Gesina Hansel

Tumor Necrosis Factor-α Inhibitor-Induced Psoriasis or Psoriasiform Exanthemata

Tumor necrosis factor-α (TNFα) inhibition is effective in the treatment of moderate-to-severe psoriasis. We report on 120 patients from the literature including six new patients (three women and three men) who developed pustular lesions during treatment with TNFα inhibitors. We identified 72 women and 36 men (several papers did not specify the gender of patients) with an age range of 13–78 years (mean 42.3 years). The primary diagnoses were rheumatoid arthritis (n = 61), ankylosing spondylitis (n = 21), psoriasis (n = 10), Crohn disease (n = 8), SAPHO (synovitis acne pustulosis hyperostosis osteitis) syndrome (n = 3), psoriatic arthritis (n = 2), and other diagnoses (n = 15). Psoriasis (except palmoplantar pustular type) was the most common adverse effect during anti-TNFα treatment (n = 73), followed by palmoplantar pustular psoriasis (n = 37) and psoriasis of the nail (n = 6), sometimes combined in the same patient. Palmoplantar pustulosis and psoriasiform exanthema was the diagnosis in ten patients each. A positive personal history of psoriasis was recorded in 25 patients. A positive family history was noted in eight patients. No data about personal (n = 7) or family history (n = 46) were available in a number of patients. Newly induced psoriasis was diagnosed in 74 patients whereas an exacerbation or aggravation of a pre-existing psoriasis was noted in another 25 patients.All three TNFα inhibitors available on the market were involved: infliximab (63 patients), etanercept (37 patients), and adalimumab (26 patients). Several patients were treated with more than a single TFNα inhibitor. The timing of cutaneous adverse effects (psoriasis and psoriasiform rash) varied considerably among patients, ranging from after a single application to a delayed response of up to 63 months after initiation of treatment. The mean time to appearance of the cutaneous adverse effect for all TNFα inhibitors was 9.5 months.

Topical pimecrolimus for skin disease other than atopic dermatitis.

Pimecrolimus is an ascomycin macrolactam. It is a specific calcineurin inhibitor that allows topical application. The highly lipophilic nature of this compound reduces the risk of systemic absorption through normal and inflammed skin. Pimecrolimus shows activity not only against T-cell activation, but also against mast cells and pruritus. Pimecrolimus 1% cream is approved for atopic dermatitis, and also has a great potential in other inflammatory skin diseases. Clinical trials have been performed in contact- and seborrhoeic dermatitis, genital lichen sclerosus, intertriginous psoriasis and cutaneous lupus erythematosus. In other diseases, the available data are limited to small case series, or individual cases of graft-versus-host disease or Netherton’s disease. Although the use of calcineurin inhibitors in the treatment of vitiligo is promising, detailed studies with pimecrolimus and ultraviolet-irradiation are necessary and there is a need for prospective randomised, double-blind controlled trials.

Deep Ulcer Shaving Combined With Split-Skin Transplantation in Distal Calciphylaxis

Calciphylaxis is a cause of painful deep ulcers. There is controversy about best wound management in this disease. A retrospective study of inpatients during the 3 years was made. Seven calciphylaxis patients were identified. All patients suffered from various associated pathologies including diabetes mellitus type II and chronic renal insufficiency. Ulcers were treated by aggressive and deep shaving combined with autologous split-skin grafting in the same session. A 30% to 90% take rate of the grafts eventually with a complete ulcer healing in 6 of 7 patients was achieved. No patient developed a deep cutaneous infection or sepsis. All patients are still alive except one. The single death was related to cardiovascular complications. In distal calciphylaxis, aggressive ulcer surgery with defect closure offers a marked improvement in quality of life and prevents early deep skin infections and sepsis as major causes of mortality.

Rituximab therapy of recalcitrant bullous dermatoses

BACKGROUND Rituximab is a monoclonal antibody directed against CD20 cell surface antigen of B-lymphocytes. Recent studies have demonstrated effectivity in recalcitrant bullous pemphigoid. The data available on other types of autoimmune bullous disease is more scant. MAIN OBSERVATION Here we report on the successful adjuvant use of rituximab in mucous membrane pemphigoid and pemphigus vulgaris in two patients with the most refractory course of disease. Both patients achieved a good clinical response. CONCLUSIONS Rituximab is a third line treatment of patients with pemphigus vulgaris and mucous membrane pemphigoid. In contrast to bullous pemphigoid, other bullous diseases do not always respond to a monotherapy with this monoclonal antibody. Nevertheless, biological therapy seems to work faster than established treatment in such cases. Risks and benefits of the treatment are discussed.

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.

Successful treatment of relapsing disseminated coccidioidomycosis with cutaneous involvement with posaconazole.

A 52‐year‐old woman with pulmonary sarcoidosis on immunosuppressive therapy developed pulmonary infiltrates and cutaneous granulomatous abscesses after a trip to the USA in April 2005. A hyphomycete was identified, further characterized by a gene probe as Coccidioides spp. and then definitively identified as Coccidioides posadasii by polymerase chain reaction and sequencing. Antibodies towards Coccidioides spp. were detected. The infection was successfully treated with posaconazole (Noxafil®), 2 x 400 mg/d.

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.

The hospital as a work of art: one hundred thirty years of dermatology in Dresden-Friedrichstadt

The department of dermatology at the Hospital Dresden-Friedrichstadt (Dresden, Germany) was founded in 1874 as one of the oldest departments of dermatology in a municipal hospital in Germany. Dresden was the capital of Saxony and, as such, one of the most influential cultural centers of Germany. This particular situation is also reflected by the hospitals history itself.

Merkel cell carcinoma of the lower leg with retroperitoneal GIST: a very rare association

SummaryMerkel cell carcinoma (MCC) is a rare neuroendocrine tumor of the skin. Although its association with other malignancies is well known, an association with gastrointestinal stromal tumor (GIST) has yet not been described.We report about a 65-year-old female patient who presented with a hypervascularized subcutaneous tumor mass of her left calf. Resection of the primary tumor and histopathological investigations confirmed the diagnosis of MCC. The patient was treated by delayed Mohs surgery, and tumor-free margins were obtained. Sentinel lymph node biopsy was negative for metastatic spread. Primary tumor and lymph node basin were treated by adjuvant radiotherapy. During staging of the patient, a second malignancy—a GIST—was detected. Neoadjuvant treatment with multikinase inhibitor imatinib induced a partial response of GIST that was eventually removed by surgery. However, 8 months later, the patient developed subcutaneous regional metastases of MCC, which were surgically removed. Adjuvant therapy was planned by oncologists.To the best of our knowledge, the occurrence of MCC and GIST in the same patient has yet not been reported. In contrast to GIST, MCC did not respond to imatinib, although c-kit mutations are common in MCC.ZusammenfassungDas Merkelzellkarzinom (MCC) ist ein seltener neuroendokriner Tumor der Haut. Obwohl bekannt ist, dass es mit anderen Malignomen gemeinsam vorkommen kann, wurde die Assoziation zum gastrointestinalen Stromatumor (GIST) bislang noch nicht beschrieben.Wir berichten über eine 65-jährige Patientin, die sich mit einem hypervaskularisierten Tumor der rechten Wade vorstellte. Die Resektion des Tumors erfolgte, und die histologische Aufarbeitung ergab die Diagnose eines MCC. Es wurde die Komplettresektion des Tumors mittels verzögerter Mohs-Chirurgie eingeleitet, und tumor-freie Schnittränder wurden erzielt. Die Sentinellymphonodektomie zeigte keine Hinweise auf metastatische Absiedlungen. Das Gebiet des Primärtumors und die regionalen Lymphknoten wurden adjuvant bestrahlt. Im Rahmen des Tumorstagings wurde ein Zweittumor – hier ein GIST – entdeckt. Die neoadjuvante Behandlung mit dem Multikinaseinhibitor Imatinib induzierte eine partielle Response des GIST, eine chirurgische Entfernung schloss sich an. Acht Monate später mussten subkutane regionale Metastasen des MCC operativ entfernt werden. Eine adjuvante onkologische Therapie ist geplant.Das gemeinsame Auftreten von MCC und GIST ist unseres Wissens noch nicht beschrieben worden. Imatinib konnte in unserem Fall den GIST verkleinern, hatte jedoch auf das MCC keinen therapeutischen Einfluss gezeigt.

Severe atypical herpes zoster as an initial symptom of fatal myelodysplastic syndrome with refractory anemia and blast excess (RAEB II)

Herpes zoster is a common disease caused due to varicella zoster virus (VZV) infection with increasing incidence by age. If the patient has a severe, extended, or treatment-recalcitrant course of herpes zoster, this must be a red flag to search for underlying pathologies. Here, we report about a 64-year-old male patient with diabetes, who came to our emergency department because of general malaise, fever, chills, and a pronounced nuchal and facial swelling on the left side. Based on herpetiform-grouped vesicles and yellowish crusts, an impetiginized facial herpes zoster was diagnosed, and combined antiviral and antibiotic treatment was initiated. He was HIV negative. Despite intensified treatment, his situation worsened. We observed blasts in peripheral blood, but bone marrow biopsy was initially denied. Some days later after deterioration of his disease, he accepted further diagnostics. A myelodysplastic syndrome with blast excess (refractory anemia and blast excess II, RAEB II) could be confirmed. The following translocations were detected: t(2;12)(p13; q13) and t(6;9)(p22;q34). REAB II has an unfortunate prognosis. Cytoreductive treatment was initiated by the hematooncologist. Unfortunately, the patient deceased due to septic shock.