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Oberflachliche Pilzinfektionen der Haut sind haufig und weltweit verbreitet. Neueren Schatzungen zufolge leidet allein etwa ein Drittel der europaischen Bevolkerung an einer Fusmykose, wobei die Dermatophyteninfektion der freien Haut, die Tinea pedis, im Vordergrund steht. Die Tinea pedis interdigitalis als bei Weitem haufigste Manifestationsform kann heute erfolgreich topisch behandelt werden. Hierfur steht eine ganze Reihe von topisch wirksamen Antimykotika zur Verfugung. Haufig eingesetzt werden die Azole, aber auch die Hydroxypyridone und die Allylamine, seltener die Morpholine. Die meisten Antimykotika weisen gegenuber Dermatophyten, den Erregern der Tinea pedis, uberwiegend fungistatische Effekte auf, wahrend Terbinafin als Vertreter der Allylamine uberwiegend fungizid wirkt. Aufgrund dieser Eigenschaft sind unter topischem Terbinafin kurzere Behandlungszeiten moglich. Fur eine effektive Behandlung bei unkomplizierter Tinea pedis interdigitalis mussen Azolcremes nicht selten 2-mal taglich uber 4 Wochen angewendet werden, wahrend Terbinafin als 1%ige Creme nur 1-mal taglich uber 1 Woche aufzutragen ist. Seit dem Jahr 2006 steht eine neue galenische Darreichungsform des 1% Terbinafins zur Verfugung, die nur ein einziges Mal aufgetragen werden muss. Diese filmbildende Losung zeigt moglicherweise Vorteile im Hinblick auf die Vermeidung eines verfruhten Therapieabbruchs und damit auf Ruckfallraten im Alltag.

Summary Aim: The Sentinel Lymph Node (SLN) is of considerable prognostic relevance, because extended lymph node dissection may not be performed in patients presenting with histologically negative SLN. The aim of the present study was to prove the prognostic value of the SLN-concept in these patients. Methods: So far the clinical follow-up of 162 patients with histologically proven malignant melanoma and metastatically uninvolved (negative) SLN was investigated. Histological examination included standard methods (HE-Test) and special histochemical techniques (S-100, HMB-45). All patients underwent clinical examination, ultrasonic diagnosis of the regional lymph nodes, and x-ray of the chest every 3 months. Results: Despite of negative SLN-findings in 8/162 patients metastases of the malignant melanoma were found after a time period of 5-27 months. Three patients presented with recurrence in the previously mapped (negative) SLN-basin. In another case the scintigraphically visualized SLN could not be identified intraoperativelly by means of the hand-held gamma probe. One patient showed intransit-metastases or skin-metastases, respectively; another patient recurred in the scar area. One patient showed hematogenic dissemination (liver) which is not detectable by lymphoscintigraphy; in another patient metastases were found outside the primary lymphatic basin (cervical). Conclusion: In our patient group 4,9% presented with metastases despite negative SLN while published data report up to 11% (observation period 35 months), among them only 3 patients (1,9%) being real concept failures. Our results underline that there is no evidence to change this concept in patients with clinically early stage.

Optical coherence tomography (OCT) allows real-time, in vivo examination of basal cell carcinoma (BCC). A new high definition OCT with high lateral and axial resolution in a horizontal (en-face) and vertical (slice) imaging mode offers additional information in the diagnosis of BCC and may potentially replace invasive diagnostic biopsies.To define the characteristic morphologic features of BCC by using high definition optical coherence tomography (HD-OCT) compared to conventional histology.A total of 22 BCCs were examined preoperatively by HD-OCT in the en-face and slice imaging mode and characteristic features were evaluated in comparison to the histopathological findings.The following features were found in the en-face mode of HD-OCT: lobulated nodules (20/22), peripheral rimming (17/22), epidermal disarray (21/22), dilated vessels (11/22) and variably refractile stroma (19/22). In the slice imaging mode the following characteristics were found: grey/dark oval structures (18/22), peripheral rimming (13/22), destruction of layering (22/22), dilated vessels (7/22) and peritumoural bright stroma (11/22). In the en-face mode the lobulated structure of the BCC was more distinct than in the slice mode compared to histology.HD-OCT with a horizontal and vertical imaging mode offers additional information in the diagnosis of BCC compared to conventional OCT imaging and enhances the feasibility of non-invasive diagnostics of BCC.

Adjuvant IFN-α treatment for patients with malignant melanoma is often complicated by depression. The influence of dosage, however, is unknown.The authors sought to elucidate this dosage effect.Using the Zung Self-Rating Depression Scale and the German Bf-S Self-Rating (Affectivity) Scale, the authors prospectively compared the frequency and severity of IFN-α-induced depressive symptoms between a group of 29 patients receiving low-dose and 17 patients getting high-dose induction therapy for 4 weeks.Patients receiving high-dose induction treatment had significantly higher depression scores after 4 weeks, and significantly more patients in the high-dose group developed depression.The authors concluded that frequency and severity of IFN-α-associated depression during melanoma treatment are dose-dependent.

Onychomycosis is a common problem. Today, the gold standard in the diagnosis of onychomycosis is the direct microscopy and fungal culture. But direct microscopy is regarded as having a low sensitivity and fungal culture takes long time. In addition, in cases of controlling the antifungal treatment course, the present gold standard is often not a reliable tool because of the inhibition of the fungal growth in the culture.The purpose of this study was to compare the present gold standard with histological examination with periodic acid-Schiff staining (PAS) of nail clippings in the diagnosis of onychomycosis in a large cohort.We prospectively evaluated 1146 nail samples from 851 patients with clinical signs of onychomycosis using direct microscopy and fungal culture in comparison with PAS-stain.A total of 631 nail samples revealed a positive result in at least one test. The most sensitive single test for the diagnosis of onychomycosis was PAS with 82%, followed by culture (53%) and direct microscopy (48%). In 64 cases, in which a prediagnostic antimycotic treatment has been initiated, PAS showed to have by far the highest sensitivity (88%) in comparison with culture (33%) or direct microscopy (50%).Periodic acid-Schiff staining is the single method with the highest sensitivity in terms of detection of fungal elements (hyphae) in nail specimens. Especially in cases with prior antifungal treatment, histological analysis of PAS-stained nail clippings should be considered as an appropriate diagnostic tool.

Superficial fungal infections are common and worldwide in distribution. Latest estimates suggest one- third of the population in Europe has a fungal infection of their feet, with dermatophyte infections of the skin of the feet (tinea pedis) most common. Tinea pedis interdigitalis is by far most common and can be effectively treated topically. Common agents include azoles, hydroxypyridones and allylamines, with morpholines used less frequently. While most antifungals have mainly fungistatic effects on dermatophytes, the causative agents of tinea pedis, terbinafine--an allylamine--is fungicidal. Due to this feature shorter treatment periods are possible using topical terbinafine. For effective treatment of uncomplicated tinea pedis interdigitalis, azole cream preparations are often used twice daily for four weeks whereas 1% terbinafine cream can be applied once a day for one week. Since 2006, 1% terbinafine is also available as a film-forming solution (FFS), which makes single-dose treatment possible. FFS may prove superior in daily practice with increased compliance and thus reduced recurrences.

The ‘acid mantle’ of the stratum corneum seems to be important for both permeability barrier formation and cutaneous antimicrobial defense. However, the origin of the acidic pH, measurable on the skin surface, remains conjectural. Passive and active influencing factors have been proposed, e.g. eccrine and sebaceous secretions as well as proton pumps. In recent years, numerous investigations have been published focusing on the changes in the pH of the deeper layers of the stratum corneum, as well as on the influence of physiological and pathological factors. The pH of the skin follows a sharp gradient across the stratum corneum, which is suspected to be important in controlling enzymatic activities and skin renewal. The skin pH is affected by a great number of endogenous factors, e.g. skin moisture, sweat, sebum, anatomic site, genetic predisposition and age. In addition, exogenous factors like detergents, application of cosmetic products, occlusive dressings as well as topical antibiotics may influence the skin pH. Changes in the pH are reported to play a role in the pathogenesis of skin diseases like irritant contact dermatitis, atopic dermatitis, ichthyosis, acne vulgaris and Candida albicans infections. Therefore, the use of skin cleansing agents, especially synthetic detergents with a pH of about 5.5, may be of relevance in the prevention and treatment of those skin diseases.

Human herpesviruses can be found worldwide and cause many viral infections in immunocompetent as well as in immunocompromised patients. Herpes simplex virus (HSV) diseases can be the cause of life-threatening disease, especially in neonates. After initial infection, HSV persists latently in host neurons with the risk of periodical reactivation over a lifetime. The development of acyclovir, a potent and specific nucleoside inhibitor of the herpes DNA polymerase, was a milestone in the history of antiviral drugs in the late 1970s. During the last decades a better understanding of the replication and disease-causing state of HSV types 1 and 2 has been achieved enabling the development of new and potent antiviral compounds. In the mid-1990s, for example, valacyclovir and famciclovir were launched as prodrugs of acyclovir with improved bioavailability. Despite the numerous drugs available for the systemic treatment of HSV infections, the topical application of a cream containing an antiviral agent is still the most convenient method of treating herpes simplex labialis/facialis in the general population. For some time, the topical standard treatment for recurrent HSV infections has been acyclovir cream, despite the fact that the evidence for efficacy in recurrent episodes has been equivocal. Penciclovir, a novel acyclic nucleoside analogue, has demonstrated efficacy against HSV types 1 and 2 and seems to have a pharmacological advantage due to a prolonged half-life of its active form in HSV-infected cells. This review discusses and compares the topical treatment modalities available for HSV infections. As a conclusion, different studies are available that have shown that it is possible to reduce viral replication and hasten lesion resolution with 1% penciclovir treatment beyond the prodromal phase of the HSV infection. Comparing data of topical treatment with acyclovir and penciclovir revealed a superiority for penciclovir cream showing a significant decrease in time to lesion healing, lesion area and pain. While systemic acyclovir or valacyclovir may be valid drugs especially for HSV prophylaxis, 1% penciclovir cream should be preferred as topical treatment since there are good therapeutic results independent of the phase of development of herpetic eruptions.

Knowledge of factors associated with the detection of cutaneous malignant melanomas and reasons for delay in diagnosis are essential for the improvement of secondary prevention of cutaneous melanoma. For this reason, the extent and consequence of patient and professional delay in diagnosis and treatment was investigated in 233 patients with histologically proven primary cutaneous melanomas seen at the Department of Dermatology and Allergology at the Ludwig-Maximilians-University, Munich, Germany, between January 1999 and January 2001. Personal interviews were conducted by two physicians to obtain information on patients' knowledge of melanoma symptoms, sun behaviour, delay in seeking medical attention, professional delay and related factors. The main component of delay was patient related. Nearly one-third (29.2%) of all patients reported a delay interval of more than 12 months from the onset of an observed change in a pigmented lesion or first detection of a pigmented lesion to the first visit to a physician. The delay interval from the first visit to a physician to surgical treatment was shorter (< 1 month) in most of our patients (74.7%). The predominant symptoms of melanoma detected by patients were a change in colour and an increase in size or elevation. Most patients had obtained knowledge about cutaneous melanomas from television and magazines. A delay in diagnosis and a history of many sunburns and outdoor leisure time activities were not associated with a greater tumour thickness. However, fairer skin types, lower education levels and lack of knowledge about cutaneous melanoma were associated with a greater tumour thickness. Further efforts are necessary to improve public and medical education about early detection and prompt surgical treatment, which is known to be the most effective treatment modality for cutaneous melanomas.

The Sentinel Lymph Node (SLN) is of considerable prognostic relevance, because extended lymph node dissection may not be performed in patients presenting with histologically negative SLN. The aim of the present study was to prove the prognostic value of the SLN-concept in these patients.So far the clinical follow-up of 162 patients with histologically proven malignant melanoma and metastatically uninvolved (negative) SLN was investigated. Histological examination included standard methods (HE-Test) and special histochemical techniques (S-100, HMB-45). All patients underwent clinical examination, ultrasonic diagnosis of the regional lymph nodes, and x-ray of the chest every 3 months.Despite of negative SLN-findings in 8/162 patients metastases of the malignant melanoma were found after a time period of 5-27 months. Three patients presented with recurrence in the previously mapped (negative) SLN-basin. In another case the scintigraphically visualized SLN could not be identified intraoperatively by means of the hand-held gamma probe. One patient showed intransit-metastases or skin-metastases, respectively; another patient recurred in the scar area. One patient showed hematogenic dissemination (liver) which is not detectable by lymphoscintigraphy; in another patient metastases were found outside the primary lymphatic basin (cervical).In our patient group 4.9% presented with metastases despite negative SLN while published data report up to 11% (observation period 35 months), among them only 3 patients (1.9%) being real concept failures. Our results underline that there is no evidence to change this concept in patients with clinically early stage.

Primary malignant melanoma of the lung (PMML) is a rare neoplasm that may be misdiagnosed as one of the more common types of lung cancer. Most cases are characterized by a very poor prognosis, ultimately leading to the patient's death. Since an optimal systemic treatment schedule is not established so far, early detection of lymph node metastases may be important for surgical interventions. We report on a 55-year-old male patient with a primary bronchial malignant melanoma of his left lower lobe that was treated by pneumonectomy. 11 and 17 months after removal of the PMML, suspicious lymph nodes in the patient's left axilla were identified by 7.5 MHz-ultrasound examinations. Again surgical treatment was performed and histopathology showed lymph node metastases of malignant melanoma. During adjuvant therapy with interferon alpha (3 x 6 Mio IE per week) no further relapse has been observed with a follow-up of 8 months after the last operation. An overview of primary melanoma of the lung is given and diagnostic options are discussed. The 7.5 MHz-ultrasound examination appears to be especially helpful in the early detection of lymph node metastases leading to early initiation of surgical treatment possibly associated with a prolonged survival in our patient.

Interferon-alpha (IFN-alpha) is of high interest in the adjuvant treatment of malignant melanoma. During long term treatment, psychiatric side effects play an important role and not infrequently lead to reduction or discontinuation of therapy. Most common are sleeping disturbance, agitation, weariness, sleepiness, irritability, social withdrawal and depression, which most often develop during the first three months of the therapy. Also more severe side effects may occur, like delirium, organic depression, psychotic episodes and organic personality change, which in some patients may even lead to suicidal thoughts or suicide attempts, which is illustrated in two case reports. Therapeutic intervention depend to the severity of side effects. Moderate depressive syndromes may successfully be treated by antidepressive drugs like serotonin reuptake inhibitors (SSRI), which may even allow continuation of IFN-alpha therapy. In patients with severe depression or organic personality changes with increased risk of suicide, immideate discontinuation of IFN-alpha therapy is mandatory and treatment in a psychiatric hospital must be considered.