Frauke Benedix

Phototherapy with Narrowband vs Broadband UVB

Phototherapy with ultraviolet (UV) radiation of wavelengths between 280 and 320 nm (UVB) is a safe and effective treatment for a variety of diseases. In addition to standard broadband UVB (bUVB), narrowband phototherapy with fluorescent bulbs emitting near monochromatic UV around 311 nm (nUVB) has become an important treatment for diseases such as psoriasis, atopic dermatitis and vitiligo. In addition to these indications, the number of diseases for which nUVB phototherapy is reported to be effective is continuously growing. The differential effects of nUVB phototherapy in comparison to other UV wavelengths as well as established and new indications for this treatment modality are reviewed.

Trichophytic Majocchi granuloma mimicking Kaposi sarcoma

A 68‐year‐old man presented with a one month history of painful blue‐red papules and nodules on an erythematous base on the top of his feet, as well as dystrophic toenails. He had undergone renal transplantation six months previously for membranous glomerulonephritis, and was immunosuppressed with tacrolimus 3 g, mycophenolate mofetil 1500 mg and prednisolone 5 mg daily. His tacrolimus level was 29.8 ng/ml (expected level 6–8 ng/ml). Even though the cutaneous lesions strongly suggested Kaposi sarcoma, the histological examination revealed a dermal abscess in which hyphae and spores were seen with PAS staining. ELISA‐PCR of the biopsy identified Trichophyton rubrum, which was also grown on culture of the biopsy tissue. The diagnosis of Majocchi granuloma secondary to excessive immunosuppression was made. Systemic treatment with terbinafine 250 mg per day and topical ciclopirox olamine completely cured the granulomatous skin lesions, and later the nails.

Prevention of polymorphic light eruption with a sunscreen of very high protection level against UVB and UVA radiation under standardized photodiagnostic conditions.

Polymorphic light eruption (PLE), with an overall prevalence of 10-20%, is mainly provoked by ultraviolet A (UVA) (320-400 nm) and to a lesser degree by UVB (280-320 nm). The most effective prophylaxis of PLE, application of UV protection clothing, is not feasible for all sun-exposed areas of the skin and UV-hardening is time-consuming and may be associated with side-effects. Most sunscreens protect predominantly against UVB and therefore fail to prevent PLE. The protection level of potent UVA-protective filters remains unresolved. This single-centre, open, placebo-controlled, intra-individual, comparative study, analysed the efficacy of a sunscreen of very high protection level against UVB and UVA, containing methylene bis-benzotriazolyl tetramethylbutylphenol (Tinosorb M), bis-ethylhexyloxyphenol methoxyphenyl triazine (Tinosorb S) and butyl methoxydibenzoylmethane as UVA absorbing filters, in the prevention of PLE under standardized photodiagnostic conditions. After determination of the minimal erythema dose at day 0, photoprovocation was performed in 12 patients with a clinical history of PLE, on days 1, 2 and 3 with 100 J/cm2 UVA and variable doses of UVB, starting with the 1.5-fold minimal erythema dose of UVB. Prior to irradiation, placebo was applied to the right and sunscreen to the left dorsal forearm under COLIPA (European Cosmetic, Toiletry and Perfumery Association) conditions. In 10 patients PLE could be provoked at the placebo site, with positive reactions in 90% of the UVA, 40% of the UVB and 90% of the UVA/UVB irradiated fields. At the site with the active treatment none of these patients developed PLE. These data demonstrate that a sunscreen with effective filters against UVA and UVB can successfully prevent the development of PLE. Further studies are needed to examine whether regular application of sunscreen under everyday conditions, especially in doses less than the tested COLIPA-norm, could be an equivalent alternative to UV-hardening therapy.

Response of Ulcerated Necrobiosis Lipoidica to Clofazimine

© 2009 The Authors. doi: 10.2340/00015555-0722 Journal Compilation

A young woman with recurrent vesicles on the lower lip: fixed drug eruption mimicking herpes simplex.

A 23-year-old woman presented with recurrent herpetiform vesicles of the lower lip, but all diagnostic measures for herpes virus infection including herpes viridae specific PCR were negative. Medical history revealed that she also had chronic recurrent vulvovaginal candidiasis, which had been treated with various regimes, including repetitive applications of fluconazole. Consequently, fluconazole-induced fixed drug eruption was suspected, but skin tests performed with fluconazole remained with-out response. Consecutive repeated oral provocation tests with fluconazole were carried out and resulted in the development of burning herpetiform vesicles of the lower lip. Histopathology revealed a subepidermal and superficial perivascular infiltrate, basal vacuolated and apoptotic keratinocytes, intra-epidermal lymphocytes and intra-epidermal multilocular vesicles. Together with the clinical history and picture, fluconazole-induced fixed drug eruption mimicking labial herpes simplex virus infection was diagnosed. Oral provocation tests with an alternative systemic antifungal treatment, itraconazole, were well tolerated, systemic therapy with itraconazole was initiated, and no further labial vesicles developed.

Early disseminated borreliosis with multiple erythema migrans and elevated liver enzymes: case report and literature review.

A 69-year-old man presented with multiple livid maculae and infiltrated urticarial plaques, as well as elevated liver enzymes. Based on typical clinical picture, histopathology and positive PCR from a skin biopsy, we diagnosed an early disseminated infection with Borrelia afzelii presenting with multiple erythema migrans (erythemata migrantia) and a subclinical hepatitis. During antibiotic treatment with intravenous ceftriaxone, the maculae and plaques vanished almost completely and the liver enzymes decreased within 14 days. Dermatologists should keep in mind that early disseminated borreliosis can present with multiple erythema migrans and hepatitis.

Neue und etablierte indikationen der UV-B-311-nm- phototherapie

UV‐B‐Breitband‐Phototherapie (280 – 320 nm) stellt eine effektive und sichere Therapiemöglichkeit für zahlreiche entzündliche Erkrankungen der Haut dar. Neben der UVB‐Breitband‐Phototherapie hat insbesondere die UV‐B‐Schmalspektrum‐Therapie, mit einem Emissionsspektrum zwischen 310 – 315 nm, für die Behandlung der Psoriasis, der atopischen Dermatitis und der Vitiligo zunehmend an Bedeutung gewonnen. Die UV‐B‐Schmalspektrumphototherapie, auch als UV‐B‐311‐nm‐Phototherapie bezeichnet, hat sich in den letzten Jahren auch bei weiteren Erkrankungen, wie Mycosis fungoides, polymorpher Lichtdermatose, Pruritus und GvHD, als effektiv erwiesen. Die unterschiedlichen Effekte der Schmalspektrum‐UV‐B‐Therapie im Vergleich zu anderen etablierten Phototherapien sowie neue und etablierte Indikationen werden in diesem Artikel diskutiert.

New and established indications for phototherapy with narrowband UVB

UV‐B‐Breitband‐Phototherapie (280 – 320 nm) stellt eine effektive und sichere Therapiemöglichkeit für zahlreiche entzündliche Erkrankungen der Haut dar. Neben der UVB‐Breitband‐Phototherapie hat insbesondere die UV‐B‐Schmalspektrum‐Therapie, mit einem Emissionsspektrum zwischen 310 – 315 nm, für die Behandlung der Psoriasis, der atopischen Dermatitis und der Vitiligo zunehmend an Bedeutung gewonnen. Die UV‐B‐Schmalspektrumphototherapie, auch als UV‐B‐311‐nm‐Phototherapie bezeichnet, hat sich in den letzten Jahren auch bei weiteren Erkrankungen, wie Mycosis fungoides, polymorpher Lichtdermatose, Pruritus und GvHD, als effektiv erwiesen. Die unterschiedlichen Effekte der Schmalspektrum‐UV‐B‐Therapie im Vergleich zu anderen etablierten Phototherapien sowie neue und etablierte Indikationen werden in diesem Artikel diskutiert.

Transient zinc deficiency in preterm infants

Zinc is an essential element and necessary for various cellular functions. Preterm infants may have a negative zinc balance and are therefore especially susceptible for symptomatic zinc deficiency. We report on a preterm child with distinct clinical manifestations of zinc deficiency confirmed by histology and laboratory analysis who quickly healed with oral zinc therapy.ZusammenfassungZink ist ein essenzielles Spurenelement und wird für eine Vielzahl von Zellfunktionen benötigt. Frühgeborene können eine negative Zinkbilanz aufweisen und sind daher besonders anfällig für einen symptomatischen Zinkmangel. Wir berichten über ein Frühgeborenes mit ausgeprägtem klinischen Bild eines histologisch und laborchemisch diagnostizierten Zinkmangels, der unter einer oralen Zinksubstitution rasch vollständig abheilte.AbstractZinc is an essential element and necessary for various cellular functions. Preterm infants may have a negative zinc balance and are therefore especially susceptible for symptomatic zinc deficiency. We report on a preterm child with distinct clinical manifestations of zinc deficiency confirmed by histology and laboratory analysis who quickly healed with oral zinc therapy.

Metastasizing squamous cell carcinomas in a patient treated with extracorporeal photopheresis for cutaneous T-cell lymphoma

Sir, Extracorporeal photopheresis (ECP) is described as effective and safe in the treatment of erythrodermic cutaneous T-cell lymphoma (CTCL) (1). It is thought that ECP acts mainly through the induction of apoptotic cell death in leukocytes; this apoptotic cell death may cause subclinical immunosuppression. Actinically derived squamous cell carcinoma (SCC) are usually found in patients with an extensive lifetime sun exposure and are typically not aggressive. Moreover, CTCL patients are not known to have an increased incidence of SCC, not even in those who have undergone multiple psoralen plus UVA (PUVA) photochemotherapies (2, 3). Here we describe a patient with CTCL in whom multiple SCC with rapid growth and metastatic lymph node involvement developed shortly after ECP treatment.