus requiring correct diagnosis and appropriate therapy.

The spectrum of dermatologic findings related to human immunodeficiency virus includes a variety of cutaneous and mucocutaneous disorders. The most frequent diagnoses are oral candidiasis, seborrheic dermatitis, pyodermas and Kaposi's sarcoma. Distinctive skin lesions occur at various stages of HIV infection. Especially herpes zoster, seborrheic dermatitis and oral candidiasis may act as indicators, and their recognition is of particular importance for the early diagnosis of HIV infection and for the prevention of further opportunistic infections. In addition, some dermatologic findings as mollusca contagiosa and Kaposi's sarcoma occur mostly as late manifestations and may constitute a cutaneous correlate of advanced cellular immune deficiency.