Joachim Krischer

Regression of Kaposi's sarcoma during therapy with HIV-1 protease inhibitors: A prospective pilot study

BACKGROUND Early studies using HIV protease inhibitors (PI) showed regression of Kaposis sarcoma (KS) lesions in some patients. OBJECTIVE Our purpose was to determine prospectively the influence of PI on HIV-related KS. METHODS KS lesions of nine patients with progressive cutaneous disease were prospectively evaluated clinically and by means of epiluminescence microscopy before and during PI therapy. HIV viremia and CD4 cell count were measured in parallel. RESULTS All patients experienced reduction or initial stabilization of KS lesions during the first 4 to 8 weeks of HIV-1 PI therapy. After a median follow-up of 7 months and according to AIDS Clinical Trials Groups criteria, six patients had a partial response, two showed stable disease, and in one noncompliant patient KS progressed, requiring chemotherapy. With epiluminescence microscopy, a reduction in skin surface alterations, lesional size, and color intensity was demonstrated in six of nine patients. PI induced a median decrease in viremia of 1.66 log and a median increase in the CD4 count of 49 cells/mm3. CONCLUSION In this series, HIV PI therapy reduced or stabilized KS. The efficacy of HIV-1 PI in KS may result from the improvement in cellular immunity. These results suggest the use of PI in AIDS-related KS regardless of the level of CD4 lymphocyte count and HIV viremia.

Red fingers syndrome in patients with HIV and hepatitis C infection

SIR—We observed a cutaneous sign involving the hands and feet of more than 1% of HIV-1 infected patients attending our clinic. Well-demarcated distal erythema of fingers and toes with multiple periungual telangiectasia were found in nine HIVinfected patients (figure). This symptom was permanent (eight of nine), painless (eight of nine), and there were no other complaints or Raynaud’s phenomenon. Median duration of symptoms was 9 months (range 0·5–90). All patients had abused intravenous drugs or alcohol. Laboratory data showed no antinuclear antibodies in eight (one patient had antibodies at a titre of 1/2560), normal muscle enzyme values (creatine kinase or aldolase) in seven of seven, and cryoglobulinaemia in three or three. Capillaroscopy examinations were normal (four of four) but histology showed dilated capillaries in the only skin biopsy specimen examined. Medications at the time of diagnosis were methadone (seven), benzodiazepines (six), co-trimoxazole (two), sulfadiazine/pyrimethamine (two), pentamidine (two), and zidovudine (one). Concomitant or previous opportunistic diseases were toxoplasmosis (two), disseminated mycobacteriosis infection (one), tuberculosis (one), lymphoma (one), and weight loss (four). Active viral hepatitis was found in all patients. All patients were hepatitis C antibody-positive. Hepatitis C RNA was found in six, delta hepatitis antigen in two, and one was HBs-antigen positive. THE LANCET

Childhood Bullous Pemphigoid: Report of a Case with Life‐Threatening Course During Homeopathy Treatment

Abstract:  Bullous pemphigoid (BP) is an autoimmune blistering disorder that may very rarely occur in childhood. We describe a 9‐month‐old child who developed bullous pemphigoid while she was being treated for presumptive atopic eczema with a homeopathic regimen comprising sulfur, mercury, cantharides, and Rhus (Toxicodendron). She had generalized bullae and a progressive worsening of her general condition with asthenia, dehydration, malnutrition. While the role of homeopathy in triggering the disease remains unclear, our observation attests to the potential life‐threatening course of childhood BP in instances where appropriate treatment is withheld.

The Use of Digital Dermoscopy for the Follow-Up of Congenital Nevi: A Pilot Study

One of the main problems in the management of congenital nevi is the potential risk for malignant transformation and the resulting need for follow‐up examination. Dermoscopy is a noninvasive technique that has been shown to be useful for the follow‐up of benign melanocytic skin lesions as well as the early diagnosis of malignant melanoma. Therefore we thought to use the digital dermoscopy (DD) technique for the follow‐up of congenital nevi. For documentation purposes we registered an overview, and the following standardized dermoscopic images of every lesion: representative architectural pattern, border of the lesion, and regions of “special interest.” In all instances the examination with digital dermoscopy was well tolerated by the patients and the integration of the parents to the “live” examination on the computer screen was appreciated. The follow‐up was easy to perform with these standardized documents. We showed the feasibility of follow‐up of congenital nevi using digital dermoscopy. Furthermore, we identified three different patterns as well as some typical structures seen in congenital nevi by DD.

Malassezia spp Carriage in Patients with Seborrheic Dermatitis

The role of Malassezia spp in seborrheic dermatitis (SD) is controversial. To compare the cutaneous density and the cultural characteristics of Malassezia in persons with or without SD, quantitative cultures were obtained by stripping the forehead with a tape placed on Leeming and Notman medium. Plates were incubated at 37°C in a plastic bag, and colonies were counted after 14 days. High yeast density was defined as >100 colony forming units (CFU)/tape. Volunteers were divided into four groups depending on their HIV serology [HIV (+) versus HIV (‐) or unknown] and their clinical status (with or without SD). 126/129 cultures were positive (97.7%). Malassezia spp density was low on clinically normal skin in all HIV (‐) persons (40/40) but was high in 8/34 (24%) HIV (+) persons without SD (p<0.001). In SD patients, high densities were found in 10/22 (45%) HIV (+) and in 17/33 (52%) HIV (‐) persons. The strains could be divided into three basic groups on the basis of their cultural characteristics. Colony morphology type A predominated on normal skin (72%), and morphology type C predominated on persons with SD (78%). High yeast density can be present without skin symptoms. The pathogenicity of Malassezia seems more likely to be determined by the subtype present on the skin rather than by its density.

Neutrophil Eccrine Hidradenitis in a Patient with AIDS

Neutrophilic eccrine hidradenitis (NEH), first described as a rare, transient, and benign complication of various chemotherapy regimens for acute leukemia, has also been observed in other conditions, including three HIV‐positive patients and even in otherwise healthy individuals (1–3). A similar histological pattern was described after intradermal bleomycin injections into normal human skin (4). We report the first case of NEH in a hemophilic HIV infected patient treated with stavudine, a new reverse transcriptase inhibitor.

Pseudoporphyria induced by nabumetone

Nabumetone is a nonsteroidal anti-inflammatory drug, which has only rarely been associated with photosensitivity. We report a case of bullous lesions arising over photoexposed areas in a patient treated with nabumetone.

Epiluminescent Light Microscopy of Melanocytic Lesions after Dermoepidermal Split

BACKGROUND In vivo epiluminescent light microscopy (ELM) of pigmented skin lesions reveals numerous elementary structures. Among them, the pigment network (PN), black dots (BD) and brown globules (BG) constitute important semiologic features. Based on histological extrapolations, it has been postulated that PN should reflect the presence of melanin in the epidermis and its honeycomb aspect should result from the dermoepidermal architecture. OBJECTIVE To demonstrate this directly by analyzing separately by ELM the epidermal and dermal sides of melanocytic lesions. METHODS We split the epidermis from the dermis of 10 pigmented lesions (6 lentigos, 4 nevocytic nevi) by incubation with dispase. ELM images were done in vivo before excision, then ex vivo on the whole specimen and separately on the split epidermis and dermis. Epidermal and dermal specimens were finally controlled by histology. RESULTS PN was observed only on the epidermal side of the split. Its organization was remarkably conserved after the procedure as compared with prior in vivo images. In contrast, pigmentation observed on dermal sides of the splits showed no organized pattern and corresponded to melanophages. BG were found on the dermal side and BD on the epidermal side of the split lesions, which confirms previous hypotheses. CONCLUSION By subtracting the dermal pigmentation and vessels from the image, the split technique has thus established the epidermal origin of the PN and given a more detailed ELM analysis of network components.

Oral Isotretinoin in HIV-Positive Women with Acne: Report of Three Cases

Among the facial dermatoses in patients infected with human immunodeficiency virus (HIV), seborrheic dermatitis is the most common [1]. Follicular papular-pustular diseases have been reported and are attributed to infectious agents such as Staphylococcus aureus, Malassezia sp., Candida sp. and Demodex. Demodex-mite-positive rosacea-like eruptions are even reported in children [2, 3]. The typical flare of acne is not reported in detail in the literature, but acne rosacea is well known in men. We observed 3 HIV-positive women with acneiform eruptions on the face.