Andreas Nowak

Acne inversa (Hidradenitis suppurativa): A review with a focus on pathogenesis and treatment

Acne inversa (AI) is a disabilitating chronic inflammatory disease with major negative impact on quality of life and significant co-morbidities. This is an important link to insights into immune dysfunction, which stimulated therapeutic approaches like tumor necrosis-α inhibitor therapy. This new off-label drug treatment is particularly beneficial when used in combination with wide excision of inflamed skin and subcutaneous tissue. Retinoids have been reported to be helpful in secondary prevention. The standard of therapy in advanced cases is surgery with wide excisions and healing by secondary intention. This treatment results in significant reduction of complaints and achieves satisfactory body contouring.

Giant epithelial malignancies (Basal cell carcinoma, squamous cell carcinoma): a series of 20 tumors from a single center.

Background: Among nonmelanoma skin cancer (NMSC), basal cell carcinoma (BCC), and squamous cell carcinoma (SCC) are the most common. Giant NMSCs have occasionally reported in the medical literature with particular problems related to diagnosis and treatment. The aim of this study was to analyze patients, treatment, and outcome with giant BCC/SCC. Materials and Methods: We analyzed our files between January 1, 2008, and December 31, 2011, of an academic teaching hospital in the dermatology department. Patients were analyzed according to demographic factors, clinical presentation, histopathology, treatment, and outcome. American Society of Anesthesiology physical status system was used to assess the fitness of patients before surgery. Results: The frequency of giant NMSC was estimated as 0.4% for both tumor entities. 80% of giant BCC patients were female and 100% of giant SCC patients were male. The mean age was 81.5 ± 8.5 years for BCC) and 79.5 ± 11.4 years for SCC. The major anatomical site was the scalp. Four of 10 BCCs were classified metatypic (basosquamous). Perineural infiltration was seen in 5 NMSCs. Seventy percent of patients had an ASA score ≥3. Surgery was performed in general anaesthesia in 5 (BCC) and 6 (SCC) patients, respectively. All other patients were operated in local or tumescence anesthesia. Blood transfusions were necessary in five patients. The primary treatment was delayed Mohs technique. Defect closure was realized with rotational flaps in most cases. Neoadjuvant chemoimmune therapy and adjuvant combined cetuximab/radiotherapy have been performed in three patients. We observed three deaths, all unrelated to NMSC. 75% of patients achieved complete remission. Conclusions: Giant NMSC is uncommon but not rare. These tumors are high-risk subtypes. Treatment needs an interdisciplinary approach.Background: Among nonmelanoma skin cancer (NMSC), basal cell carcinoma (BCC), and squamous cell carcinoma (SCC) are the most common. Giant NMSCs have occasionally reported in the medical literature with particular problems related to diagnosis and treatment. The aim of this study was to analyze patients, treatment, and outcome with giant BCC/SCC. Materials and Methods: We analyzed our files between January 1, 2008, and December 31, 2011, of an academic teaching hospital in the dermatology department. Patients were analyzed according to demographic factors, clinical presentation, histopathology, treatment, and outcome. American Society of Anesthesiology physical status system was used to assess the fitness of patients before surgery. Results: The frequency of giant NMSC was estimated as 0.4% for both tumor entities. 80% of giant BCC patients were female and 100% of giant SCC patients were male. The mean age was 81.5 ± 8.5 years for BCC) and 79.5 ± 11.4 years for SCC. The major anatomical site was the scalp. Four of 10 BCCs were classified metatypic (basosquamous). Perineural infiltration was seen in 5 NMSCs. Seventy percent of patients had an ASA score ≥3. Surgery was performed in general anaesthesia in 5 (BCC) and 6 (SCC) patients, respectively. All other patients were operated in local or tumescence anesthesia. Blood transfusions were necessary in five patients. The primary treatment was delayed Mohs technique. Defect closure was realized with rotational flaps in most cases. Neoadjuvant chemoimmune therapy and adjuvant combined cetuximab/radiotherapy have been performed in three patients. We observed three deaths, all unrelated to NMSC. 75% of patients achieved complete remission. Conclusions: Giant NMSC is uncommon but not rare. These tumors are high-risk subtypes. Treatment needs an interdisciplinary approach.

Management of Severe Anogenital Acne Inversa (Hidradenitis Suppurativa)

BACKGROUND Severe anogenital acne inversa (AI) is a debilitating chronic inflammatory disease with a major negative effect on quality of life. OBJECTIVES To evaluate the role of surgery in the treatment of severe anogenital AI. METHODS We analyzed the records of patients with anogenital AI from 2000 to 2010. Assessment was done using the Hidradenitis Suppurativa Lesion, Area, and Severity Index (HS‐LASI), pain visual analogue scale, physician global assessment (PhGA), and patient global assessment (PaGA). Comorbidities and adverse events were analyzed. RESULTS Sixty‐seven patients with a Hurley score of 3 were identified. Mean follow‐up was 56.9 ± 41.3 months. A number of comorbidities were observed. After surgery, mean pain scores decreased from 6.3 ± 1.5 to 0.8 ± 0.7, PhGA improved from 6.8 ± 1.2 to 0.9 ± 0.6, PaGA improved from 7.3 ± 1.2 to 1.1 ± 0.5, and HS‐LASI decreased from 41.8 ± 21.3 to 2.4 ± 2.8. Adverse reactions were seen in 10.4%. The total relapse rate was 6% (5 patients) with only one case with healing by secondary intention (2% of 49 patients). CONCLUSIONS Surgery is the cornerstone of treatment for advanced AI. Healing by secondary intention results in significant reduction of complaints and achieves satisfying body contouring.

Acupuncture for treatment of hospital-induced constipation in children: a retrospective case series study

Objective Acupuncture is a promising option in the treatment of functional bowel disorders. The aim of this study was to evaluate the feasibility and acceptance of acupuncture for the treatment of hospital-induced constipation (HIC) in children. Methods Bilateral stimulation of acupuncture point LI11 was applied in 10 children with HIC using fixed indwelling acupuncture needles (0.9 mm long) before considering starting conventional local constipation therapy with laxative suppositories. The clinical records were studied retrospectively for feasibility, acceptance and effectiveness of acupuncture. Results Acupuncture was feasible in all children and application of the indwelling needles was tolerated without fear. Side effects were not observed. After a median of 3 days of HIC, all children defaecated within 2 h after LI11 stimulation. No patient required conventional local constipation therapy. Conclusions Acupuncture for the treatment of HIC is feasible and acceptable. Its effect should be verified in a randomised controlled trial.

A 10-year analysis of primary cutaneous malignant melanoma with sentinel lymph node biopsy and long-term follow-up.

Sentinel lymph node biopsy (SLNB) is an important tool for accurate staging of patients with melanoma. There is an ongoing debate whether the procedure provides therapeutic benefits or not.

Vagal sensory evoked potentials disappear under the neuromuscular block - an experimental study.

BACKGROUND Transcutaneous vagal nerve stimulation is a promising treatment modality in patients suffering mood disorders and chronic pain, however, the mechanisms are still to be elucidated. A recently developed technique of EEG responses to electrical stimulation of the inner side of the tragus suggests that these responses are far field potentials, generated in the vagal system - Vagal Sensory Evoked Potentials (VSEP). OBJECTIVE To reproduce the VSEP technique free from myogenic artifacts. METHODS Fourteen ASA I-II patients scheduled for elective surgery in standardized Total Intravenous Anesthesia (TIVA) were enrolled. Transcutaneous electrical stimulation was applied to the inner side of the right tragus. Averaged EEG responses were recorded from the electrode positions C4-F4 and T4-O2 before and after induction of TIVA, during the maximal effect of the non-depolarizing muscle relaxing agent, cis-atracurium (C-AR) and after recovery from C-AR under TIVA. RESULTS Typical response curves with P1, N1 and P2 peaks could be reproduced in all patients before and after anesthesia induction. The response curves disappeared during the C-AR action and re-appeared after recovery from C-AR under TIVA. CONCLUSION The disappearance of the scalp responses to electrical tragus stimulation under the neuromuscular block suggests a muscular origin of these potentials.

Treatment of elderly patients with advanced lipedema: a combination of laser-assisted liposuction, medial thigh lift, and lower partial abdominoplasty

Background Lipedema is a rare female disorder with a characteristic distribution of adipose tissue hypertrophy on the extremities, with pain and bruising. In advanced stages, reduction of adipose tissue is the only available effective treatment. In elderly patients with advanced lipedema, correction of increased skin laxity has to be considered for an optimal outcome. Methods We report on a tailored combined approach to improve advanced lipedema in elderly females with multiple comorbidities. Microcannular laser-assisted liposuction of the upper legs and knees is performed under tumescent anesthesia. Medial thigh lift and partial lower abdominoplasty with minimal undermining are used to correct skin laxity and prevent intertrigo. Postsurgical care with nonelastic flat knitted compression garments and manual lymph drainage are used. Results We report on three women aged 55–77 years with advanced lipedema of the legs and multiple comorbidities. Using this step-by-step approach, a short operation time and early mobilization were possible. Minor adverse effects were temporary methemoglobinemia after tumescent anesthesia and postsurgical pain. No severe adverse effects were seen. Patient satisfaction was high. Conclusion A tailored approach may be useful in advanced lipedema and is applicable even in elderly patients with multiple comorbidities.

A 10-year analysis of cutaneous mesenchymal tumors (sarcomas and related entities) in a skin cancer center.

Background  Mesenchymal neoplasms (sarcomas) of skin are rare. Patients with sarcomas were analyzed over the last decade.

Comorbidities, treatment, and outcome in severe anogenital inverse acne (hidradenitis suppurativa): a 15-year single center report.

Acne inversa (hidradentitis suppurativa; AI) is a severe chronic relapsing inflammatory skin disease of unknown cause. Anogenital AI has the strongest negative impact on quality of life and causes great disability.

Struck by lightning: Lichtenberg figures on a 19th-century wax model

Wax models in dermatology were used to a large extent until the 1930s as three-dimensional models to illustrate various pathologic conditions and in particular cutaneous signs of disease. As an example, a young woman who was struck by lightning and developed Lichtenberg figures is presented. Lichtenberg figures are a fernlike pattern on skin, characteristic of lightning. Such a wax model housed in the German Hygiene Museum Dresden, Germany, illustrates the significance of wax models and how, even today, they can play an important role in medical education.