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Background Studies on patch testing with workplace materials and evaluation of current occupational relevance of positive patch test reactions are scarce in patients with occupational dermatitis (OD). Objectives To identify frequent sensitizations with occupational relevance and to determine the value of patch testing with workplace materials in OD patients. Patients and methods Results and clinical data of 654 patients with suspected OD patch tested between 2013 and 2017 were analysed. Results Occupational allergic contact dermatitis was diagnosed in 113 (17.3%) patients. Mechanics had the widest range of occupational sensitizations. Sensitization to epoxy resin was rated occupationally relevant in almost all handicraft trades. Among positive patch test reactions to workplace products, those to water-based metal working fluids and leave-on cosmetic products were most frequent. Despite frequent testing, protective gloves only rarely elicited positive reactions. Preservatives and rubber compounds were most frequently identified as currently occupationally relevant. Conclusions Rubber allergy is occupationally relevant especially in healthcare workers and cleaners. Generally, preservatives including formaldehyde releasers are important allergens in OD patients. Leave-on cosmetic products must not be forgotten as allergen sources. Patch testing both workplace materials and standardized test preparations has a complementary value and is beneficial for the diagnostic work-up of OD patients.

Background The Atopic Dermatitis (AD) TREATgermany registry was initiated by the German Society for Dermatology (DDG) in 2011 to evaluate the ‘real‐life’ situation of health care for patients with AD. Objectives Interim data analysis on baseline characteristics as well as current and prescribed systemic treatments of the TREATgermany registry patients. Methods Patients (≥18 years) with moderate‐to‐severe AD [objective (o)SCORAD > 20], or with current or previous anti‐inflammatory systemic treatment for AD within 24 months, were included and are followed up over at least 24 months. To assess clinical signs, the eczema area severity index (EASI, 0–72), the oSCORAD (0–83) and the Investigator Global Assessment (IGA; 6‐point scale) were used. The disease severity was globally scored by the patients [Patient Global Assessment (PGA); six‐step Likert scale]. Disease symptoms were assessed by the patient‐oriented eczema measure (POEM, 0–28) and numeric rating scales (NRS, 0–10). Health‐related quality of life was measured using the dermatological life quality index (DLQI, 0–30). Results A total of 612 patients were recruited across 32 sites between 06/2016 and 01/2019 (mean age: 42.6 ± 14.2 years; mean oSCORAD: 40.8 ± 16.3). The mean POEM score was 16.3 ± 7.5. Pruritus was rated highest among subjective symptoms (NRS: 5.4 ± 2.7). The mean DLQI value was 11.3 ± 7.5. The frequency of arterial hypertension was lower (20.8%) compared with the general population, whilst this was higher for depression (10%). More than 60% of the patients had received systemic glucocorticosteroids, and 36.8% had received cyclosporine A prior to inclusion. Dupilumab was the leading substance documented as either ‘current’ (12.1%) or ‘prescribed’ (31.4%) at baseline. Conclusions These ‘real‐life’ data clearly demonstrate the substantial disease burden. Most of TREATgermany patients were already treated with or prescribed dupilumab at baseline. Moreover, current findings indicate the urgent need for further alternative agents in order to achieve a perceptible improvement of quality of life of patients with moderate‐to‐severe AD.

Background: Clinical registries may provide high-quality evidence on the use and effectiveness of therapeutic interventions under real-life conditions. Adults with moderate-to-severe atopic eczema (atopic dermatitis [AD]) are enrolled into TREATgermany and prospectively followed over at least 2years. This paper analyses the association between dermatological quality of life and work limitations.Materials and Methods: Treatment modalities and abroad set of physician- and patient-reported outcome measures are documented using validated instruments to assess clinical disease severity (EASI [Eczema Area and Severity Index], objective SCORAD [objective-SCORing Atopic Dermatitis]), quality of life (DLQI [Dermatology Life Quality Index]), symptoms (POEM [Patient-oriented Eczema Measure]), global disease severity, as well as patient satisfaction and work limitations including presenteeism (WLQ [Work Limitation Questionnaire]). From 06/2016 until 12/2017, 241 individuals (mean age 43 +/- 15years, 38.6% female) were enrolled at 19recruitment centers;69% of the patients were employed.Results: Employed persons had DLQI and WLQ scores of 10.6 +/- 6.9points and 17.7 +/- 18.1%, respectively. Mean presenteeism was substantial accounting for 9.2%. With coefficients of 0.39 and 0.33 WLQ and presenteeism scores significantly correlate with DLQI (p

Das atopische Ekzem des Kindesalters ist mit einer stadiengerechten topischen Therapie in der Mehrheit der Falle gut behandelbar. Herausforderungen stellen die schweren Verlaufsformen mit rezidivierenden Superinfektionen, das Management assoziierter Nahrungsmittelallergien sowie die psychosozialen Aspekte einer chronischen Erkrankung im Familienkontext dar. In dieser Altersgruppe liegt ein besonderer Fokus auf der Pravention – primar und im Hinblick auf die Entwicklung weiterer Erkrankungen des atopischen Formenkreises. In einigen dieser Bereiche haben sich in den letzten Jahren neue Aspekte ergeben, die das praktische Management des atopischen Ekzems im Kindesalter verandert haben oder in Zukunft verandern konnten.

Bacterial infections of the skin are often seen by dermatologists. The majority of infections are caused by the gram-positive bacteria Staphylococcus aureus and Streptococcus pyogenes. These induce blistering/erosive (impetigo, ecthymata) and abceeding (folliculitis) infections of the skin, respectively. Owing to their differences in virulence factors and host immunity, these strains can lead to varying presentations and courses of the infections. This review focuses on impetigo, folliculitis, perianal streptococcal dermatitis, and ecthymata.

Zusammenfassung Die uberwiegende Zahl der malignen Melanome („schwarzer Hautkrebs”) treten an der sichtbaren Haut auf. Werden sie rechtzeitig erkannt, ist die Behandlung nach Exzision mit Sicherheitsabstand abgeschlossen. Dagegen haben Patienten mit metastasiertem Melanom trotz neuer Therapien weiterhin eine sehr schlechte Prognose. Daher hat die Fruherkennung beim malignen Melanom einen sehr hohen Stellenwert. Der „weise Hautkrebs” ist aufgrund des geringen Metastasierungsrisikos prognostisch deutlich gunstiger, jedoch konnen auch hier durch fruhzeitige Behandlung eingreifende Therapien vermieden werden. Der Artikel gibt praktische Hinweise, auf welche Hautveranderungen Therapeuten bei ihren Patienten achten sollten.

Bestimmte Dermatosen konnen von vorangehenden oder parallel bestehenden Infektionen ausgelost oder verschlechtert werden. Die Psoriasis vulgaris etwa kann Folge einer Streptococcus-pyogenes-Infektion sein, der Lichen ruber durch Hepatitis-C-Viren ausgelost werden.

Silikon ist ein in der Medizin vielfach eingesetztes Material und spielt unter anderem in der plastischen Rekonstruktion eine grose Rolle. Die Anwendung von Silikon kann jedoch fur den Patienten erhebliche, teils nicht abschatzbare Konsequenzen haben, von Schwellungen und Rotungen im Bereich der Injektionsstelle uber regionale Lymphadenopathie bis hin zur Entwicklung schwerer Hautlasionen, auch fern des Applikationsortes, wie im hier geschilderten Fall einer Patientin, die wenige Jahre nach Silikoninjektion in beide Gesashalften massive Ulzerationen gesasabwarts entwickelte. Daruber hinaus sind Systemreaktionen wie intrapulmonale Granulome, Embolien und assoziierte Pneumonien moglich. Auch ein Zusammenhang mit der Entwicklung von Autoimmunerkrankungen und Neoplasien wird diskutiert. Therapiemoglichkeiten bestehen in der operativen Entfernung des Materials sowie antiinflammatorischen Lokal- und Systemtherapien. Erstere ist jedoch angesichts einer diffusen Verteilung von Silikon haufig nicht vollstandig moglich, fur Zweitere fehlen Erfahrungswerte, vor allem im Langzeitverlauf. Flussiges Silikon zur kosmetischen Injektion ist daher weder in Europa noch in den USA zugelassen. Aber auch bei der Verwendung von Silikonimplantaten sollte stets eine sorgfaltige vorherige Abwagung und Aufklarung sowie eine Durchfuhrung nur durch fachlich geschultes Personal erfolgen. Daruber hinaus empfehlen sich regelmasige Nachsorgeuntersuchungen sowohl bei Implantattragern als auch jenen Patienten, denen in der Vergangenheit flussiges Silikon injiziert wurde.

Because of the increasing incidence of resistance to beta-lactam antibiotics, dermatologists will be increasingly confronted with methicillin-resistant S. aureus (MRSA) strains which display a great variability of their virulence factors. In view of the high mortality of systemic MRSA infections (estimated 700-1.500 deaths per year in Germany), dermatologists should be well aware of the various aspects of diagnosis, therapy and prevention of this problem bacteria. Adequate screening measures must be in place to identify high-risk patients and institute appropriate prophylactic measures and therapy. If only colonization is present, topical antiseptic measures are sufficient. If an infection is present, either systemic or topical therapeutic approaches may be indicated. We review the role of MRSA infection and colonization in skin diseases.

B-Zellen sind fur die Ausbildung einer humoralen Immunantwort verantwortlich. Sie proliferieren und differenzieren in den sekundaren lymphatischen Organen. IgE ist das Schlusselmolekul allergischer Erkrankungen vom Typ I und wird von B-Zellen nach Stimulation uber CD40 und IL-4/IL-13 produziert. Zahlreiche Molekule aus der Steroidhor-monrezeptorfamilie konnen die IgE-Produktion hemmen und stellen interessante therapeutische Zielstrukturen der Zukunft dar.

Die Kolonisierung mit Staphylococcus aureus der lasionalen und nicht lasionalen Haut der Patienten mit atopischem Ekezm (AE) ist einer der wichtigsten Einflussfaktoren bezuglich des Schweregrads und der Haufigkeit von Exazerbationen der Erkrankung. Atopische Haut ist besonders anfallig fur die Besiedelung mit S. aureus. Die Kolonisierung fuhrt zu einer dauernden Stimulation des Immunsystems der Patienten mit AE, insbesondere durch Staphylokok-kensuperantigene. Dies hat ein verstarktes Einwandern von T-Lymphozyten in die Haut sowie eine vermehrte IgE-Synthese zur Folge. Weiter ist in der Haut von Patienten mit AE die Produktion von hautspezifischen, antibakteriell wirksamen Peptiden wie LL-37, HBD-2 und HBD-3 vermindert. Die therapeutische Kontrolle der Besiedelung durch Staphylokokken ist daher eine wichtige Saule im Rahmen eines Therapiekonzepts des AE.

Background Microbial skin colonization with Staphylococcus aureus is known to play an important role in atopic eczema (AE). Recently, an antibacterial effect of silver-coated textiles on S. aureus colonization has been demonstrated. Objectives To investigate clinical efficacy and functionality of silver-coated textiles in AE, a multicentre, double-blind, placebo-controlled trial was conducted. Patients/methods From November 2001 to August 2002, 68 consecutive outpatients clinically diagnosed with generalized AE were included in the study. Inclusion criteria were the clinical diagnosis of AE with a moderate severity as measured by the scoring of atopic dermatitis (SCORAD) index with at least 20. Patients were instructed to wear either silver-coated (verum, 35 patients + 2 dropouts) or cotton garments (placebo, 22 patients + 9 dropouts) directly on the skin for 2 weeks. Only basic skin care and ongoing therapy with topical steroids or oral antihistamines was permitted. Clinical severity was assessed using the ‘SCORAD’ before, during and at the end of study. Quality of life (QOL), wearing comfort (WC) and functionality (FU) of study clothes were measured in parallel. Patients documented their subjective and objective symptoms daily. Results In the verum group, eczema improved significantly after 1 week with further enhancement until the end of study ( P = 0.03 and P < 0.001). Silver-coated textiles were comparable to cotton in WC and FU. Pruritus and self-assigned skin condition improved significantly more than with placebo ( P < 0.001 and P = 0.003). Conclusions In conclusion, silver-coated textiles are able to improve objective and subjective symptoms of AE significantly within 2 weeks, showing a good wearing comfort and functionality comparable to cotton.

Background: In atopic eczema (AE), skin colonization with Staphylococcus aureus is known to play a major triggering and possibly pathophysiological role. Methods: In this open-labeled controlled side-to-side comparative trial, affected sites (flexures of both elbows) in 15 patients diagnosed as having generalized or localized AE were evaluated regarding S. aureus colonization and clinical severity of AE over a 2-week period. Flexures of the elbows were covered with silver-coated textiles on one arm and cotton on the other for 7 days followed by a 7-day control period. Results: A highly significant decrease in S. aureus colonization could be seen on the site covered by the silver-coated textile already 2 days after initiation lasting until the end of the treatment. Seven days after cessation, S. aureus density remained significantly lower compared to baseline. In addition, significantly lower numbers of S. aureus were observed on the silver-coated textile site in comparison to cotton at the end of treatment as well as at the time point of control. Clinical improvement correlated with the reduction of S. aureus colonization. Conclusion: A superior improvement achieved by silver-coated compared to cotton textiles paralleled a potent anti-S.-aureus effect.

Granuloma annulare is a common granulomatous infiltration of the skin of unknown etiopathogenesis. We analyzed granuloma annulare biopsies in 11 patients and could find in all patients significant numbers of CD4-T cells. These cells showed a broad usage of the different T cell receptor Vbeta families and a rather unbiased repertoire when the complementary determining region 3 spectra were analyzed by the Immunoscope technique. Comparison with the peripheral blood mononuclear cell repertoire, however, identified in all patients few skin-specific expansions, which were for one patient also present in two distinct skin sites. Extensive sequence analysis of the complementary determining region 3 region confirmed the presence of a limited number of skin-specific expansions together with various nonspecific T cell infiltrations. Analysis of the intralesional cytokine expression revealed abundant production of interleukin-2, which was not dominant in granulomas from leprosy patients and was not reflected by the cytokine profile in peripheral blood mononuclear cells. These results demonstrate the capacity of the granulomatous response to recruit T cells in high numbers with only few clones expanding specifically. The high local production of interleukin-2 might thereby play an important role in the nonspecific attraction of T cells to the granulomatous site.

Psoriasis is characterized by an apoptosis-resistant and metabolic active epidermis, while a hallmark for allergic contact dermatitis (ACD) is T cell-induced keratinocyte apoptosis. Here, we induced ACD reactions in psoriasis patients sensitized to nickel (n = 14) to investigate underlying mechanisms of psoriasis and ACD simultaneously. All patients developed a clinically and histologically typical dermatitis upon nickel challenge even in close proximity to pre-existing psoriasis plaques. However, the ACD reaction was delayed as compared to non-psoriatic patients, with a maximum intensity after 7 days. Whole genome expression analysis revealed alterations in numerous pathways related to metabolism and proliferation in non-involved skin of psoriasis patients as compared to non-psoriatic individuals, indicating that even in clinically non-involved skin of psoriasis patients molecular events opposing contact dermatitis may occur. Immunohistochemical comparison of ACD reactions as well as in vitro secretion analysis of lesional T cells showed a higher Th17 and neutrophilic migration as well as epidermal proliferation in psoriasis, while ACD reactions were dominated by cytotoxic CD8+ T cells and a Th2 signature. Based on these findings, we hypothesized an ACD reaction directly on top of a pre-existing psoriasis plaque might influence the clinical course of psoriasis. We observed a strong clinical inflammation with a mixed psoriasis and eczema phenotype in histology. Surprisingly, the initial psoriasis plaque was unaltered after self-limitation of the ACD reaction. We conclude that sensitized psoriasis patients develop a typical, but delayed ACD reaction which might be relevant for patch test evaluation in clinical practice. Psoriasis and ACD are driven by distinct and independent immune mechanisms. peerReviewed

Background Tinea capitis is the most common dermatophytosis of childhood with increasing incidence. Whereas griseofulvin is considered by many as the mainstay of treatment, newer oral antifungal agents, including fluconazole, itraconazole and terbinafine have demonstrated higher efficacy, resulting in shorter treatment durations. Objectives We aimed to determine the optimum regimen for the treatment of childhood tinea capitis with itraconazole. Methods A mycological culture outcome-dependent combination of a 28-day continuous and facultative additional 14-day courses with itraconazole was used in 42 children (20 girls; 22 boys) aged 12–140 months (mean 66) with tinea capitis due to Microsporum canis (n = 26) and Trichophyton violaceum (n = 16). The drug was given orally according to the patients’ body weight (50 mg daily for

The T-cell-reactive (eg, tuberculoid and reversal) forms of leprosy represent a well-defined granulomatous reaction pattern against an invading pathogen. The immune response in cutaneous sarcoidosis is a granulomatous condition that pathologically is very similar to T-cell reactive leprosy. However, it lacks a defined causative agent. In view of the role of NKT cells in murine granulomas induced by mycobacterial cell walls, we have searched for the presence of NKT cells in the cutaneous lesions of both leprosy and sarcoidosis. These cells were present in T-cell-reactive leprosy but were undetectable in cutaneous sarcoidosis. We have also studied the TCR Vα repertoire in the two diseases. In addition to Vα24 + NKT cells, all patients with T-cell-reactive leprosy showed a very restricted T-cell-reactive Vα repertoire with a strong bias toward the use of the Vα6 and Vα14 segments. Vα6 and Vα14 + T cells were polyclonal in terms of CDR3 length and Jα usage. In contrast, most sarcoidosis patients showed a diverse usage of Vα chains associated with clonal or oligoclonal expansions reminiscent of antigen-driven activation of conventional T cells. Thus the origin and perpetuation of the two kinds of granulomatous lesions appear to depend on altogether distinct T-cell recruiting mechanisms.

Hepatosplenic gammadelta T-cell lymphoma is a recently identified entity in which lymphoma cells bearing the gammadelta T-cell receptor (TCR) infiltrate the sinusoids of the liver and the sinuses of the splenic red pulp and bone marrow, without lymph node involvement. It is also characterized by a recurrent cytogenetic finding, isochromosome 7q (i7q10). The authors report a case of hepatosplenic lymphoma of alphabeta T-cell phenotype that shares the same clinical, histologic, and cytogenetic characteristics of the previously described hepatosplenic gammadelta T-cell lymphoma. Fluorescent in situ hybridization performed with chromosome 7 probes showed the typical pattern of isochromosome 7q. Genomic analysis of the TCR gamma locus failed to detect a clonal rearrangement. This unique case of hepatosplenic lymphoma of alphabeta T-cell phenotype supports the possibility that lymphoid populations of different alphabeta or gammadelta phenotype that share similar homing and presumably functional properties could give rise to lymphomas displaying similar clinical and pathologic findings.

Fourteen patients suffering from acute, exacerbated atopic eczema were screened for changes in collagen I and collagen III metabolism in serum (n = 11), urine (n = 11) and skin biopsies (n = 9) before and after medium-dose ultraviolet (UV) A1 phototherapy (15 exposures of 50 J/cm2 over a 3-week period, total dose 750 J/cm2). Mature collagen I and, to a lesser extent, mature collagen III were found to be decreased after the therapy in skin samples from the irradiated patients. As markers of collagen I degradation, the cross-links pyridoline and deoxypyridoline were analysed in urine using high-performance liquid chromatography. Both cross-links were found to be mildly increased after UVA1 phototherapy, without reaching statistical significance. As markers of de novo collagen synthesis we screened for the procollagen I-carboxyterminal peptide (PICP) and procollagen III-aminoterminal peptide (PIIINP) levels in serum and skin. The ratio of PICP to PIIINP in serum dropped significantly after the UVA1 phototherapy, suggesting a different impact of UVA1 on the two collagens. These findings were paralleled by a diminished ratio of PICP to PIIINP in tissue samples. Staining for matrix metalloproteinase 1 (MMP-1) and its specific counterpart, tissue inhibitor of MMP-1 (TIMP-1), showed slight increases for both proteins by therapeutic UVA1; this was also seen in serum for TIMP-1 but not MMP-1. In our study, high-energy UVA1 doses induced changes of the skin collagens in patients with atopic eczema which are measurable by their metabolites in serum and urine.

Summary Background Ultraviolet (UV) A1 phototherapy is an effective anti-inflammatory treatment modality that influences fibroblast functions. Objectives To document the effects of UVA1 treatment in patients with localized scleroderma (LS) in a retrospective study (at least 6 months after UVA1 treatment) and in a prospective study before and immediately after medium-dose UVA1 irradiation. Methods In total, 30 patients (retrospective study n = 17, prospective study n = 13) with LS receiving UVA1 phototherapy five times weekly (for 3–6 weeks) were investigated. Improvement was documented using standardized questionnaires and clinical evaluation (using modified Rodnan skin score, Cutometer and 7·5-MHz ultrasound measurements). Levels of collagen I and collagen III metabolites were measured in serum and urine. Results In the retrospective study, medium-dose UVA1 phototherapy had been performed 6 months–3 years earlier (cumulative dose 750–1400 J cm−2; mean ± SD number of irradiations 19·3 ± 3·8). Fourteen of 17 patients (82%) reported an improvement in symptoms following UVA1 therapy. In the prospective study, skin elasticity increased in 77% of the patients following medium-dose UVA1 phototherapy (cumulative dose 750–1250 J cm−2; mean ± SD number of irradiations 20·8 ± 4·0). 7·5-MHz ultrasound measurements showed a mean reduction of lesional skin thickness of 13% compared with skin thickness before UVA1 phototherapy. The ratio of deoxypyridinoline to creatinine was significantly elevated in about two-thirds of the patients. Conclusions This open study showed a positive short- and long-term efficacy of UVA1 phototherapy in patients with LS, with a reduction in sclerotic plaques, an increase in skin elasticity and a reduction of lesional skin thickness. UVA1 phototherapy had a significant effect on collagen metabolism. UVA1 phototherapy can be regarded as a safe treatment modality for patients with LS.

Dear Editor: Pyoderma gangrenosum (PG) is part of the spectrum of the neutrophilic dermatoses, a group of inflammatory disorders of unknown aetiology that share a tendency towards pathergy and the presence of noninfectious neutrophilic infiltrates, mainly in the skin. In 40% to 50% of the cases, the formation of PG can be worsened by a nonspecific external stimulus such as a trauma or a surgery. This phenomenon, called pathergy, conduces to avoid any surgical excision of the lesion. However, the diagnosis is often omitted, and the rapid evolution of the cutaneous necrosis forces the surgeon to perform a surgical debridement of the wound as one of the main differential diagnoses is a necrotizing fasciitis that requires a fast surgical reaction. Then, it often causes an exacerbation of the lesion, and it can have disastrous consequences. Unlike PG, which may appear spontaneously or as a result of the pathergy phenomenon, postoperative PG (PPG) is clearly related to previous surgery. PPG, also known as postoperative progressive gangrene of Cullen, is a rare and rapidly developing complication of surgical procedures. Since the first description by Cullen in 1924, nearly 100 cases of PPG developing on surgical wounds have been reported. The diagnosis of PPG is based on clinical features and always requires exclusion of other conditions, as misdiagnosis exposes patients to risks associated with inappropriate treatment. Sequencing of 16S ribosomal (r)RNA is an accurate method for microbial detection, and identification to exclude an infectious origin in cases where cultures do not grow microorganisms and antibiotics have been previously given to patients. Nevertheless, histopathology of the skin is the most common investigation to confirm the diagnosis of PG. Here, we report a case of an abdominal PPG that occurred after laparoscopic sigmoidectomy. A 39-yearold patient was transferred to our hospital with a progressive ulceration at the lower abdomen 3 weeks after a laparoscopic sigmoid resection due to diverticulosis. Shortly after the initial surgical procedure, the patient emerged a wound infection at the site of the resection area of the sigmoid in the right lower abdomen. The initial bacterial culture showed an infection with Staphylococcus aureus that was sensitive for standard antibiotics. In the following, the patient was treated with piperacilline/sulbactam, but the wound situation didn’t improve. After surgical wound debridement and ongoing treatment with antibiotics but progressive phlegmon, the patient was transferred to our hospital due to a suspected infection with anaerobic bacteria and necrotizing fasciitis. The initial serum infection parameters showed a high leucocytosis of 19.76 G/l (standard value 6.0–9.0 G/l) and a C-reactive protein (CRP) of 13.6 mg/dl (standard value

Six patients (3 children and 3 adults) with acute exacerbated atopic eczema were treated with basic emollients in combination with chlorhexidine-soaked dressings over a period of three days using the "wet-pyjama" technique. Improvement of eczema was documented with the severity score "Scoring of Atopic Dermatitis" (SCORAD); most pronounced changes were found for the subjective parameters itch and sleep loss. Paralleling skin improvement a reduction of Staphylococcus aureus colonisation was noted. Improvement of skin changes lasted beyond the active treatment period. Wet-wrap dressings are an effective treatment modality for atopic eczema without use of corticosteroids and can be used easily on an outpatient basis when manufactured dressings are used.

Reticular erythematous mucinosis (REM) syndrome primarily affects young women; the skin lesions usually appear on the chest and upper back. REM is diagnosed on the basis of the clinical picture and histological findings. REM syndrome is often associated with lupus erythematosus tumidus. Both diseases respond well to treatment with chloroquin. Topical tacrolimus and the use of a pulsed dye laser have fewer side effects and have also proved to be effective.

Lyme borreliosis is a common infectious disease that can affect myocardial muscle or the central nervous system if not treated at an early stage. Here we report a unique case of an atypical location of lymphocytoma cutis in a 3-year-old boy. Histologic and immunohistochemical analysis revealed the correct diagnosis.

The simultaneous occurrence of psoriasis driven by type 1 helper T (Th1) cells and type 17 helper T (Th17) cells and atopic eczema dominated by type 2 helper T (Th2) cells is rare. Here, we describe three patients with co-occurring psoriasis and atopic eczema with an antagonistic course and distinct T-cell infiltrates in lesions from psoriasis and those from atopic eczema. Sensitized patients with psoriasis had a reaction to epicutaneous allergen challenge, with clinically and histologically verified eczema lesions containing a large number of allergen-reactive T cells. These findings support a causative role for T cells triggered by specific antigens in both psoriasis and atopic eczema. (Supported by the German Research Foundation and others.)

Background: Most treatment protocols for vitiligo require a long treatment duration and usually do not result in complete repigmentation. Therefore, cosmetically acceptable and easily to handle alternatives are warranted. Objective: To evaluate the properties of dihydroxyacetone (DHA) in a new formulation for the treatment of vitiligo on exposed areas. Methods: We treated 10 patients suffering from vitiligo affecting the face and/or hands with a newly introduced, commercially available self-bronzing cream containing DHA 5%. DHA was applied every second day. Results: The characteristic pigmentation showed very satisfactory cosmetic results in 8 out of 10 patients after 2 weeks of treatment. Conclusion: The new DHA formulation is a practical and well-accepted treatment modality.

Importance of the field: Atopic eczema is highly colonized with Staphylococcus aureus in lesional as in non-lesional skin. Antimicrobial therapy as part of a comprehensive therapeutic concept in atopic eczema has been discussed for a long a time.Areas covered in this review: A complete literature review of the accessible publications concerning antibacterial and antiseptic therapy has been undertaken.What the reader will gain: This review covers the literature on antimicrobial therapy in atopic eczema and will try to weigh the different publications in the field.Take-home message: A beneficial role for antibacterial/antiseptic therapy on top of anti-inflammatory therapy in atopic eczema has to be questioned. However, a role in prevention of overt skin infection seems possible.

The present review aims at giving a condensed view on the current status of therapy of atopic eczema - a common chronically relapsing inflammatory skin disease. Atopic eczema is a multifactorial disease with a tendency for chronification. Owing to the associated genetic factors, therapeutic amelioration of skin symptoms is often only transient. Therefore, treatment basically focuses on symptomatic relief. Atopic eczema treatment should more than any other disease be guided by an individualized approach taking not only the phenotype and genotype of the disease but also psychosocial and gender aspects into account. Significant gains have been made in our understanding of atopic eczema, especially recent insights into genetic and immunologic mechanisms, but still, there is no single treatment to date that has proven to be the quantum leap for atopic patients. Novel treatments have been developed and trialled, however, more studies on novel therapies such as biologicals addressing efficacy, optimum dose and duration of treatment and the target phenotype are urgently needed. Hopefully, the tremendous progress in basic research in the last years will provide new targets for prevention and treatment in the future.

Wir berichten uber einen 26jahrigen Patienten mit seit 4 Jahren bestehender, seit 2 Jahren das Vollbild einer Purpura Schonlein-Henoch zeigender Purpura, fur die trotz wiederholter, sorgfaltiger Abklarung ein Ausloser nicht festzustellen war. Nachdem es unter verschiedenen therapeutischen Masnahmen, die u.a. die systemische Gabe von Glukokortikoiden und Azathioprin sowie Pentoxifyllin-Infusion beinhalteten, nicht gelungen war, die Gelenkschmerzen, die Magen-Darm-Symptomatik und die Hautveranderungen zu kontrollieren, wurde nach Kontrolle der Glukose-6-Phosphatdehydrogenase und unter Uberwachung des Methamoglobinspiegels eine Behandlung mit Dapson in einer Dosierung von 100 mg taglich durchgefuhrt. Hierunter kam es innerhalb von 2 Wochen zu Symptomfreiheit, die bis jetzt uber 6 Monate andauert. Dapson stellt somit bei therapieresistenter Purpura Schonlein-Henoch eine Therapiealternative dar.

Atopic eczema is a common inflammatory skin disease showing chronically relapsing eczema and high association with elevated serum IgE levels. A subgroup of atopic eczema patients requires systemic immunomodulatory treatment for long time periods. However, beyond cyclosporine A and azathioprine, only limited consent exists on systemic treatment options.Timely published systemic treatment modalities include studies on efalizumab (anti-CD11a antibody), infliximab, adalimumab, and etanercept (anti-TNF-alpha treatment), omalizumab (an anti-IgE antibody), rituximab (an anti-CD20 antibody), specific immunotherapy, leflunomide, and leukotriene receptor antagonists with varying clinical results and with particular safety profiles.Although there is not yet a treatment modality reaching clinical efficacy of cyclosporine A as gold standard of systemic therapy, limitation in its application duration as in its side effect profile as well as the search for alternatives has set a focus on the new alternatives of which especially B-cell-directed therapies might be promising candidates.

We report the case of a 45-year-old Caucasian woman suffering from cutaneous myiasis. With the use of scanning electron microscopy, we placed special focus on the mechanisms by which Dermatobia hominis can fasten securely within the human skin.

Background/Purpose: Disseminated granuloma annulare is a benign granulomatous skin disease of unknown etiology. Recently, UVA1 (340–400 nm) phototherapy has been found effective in a small series of four patients. The purpose of this two-center study was to determine the rate and duration of clinical response to UVA1 phototherapy in a larger cohort of 20 patients with disseminated granuloma annulare. Methods: Twenty patients with long-standing, stable disease (median 42 months, 95% CI 23–105) underwent UVA1 phototherapy. Sixteen patients were treated with a high-dose regimen (median single dose 110 J/cm2, 95% CI 103–121) and four patients with a medium-dose regimen (median single dose 50 J/cm2, CI 50–50). The clinical response was graded on a 5-point scale [0=none, 1=poor, 2=moderate, 3=substantial, 4=(near) complete]. After cessation of therapy, patients with a clinical score of 3 or 4 were followed up to evaluate the duration of clinical improvement. Results: At the end of treatment, five patients each had substantial improvement or (near) complete clearance. Another five patients had a moderate response, three patients were considered as poor responders and two patients as treatment failures. Out of the 10 patients with good or excellent response nine were available for follow up. Of these, two patients were still clear after 3 and 6 months, and seven patients relapsed after a median of 3 months (95% CI 1.68–6.46). Conclusions: UVA1 phototherapy provided good or excellent results in half of our 20 patients with disseminated granuloma annulare. In the majority of patients with a satisfactory response, however, discontinuation of treatment was followed by early recurrence of disease.

Background:The therapy of disseminated granuloma annulare has often limited success. Treatment of granuloma annulare with fumaric acid esters (FAE) has recently been reported to be effective in 2 patients. Objectives: To assess the efficacy of a systemic therapy with FAE in consecutive patients with disseminated granuloma annulare. Methods:Eight patients with disseminated granuloma annulare were treated with FAE in tablet form according to the standard therapy regimen used in psoriasis. The colour and the elevation of the skin lesions were assessed by a visual analogue scale before and after therapy. Results:Systemic therapy with FAE induced a significant clinical improvement in elevation and colour of skin lesions, with remission in 3 and partial remission in 4 patients. One patient remained unchanged. Side-effects associated with the therapy were seen in 6 patients. Conclusions: Systemic therapy with FAE can be effective in patients suffering from disseminated forms of granuloma annulare, but side-effects of FAE have to be taken into consideration.

UVA1 (340-400 nm) therapy proved to be highly effective in patients with severe atopic dermatitis. The optimal dose regarding therapeutic efficacy and possible side effects is still to be evaluated. In vitro cell culture as well as in vivo animal studies recently indicated that a correlation between UVA irradiation and photoaging, skin carcinogenesis, or melanoma induction may exist. Therefore it seems appropriate to focus research activities on reducing the UVA1 dose applied during phototherapeutic regimens minimizing nonbeneficial side effects.The present study was performed to evaluate the therapeutic effectiveness and long-term efficacy of medium-dose UVA1 irradiation in patients treated for acute exacerbated atopic dermatitis.Thirty-two patients underwent a medium-dose UVA1 therapy consisting of 15 treatments applied from Monday to Friday for a period of 3 weeks. The applied dose per treatment was 50 J/cm(2) resulting in a cumulative dose of 750 J/cm(2). Clinical severity was assessed according to the SCORAD index before and after irradiation as well as in monthly intervals up to 3 months after cessation of phototherapy.Medium-dose UVA1 phototherapy is effective for alleviating acute exacerbated atopic dermatitis as shown by a significant reduction of SCORAD ratings (P.001) at the end of the active UV treatment period. A significant skin improvement was still present 1 month later (P.001). However, at the end of the 3-month posttreatment observation period the skin condition had reached the pretreatment level.According to our data, medium-dose UVA1 phototherapy is a highly effective, nonsteroidal, therapeutic alternative for treatment of acute exacerbated atopic dermatitis. However, effectiveness is merely short term, limited, and is followed by recurrence of symptoms within a 3-month observation interval.

A 78-year-old woman presented with a 3-year history of slowly growing painless nodular lesions on both legs that were refractory to topically applied corticosteroids. On physical examination there were approximately 20 erythematous waxy plaques and nodules on edematous lower legs (Figure 1). Twenty years prior, the patient had undergone hysterectomy and adnexectomy followed by radiation for treatment of endometrial cancer. Thereafter, she experienced chronic lymphedema of both legs. Furthermore, the patient has chronic heart failure (NYHA class III), obesity (body mass index [BMI], 32 [calculated as weight in kilograms divided by height in meters squared]), arterial hypertension, and type II diabetes mellitus. For 60 years she had been receiving thyroid hormone therapy with levothyroxine sodium (currently 100 μg/d) for treatment of hypothyroidism. She did not have a history of Graves disease. Results of laboratory investigations, including routine blood tests, tests of liver enzymes, renal function, and thyroid profile, serum protein analysis, immunoglobulin levels, and autoantibody profile were within normal limits. Venous duplex ultrasonography excluded a relevant chronic venous insufficiency. A punch biopsy sample of the lower leg was obtained (Figure 2 and Figure 3). What is your diagnosis?