Markus Streit

Topical application of the tumour necrosis factor-alpha antibody infliximab improves healing of chronic wounds

The role of tumour necrosis factor‐alpha (TNF‐α) in wound healing is not clear. Elevated levels of TNF‐α have been observed in fluids from chronic wounds and have been shown to decrease over time during the healing process. Therapeutic antibodies such as infliximab can inhibit TNF‐α activity. In this case series, we applied infliximab topically to eight patients with chronic ulcers of more than 4‐month durations. The ulcers had multifactorial aetiology, with chronic venous insufficiency being the most prominent factor. All the ulcers had failed to respond to any previous conventional treatment. Infliximab was applied repeatedly to ulcers either as a 10 mg/ml solution and covered with an adhesive sheet or as a gel formulation (0·45, 1, or 4·5 mg/g) under a hydrofiber dressing/adhesive sheet. Improvement was assessed by measuring the percentage of change in the ulcer surface area. Seven of the eight patients (12 of 14 ulcers) responded to treatment with infliximab. After 4 weeks of treatment, surface area was reduced by more than 50% in 6 of the 14 treated ulcers. Within 8 weeks, five ulcers completely healed, while another four were reduced by more than 75% in size. Chronic, therapy‐resistant leg ulcers responded well to repeated topical administration of a solution or a gel containing the TNF‐α antibody, infliximab. Randomised controlled studies should be conducted to further evaluate the effect of topical infliximab on chronic wound healing.

Diagnostisches und therapeutisches Vorgehen beichronischem Pruritus

Abteilung Klinische Neurodermatologie, Klinik und Poliklinik fur Hautkrankheiten, Universitatsklinikum Munster, Dermatologische Klinik Inselspital Bern, Schweiz, Zentrum fur Allergie und Umwelt, Klinik und Poliklinik fur Dermatologie und Allergologie am Biederstein, Technische Universitat Munchen, Zentrum fur Psychosomatische Medizin, Psychosomatische Dermatologie, Universitatsklinikum Giessen, Hautarztpraxis, Nurnberg, Dermatologie Bad Bentheim, Paulinenkrankenhaus, Bad Bentheim, Klinik fur Dermatologie und Venerologie, Universitatsklinikum Magdeburg, Klinische Sozialmedizin, Berufs und Umweltdermatologie, Universitatsklinikum Heidelberg

Eosinophilic fasciitis (Shulman syndrome).

We report a case of a 30-year-old Caucasian patient with progressive sclerosis of the skin mainly on the upper limbs which was diagnosed as eosinophilic fasciitis (Shulman syndrome). Circulating antibodies against Borrelia burgdorferi were detected. The association of B. burgdorferi infection with eosinophilic fasciitis is discussed.

Contact dermatitis: clinics and pathology

Contact dermatitis or eczema is a polymorphic inflammation of the skin. It occurs at the site of contact with irritating or antigenic substances. In the acute phase there is occurrence of itching erythema, papules, and vesicles, whereas in the chronic phase there is dryness, hyperkeratosis, and sometimes fissures. Contact dermatitis can be divided into irritant and allergic types. Allergic contact dermatitis is a type-IV T-cellmediated reaction occurring in a sensitized individual after contact with the antigen/allergen. Such antigens are usually low molecular weight substances (MW ~500), called haptens; 3000 contact allergens are known. The diagnosis of contact allergy is made on the basis of the history, clinical findings, and a positive epicutaneous test result. Allergic, but not irritative, contact dermatitis can spread beyond the area of contact to other body parts. Eczematous lesions are characterized by a mononuclear infiltrate consisting mainly of T cells in the dermis and epidermis, together with an intercellular epidermal edema—that is, spongiosis. In allergic contact dermatitis, skin-applied antigen is taken up by epidermal Langerhans cells and transported with the afferent lymph to the regional lymph nodes. Here, naive T lymphocytes are sensitized to become antigen-specific effector T cells, which then leave the lymph node, enter the circulation, and are recruited to the skin by means of specific cell surface molecules, to form the infiltrates. Cytokines released by infiltrating T cells eventually cause keratinocyte apoptosis.

European EADV network on assessment of severity and burden of Pruritus (PruNet): first meeting on outcome tools

Chronic pruritus is a frequently occurring symptom of various dermatoses that causes a high burden and impaired quality of life. An effective anti pruritic therapy is important for the patient, but its effectiveness is difficult to evaluate. Diverse methods and interpretations of pruritic metrics are utilized in clinical trials and the daily clinical practice in different countries, resulting in difficulties comparing collected data.

Pre- and posttransplant management of solid organ transplant recipients: risk-adjusted follow-up

Solid organ transplant recipients (SOTR) have an increased risk of skin cancer due to their long-term immunosuppressive state. As the number of these patients is increasing, as well as their life expectancy, it is important to discuss the screening and management of skin cancer in this group of patients. The role of the dermatologist, in collaboration with the transplant team, is important both before transplantation, where patients are screened for skin lesions and the individual risk for skin cancer development is assessed, and after transplantation. Posttransplant management consists of regular dermatological consultations (the frequency depends on different factors discussed below), where early skin cancer screening and management, as well as patient education on sun protective behavior is taught and enforced. Indeed, SOTR are very sensitive to sun damage due to their immunosuppressive state, leading to cumulative sun damage which results in field cancerization with numerous lesions such as in situ squamous cell carcinoma, actinic keratosis and Bowens disease. These lesions should be recognized and treated as early as possible. Therapeutic options discussed will involve topical therapy, surgical management, adjustment of the patients immunosuppressive therapy (i.e. reduction of immunosuppression and/or switch to mammalian target of rapamycin inhibitors) and chemoprevention with the retinoid acitretin, which reduces the recurrence rate of squamous cell carcinoma. The dermatological follow-up of SOTR should be integrated into the comprehensive posttransplant care.

Pruritus sine materia

Juckreiz – Pruritus – gilt als das häufigste Symptom der Haut, das als unangenehme Sinneswahrnehmung empfunden wird und häufig im Rahmen von Hauterkrankungen in der pathologisch veränderten Haut auftritt. Pruritus kann aber auch bei Erkrankungen innerer Organe ohne sichtbare Hautveränderungen wahrgenommen werden. Man spricht von einem Pruritus cum materia, wenn eine Hauterkrankung zugrunde liegt, und von einem Pruritus sine materia, wenn der Juckreiz auf initial unveränderter Haut auftritt. Gerade beim Pruritus sine materia werden der Leidensdruck des Patienten und der Stellenwert der ursächlichen Erkrankung leicht verkannt.In dieser Arbeit werden zunächst die Entstehungsmechanismen von Juckreiz dargestellt und anschließend die verschiedenen Auslöser eines Pruritus sine materia im Hinblick auf die notwendigen Abklärungen diskutiert. Zuletzt folgt eine Übersicht über die therapeutischen Möglichkeiten.

Ulcerative Sarcoidosis Successfully Treated with Apligraf

The case of a 73-year-old female patient is reported with a 25-year-long history of widespread cutaneous sarcoidosis without any known extracutaneous manifestations. The skin manifestations started with erythematous and plaque-like lesions that had ulcerated on the legs for the last half-year. A relevant venous insufficiency or other etiology of the ulcers could not be found. Histology from lesions of the trunk and from the surroundings of the ulcers revealed the typical noncaseating granulomas. A systemic involvement could not be observed; leukopenia and a slightly elevated angiotensin-converting enzyme level in the serum were found. Topical steroids did not prove successful on the ulcers. Apligraf, a bilayered skin equivalent, was transplanted twice on the ulcers leading to complete closure within 3 months. A therapy with systemic steroids could thus be avoided.

Swiss clinical practice guidelines on field cancerization of the skin.

Actinic keratosis (AK) affects millions of people worldwide, and its prevalence continues to increase. AK lesions are caused by chronic ultraviolet radiation exposure, and the presence of two or more AK lesions along with photodamage should raise the consideration of a diagnosis of field cancerization. Effective treatment of individual lesions as well as field cancerization is essential for good long-term outcomes. The Swiss Registry of Actinic Keratosis Treatment (REAKT) Working Group has developed clinical practice guidelines for the treatment of field cancerization in patients who present with AK. These guidelines are intended to serve as a resource for physicians as to the most appropriate treatment and management of AK and field cancerization based on current evidence and the combined practical experience of the authors. Treatment of AK and field cancerization should be driven by consideration of relevant patient, disease, and treatment factors, and appropriate treatment decisions will differ from patient to patient. Prevention measures and screening recommendations are discussed, and special considerations related to management of immunocompromised patients are provided.

Typical Features of Calciphylaxis in a Patient with End-Stage Renal Failure, Diabetes mellitus and Oral Anticoagulation

We report a multimorbid patient with end-stage renal failure showing a large necrosis and livedo racemosa on the right thigh. Histology revealed medial calcification of the small arteries typical of calciphylaxis. We found the typical features of the disease with different risk factors like elevated calcium-phosphate product, diabetes mellitus and oral anticoagulation. On account of the location of the skin lesions, a bad prognosis was expected. In spite of therapeutical measures with lowering of the calcium and phosphate levels, the patient died 1 month after the diagnosis had been made.