B. Hermes

Mast cells and their mediators in cutaneous wound healing – active participants or innocent bystanders?

Abstract: Mast cells are traditionally viewed as effector cells of immediate type hypersensitivity reactions. There is, however, a growing body of evidence that the cells might play an important role in the maintenance of tissue homeostasis and repair. We here present our own data and those from the literature elucidating the possible role of mast cells during wound healing. Studies on the fate of mast cells in scars of varying ages suggest that these cells degranulate during wounding, with a marked decrease of chymase‐positive cells, although the total number of cells does not decrease, based on SCF‐receptor staining. Mast cells contain a plethora of preformed mediators like heparin, histamine, tryptase, chymase, VEGF and TNF‐α which, on release during the initial stages of wound healing, affect bleeding and subsequent coagulation and acute inflammation. Various additional vasoactive and chemotactic, rapidly generated mediators (C3a, C5a, LTB4, LTC4, PAF) will contribute to these processes, whereas mast cell‐derived proinflammatory and growth promoting peptide mediators (VEGF, FGF‐2, PDGF, TGF‐β, NGF, IL‐4, IL‐8) contribute to neoangiogenesis, fibrinogenesis or re‐epithelization during the repair process. The increasing number of tryptase‐positive mast cells in older scars suggest that these cells continue to be exposed to specific chemotactic, growth‐ and differentiation‐promoting factors throughout the process of tissue remodelling. All these data indicate that mast cells contribute in a major way to wound healing, their role as potential initiators of or as contributors to this process, compared to other cell types, will however have to be further elucidated.

Expression of prothrombin, thrombin and its receptors in human scars

Abstract:  The coagulation system is thought to play a pivotal role during the initial phase of wound healing, but mechanisms and cells involved are only partly understood. We have therefore examined human scars for the expression of thrombin, its precursor prothrombin and the thrombin receptors, thrombomodulin (TM) and protease‐activated receptor‐1 (PAR‐1), compared with normal skin. Biopsies of scars were obtained from primary excision sites of melanoma patients (n = 20) and were compared with normal skin distant from the scar (n = 10), using immunohistochemistry. In addition, polymerase chain reaction analyses were performed on scar versus normal tissue and on cultured keratinocytes, fibroblasts and endothelial cells before and after stimulation with selected cytokines known to be active in wound healing. Normal epidermis was stained for prothrombin, thrombin, TM and PAR‐1, and dermal tissue was stained only for TM and PAR‐1. In scar tissue, thrombin and TM were upregulated in the epidermis and all four molecules in the dermis, independent of the age of the scars. In tissue extracts, mRNA expression of PAR‐1 and prothrombin expression were, however, unchanged and TM even slightly decreased in scars, compared with normal skin. On analysis of cultured cells, keratinocytes expressed mRNA for PAR‐1, TM and prothrombin, endothelial cells for PAR‐1 and TM, and fibroblasts for PAR‐1. An upregulation of PAR‐1 mRNA was induced in fibroblasts on exposure to tumor necrosis factor‐α (TNF‐α), while it remained unchanged in endothelial cells in response to TNF‐α. A downregulation of TM was induced in endothelial cells on exposure to TNF‐α. These findings, showing a marked modulation of thrombin, PAR‐1 and TM even in older human scar tissue, suggest that the coagulation system is not only involved during clotting, but also during the inflammatory and tissue remodelling phases of wound healing.

New lifestyle drugs and somatoform disorders in dermatology

An increasing number of healthy individuals make use of ‘lifestyle’ drugs, such as nootropics, psychopharmaca, hormones and eco‐drugs. In this respect, the fact that many people try to improve their outer appearance, solve their ‘cosmetic problems’, influence their rate of hair growth and altogether delay, halt or even reverse the natural ageing process has become a relevant matter for the practising dermatologist. Lifestyle drugs in dermatology are taken in an attempt to increase personal life quality by means of attaining a certain, psychosocially defined beauty ideal. They are not taken to manage a medically identifiable, well‐defined disease. Often, patients suffering from somatoform disorders, such as hypochondriac disorders, body dysmorphic disorders, somatization disorders or persistent somatoform pain disorders, may spontaneously ask physicians, in particular dermatologists and plastic surgeons, to prescribe them lifestyle drugs. Typically, patients repeatedly present with alleged ‘physical symptoms’ that turn out to be subjective complaints without any underlying identifiable medical disease. The use of lifestyle drugs without any proper medical indication may lead to a chronification of the emotional disorders that had ultimately been the cause of the patients’ request for such drugs. Such disorders may need to be treated promptly with psychotherapy and/or appropriate psychopharmacotherapy, and the choice of the treatment requires an accurate differential diagnostic approach.

Psychosomatic disturbances and cosmetic surgery

Medical activity in recent years has experienced a marked expansion of possi‐bilities for aesthetic surgery, usually requested by patients. Especially in derma‐tology, an increasing demand for and use of doctor/medical services by healthy individuals has resulted in a drastic change to cosmetic dermatology. The request for cosmetic surgery is emotionally or psychosocially motivated. Patients with psychological disturbances sometimes push aside possible risks and complications or deny side effects and interactions of the procedures. Subjective impairments of appearance, feelings of inferiority and social pho‐bias may be in the background of somatizing disorders. These emotional disor‐ders, such as body dysmorphic disorder, personality disorder or polysurgical addiction, often remain undiscovered but should be excluded in any patient receiving cosmetic procedures.

Nihilodermie in der Psychodermatologie

ZusammenfassungDie „Nihilodermie“ bezeichnet eine Krankheitsgruppe schwieriger dermatologischer „Problempatienten“ ohne objektivierbare Befunde, die eine wiederholte Darbietung körperlicher Symptome in Verbindung mit hartnäckigen Forderungen nach medizinischen Untersuchungen aufzeigen. Bei diesen primär psychischen Störungen handelt es sich um somatoforme Störungen, wobei die Patienten einen psychosozialen Zusammenhang meist strikt ablehnen und eine rein somatische Behandlung erwarten. Zu den heterogenen klinischen Bildern können beispielsweise Pruritus, Schmerzen, Parästhesien oder auch Entstellungsgefühle, Ökosyndrome, Erythrophobie und diffuses Effluvium gehören. Die somatoformen Störungen werden in Somatisierungsstörungen, hypochondrische Störungen, somatoforme autonome Funktionsstörungen, anhaltende somatoforme Schmerzstörungen sowie „sonstige somatoforme Störungen“ eingeteilt. Eine exakte differenzialdiagnostische Einordnung ist notwendig, um adäquate Therapiestrategien einleiten zu können. Abstract“Nihilodermia” refers to a group of difficult “problem” patients in dermatology without objective findings but with recurrent symptoms and stubborn demand for medical examination. These primary emotional disorders are somatoform disorders, but the patients usually strictly deny a psychosocial aspect and expect purely somatic treatment. Clinical patterns include pruritus, pain, paresthesias, feelings of disfiguration, eco-syndromes, erythrophobia and psychogenic pseudoeffluvium. The relevant somatoform disorders in dermatology can be differentiated as somatization disorders, hypochondriacal disorders, somatoform autonomous disorders, persistent somatoform pain disorders and “other somatoform disorders”. A precise differential diagnostic division is necessary in order to initiate adequate therapy strategies.

Suizidalität in der Dermatologie

Even in dermatology one can potentially encounter suicidal patients. A risk of suicide can be preexisting, appear as complication of skin disorders or be triggered by medications such as interferons. Patients at risk must be specifically asked about suicidal ideations and tendencies. Acute suicide risk requires immediate crisis intervention. In dermatology suicide risk has been described in severe acne conglobata (especially men) and metastatic melanoma. Patients with chronic or potentially fatal disease or severe pain may be suicidal. In addition patients with depression, alcohol dependency, substance abuse, schizophrenia or borderline personality disorder are at special risk. We review psychodermatological diseases with risk of suicide and point out treatment strategies. More attention should be focused on the early recognition of a possible risk of suicide in dermatology patients.ZusammenfassungAuch in der Dermatologie ist potenziell mit suizidalen Patienten zu rechnen. Ein Suizidrisiko kann bereits prämorbid bestehen, als Komplikation neu hinzutreten oder im Rahmen von bestimmten medikamentösen Therapien wie Interferonen als Nebenwirkung auftreten. Auf Suizidideen und Suizidabsichten müssen gefährdete Patienten offen angesprochen werden. Akute Suizidgefahr erfordert eine rasche Krisenintervention. In der Dermatologie wurde erhöhte Suizidalität bei Patienten mit Acne conglobata (Männer) und mit metastasierendem Melanom beschrieben. Grundsätzlich besteht bei Patienten mit chronischen oder präfinalen Erkrankungen und starken Schmerzen eine erhöhte Suizidalität. Besonders gilt dies bei an Depression, Abhängigkeit von Alkohol oder anderen Suchtstoffen, Schizophrenie und/oder an Borderline-Persönlichkeitsstörung erkrankten Patienten. Der Beitrag gibt einen Überblick hinsichtlich des Problembereichs Suizidalität in der Dermatologie und zeigt Strategien zum Vorgehen auf. Dem frühzeitigen Erkennen eines möglichen Suizidrisikos sollte in der Dermatologie mehr Beachtung geschenkt werden.AbstractEven in dermatology one can potentially encounter suicidal patients. A risk of suicide can be preexisting, appear as complication of skin disorders or be triggered by medications such as interferons. Patients at risk must be specifically asked about suicidal ideations and tendencies. Acute suicide risk requires immediate crisis intervention. In dermatology suicide risk has been described in severe acne conglobata (especially men) and metastatic melanoma. Patients with chronic or potentially fatal disease or severe pain may be suicidal. In addition patients with depression, alcohol dependency, substance abuse, schizophrenia or borderline personality disorder are at special risk. We review psychodermatological diseases with risk of suicide and point out treatment strategies. More attention should be focused on the early recognition of a possible risk of suicide in dermatology patients.

Nihilodermia in psychodermatology

ZusammenfassungDie „Nihilodermie“ bezeichnet eine Krankheitsgruppe schwieriger dermatologischer „Problempatienten“ ohne objektivierbare Befunde, die eine wiederholte Darbietung körperlicher Symptome in Verbindung mit hartnäckigen Forderungen nach medizinischen Untersuchungen aufzeigen. Bei diesen primär psychischen Störungen handelt es sich um somatoforme Störungen, wobei die Patienten einen psychosozialen Zusammenhang meist strikt ablehnen und eine rein somatische Behandlung erwarten. Zu den heterogenen klinischen Bildern können beispielsweise Pruritus, Schmerzen, Parästhesien oder auch Entstellungsgefühle, Ökosyndrome, Erythrophobie und diffuses Effluvium gehören. Die somatoformen Störungen werden in Somatisierungsstörungen, hypochondrische Störungen, somatoforme autonome Funktionsstörungen, anhaltende somatoforme Schmerzstörungen sowie „sonstige somatoforme Störungen“ eingeteilt. Eine exakte differenzialdiagnostische Einordnung ist notwendig, um adäquate Therapiestrategien einleiten zu können. Abstract“Nihilodermia” refers to a group of difficult “problem” patients in dermatology without objective findings but with recurrent symptoms and stubborn demand for medical examination. These primary emotional disorders are somatoform disorders, but the patients usually strictly deny a psychosocial aspect and expect purely somatic treatment. Clinical patterns include pruritus, pain, paresthesias, feelings of disfiguration, eco-syndromes, erythrophobia and psychogenic pseudoeffluvium. The relevant somatoform disorders in dermatology can be differentiated as somatization disorders, hypochondriacal disorders, somatoform autonomous disorders, persistent somatoform pain disorders and “other somatoform disorders”. A precise differential diagnostic division is necessary in order to initiate adequate therapy strategies.

Suicidal behavior in dermatology

Even in dermatology one can potentially encounter suicidal patients. A risk of suicide can be preexisting, appear as complication of skin disorders or be triggered by medications such as interferons. Patients at risk must be specifically asked about suicidal ideations and tendencies. Acute suicide risk requires immediate crisis intervention. In dermatology suicide risk has been described in severe acne conglobata (especially men) and metastatic melanoma. Patients with chronic or potentially fatal disease or severe pain may be suicidal. In addition patients with depression, alcohol dependency, substance abuse, schizophrenia or borderline personality disorder are at special risk. We review psychodermatological diseases with risk of suicide and point out treatment strategies. More attention should be focused on the early recognition of a possible risk of suicide in dermatology patients.ZusammenfassungAuch in der Dermatologie ist potenziell mit suizidalen Patienten zu rechnen. Ein Suizidrisiko kann bereits prämorbid bestehen, als Komplikation neu hinzutreten oder im Rahmen von bestimmten medikamentösen Therapien wie Interferonen als Nebenwirkung auftreten. Auf Suizidideen und Suizidabsichten müssen gefährdete Patienten offen angesprochen werden. Akute Suizidgefahr erfordert eine rasche Krisenintervention. In der Dermatologie wurde erhöhte Suizidalität bei Patienten mit Acne conglobata (Männer) und mit metastasierendem Melanom beschrieben. Grundsätzlich besteht bei Patienten mit chronischen oder präfinalen Erkrankungen und starken Schmerzen eine erhöhte Suizidalität. Besonders gilt dies bei an Depression, Abhängigkeit von Alkohol oder anderen Suchtstoffen, Schizophrenie und/oder an Borderline-Persönlichkeitsstörung erkrankten Patienten. Der Beitrag gibt einen Überblick hinsichtlich des Problembereichs Suizidalität in der Dermatologie und zeigt Strategien zum Vorgehen auf. Dem frühzeitigen Erkennen eines möglichen Suizidrisikos sollte in der Dermatologie mehr Beachtung geschenkt werden.AbstractEven in dermatology one can potentially encounter suicidal patients. A risk of suicide can be preexisting, appear as complication of skin disorders or be triggered by medications such as interferons. Patients at risk must be specifically asked about suicidal ideations and tendencies. Acute suicide risk requires immediate crisis intervention. In dermatology suicide risk has been described in severe acne conglobata (especially men) and metastatic melanoma. Patients with chronic or potentially fatal disease or severe pain may be suicidal. In addition patients with depression, alcohol dependency, substance abuse, schizophrenia or borderline personality disorder are at special risk. We review psychodermatological diseases with risk of suicide and point out treatment strategies. More attention should be focused on the early recognition of a possible risk of suicide in dermatology patients.

Borderline personality disorder in dermatology

Borderline personality disorder is a syndrome of complex psychopathology which is not very common in dermatology. The emotional symptoms are broad and variable, but typically feature emotional instability, intense anger or lack of control of anger, impulsiveness, instabilities in self-perception, problems at work, chronic feelings of emptiness, unstable partnership relations and recurrent suicidal threats. Self-inflicted injuries are common and may lead patients to dermatologists. A 26-year old woman with borderline personality was hospitalized for neurosyphilis. During inpatient treatment she repeatedly cut herself with razor blades. This article highlights the diagnostic criteria and differential approach of the borderline personality disorder in order to facilitate early recognition and therapy.ZusammenfassungDie emotional instabile Persönlichkeitsstörung (Borderline-Störung) ist ein komplexes psychopathologisches Krankheitsbild, das in der Dermatologie bisher nur wenig Beachtung gefunden hat. Die psychische Symptomatik zeigt ein breites und variables Spektrum mit Dominieren von Unruhezuständen, Getriebensein, Wutausbrüchen, Impulsivität, Instabilitäten im Selbstbild, Problemen im Beruf, innerer Leere, Partnerschaftsproblemen sowie Suizidalität. Besonders die häufig zu beobachtenden Selbstverletzungen können zur Vorstellung beim Hautarzt führen. Wir berichten über eine 26-jährige Patientin mit emotional instabiler Persönlichkeitsstörung, die aufgrund einer Neurolues stationär behandelt wurde und sich während des Krankenhausaufenthaltes zahlreiche Selbstverletzungen zufügte. Der vorliegende Beitrag legt die komplexen Diagnosekriterien und Differenzialdiagnosen der emotional instabilen Persönlichkeitsstörung dar, um frühzeitiges Erkennen und Therapieeinleitung zu ermöglichen.AbstractBorderline personality disorder is a syndrome of complex psychopathology which is not very common in dermatology. The emotional symptoms are broad and variable, but typically feature emotional instability, intense anger or lack of control of anger, impulsiveness, instabilities in self-perception, problems at work, chronic feelings of emptiness, unstable partnership relations and recurrent suicidal threats. Self-inflicted injuries are common and may lead patients to dermatologists. A 26-year old woman with borderline personality was hospitalized for neurosyphilis. During inpatient treatment she repeatedly cut herself with razor blades. This article highlights the diagnostic criteria and differential approach of the borderline personality disorder in order to facilitate early recognition and therapy.

Lifestyle Drugs in Old Age - A Mini-Review

Normal aging is no disease. The individual lifestyle may be responsible for a large fraction of the so-called ‘age-related’ changes. An increasing number of healthy individuals make use of ‘lifestyle’ drugs, such as nootropics, psychopharmaca, hormones and ecodrugs. In this respect, the fact that many people try to improve their outer appearance, to solve their ‘cosmetic problems’, to influence their rate of hair growth and to altogether delay, halt or even reverse the natural aging process has become a relevant matter for the practising doctor. Lifestyle drugs are taken in an attempt to increase personal life quality by means of attaining a certain psychosocially defined medical or beauty ideal, rather than to manage a medically identifiable, well-defined disease. Often, patients suffering from somatoform disorders such as hypochondriac disorders, body dysmorphic disorders, somatization disorders or persistent somatoform pain disorders may spontaneously ask physicians to prescribe them lifestyle drugs. Also, when ‘healthy’ people demand a lifestyle drug, possible side effects and contraindications must be taken into consideration and ruled out.