Mihael Skerlev

Phototherapy in Pediatric Patients

Abstract: The treatment of children with psoriasis, atopic dermatitis (AD), pityriasis lichenoides, and scleroderma poses a therapeutic problem because all therapeutic options are associated with numerous side effects. Therefore ultraviolet A and B (UVA and UVB) phototherapy is presented as a possible alternative to some of these therapies, primarily topical and systemic corticosteroids, in children. Our results in treating children with phototherapy and psoralen plus UVA (PUVA) bath phototherapy over the past 5 years are reported. UVB therapy (TL01) was used in 20 psoriatic children (6 boys, 14 girls; ages 6–14 years) during the stage of disease exacerbation and in 9 children (3 boys, 6 girls; ages 8–16 years) with pityriasis lichenoides. Combined UVA/UVB phototherapy was applied in 21 AD children (7 boys, 14 girls; ages 4–15 years). Photochemotherapy with local application of a PUVA bath was used in six children (2 boys, 4 girls; ages 9–16 years) with circumscribed scleroderma and in one girl with systemic scleroderma. All children received short courses of phototherapy with either no maintenance or short maintenance. All three therapeutic protocols resulted in a certain degree of improvement in most of the study patients. None of the patients exhibited any early phototherapy side effects. We conclude that phototherapy and PUVA bath are valuable and safe therapeutic options for selected children who do not respond to other treatments.

The role of Malassezia furfur in dermatology

Yeasts of the genus Malassezia have been recognized as members of the microbiologic flora of the skin for over a century. Under certain conditions, they can cause superficial infection of the skin and associated structures, and they can become an opportunistic pathogen in patients with catheters.

HPV-associated diseases

Nearly 200 distinct human papilloma viruses (HPVs) have now been recognized, and each is associated with a specific set of clinical lesions. They are associated with a spectrum of diseases, from benign verrucae vulgares and condylomata acuminata to the malignancies of the cervix, vulva, anus, and penis. Disease associated with HPV can be divided into skin and mucosal lesion of the genital and extragenital regions. The relationship between HPV and nonmelanoma skin cancer (NMSC) is important clinically, because NMSC is the most common form of malignancy among fair-skinned populations. HPVs have also been detected in skin tags, lichen sclerosus, seborrheic keratoses, actinic keratoses, epidermal cysts, psoriatic plaques, and plucked hairs, but cutaneous HPV can be found on healthy skin.

Human papillomavirus male genital infections: clinical variations and the significance of DNA typing

Anogenital human papillomavirus (HPV) infections are the most frequently diagnosed sexually transmitted diseases (STDs) of viral origin. The HPV types associated with such lesions have been studied extensively during the last several years.1,2 HPV-associated genital pathology represents one of the major problems with STDs, due to the high recurrence rate, difficulty in eradication, and the oncogenic potential of some HPV types.3–5 HPV genital infections are also among the most frequent diagnoses made in the STD Out-patient Clinic of the Department of Dermatology and Venereology of the Zagreb University Medical School. The frequency of HPV genital infections ranged from 125 patients in 1991 to 193 patients in 2000.6,7 Generally, the patients with HPV genital infection visit the STD Clinic regularly, and their compliance rate is mostly satisfactory, as opposed to patients carrying the diagnosis of nongonococcal urethritis. The association between certain HPV types and cervical intraepithelial neoplasia is well documented among Croatian women8–11; however, similar studies are very rare.12 During the last few years, different diagnostic tools have been used for the patients with HPV genital infection, including pathohistology.13–15 The results have not been sufficiently satisfactory in certain cases; ie, the answer was not precise enough as to whether the lesion was HPV induced or not. Because of the small sample size that can only be taken for HPV DNA detection from male genital lesions, we used a very sensitive and specific molecular method, the polymerase chain reaction (PCR) with HPV consensus primers. With type-specific primers, we typed HPV types 6/11, 16, 18, 31, and 33. Restriction fragment length polymorphism (RFLP) was applied on HPV 6/11 PCR products to distinguish further between HPV types 6 and 11. This would permit us to evaluate the value of viral detection by means of PCR in case of male anogenital lesions.

Molluscum contagiosum from infancy to maturity

Molluscum contagiosum (MC) is a common cutaneous viral infection caused by a large DNA poxvirus that affects both children (1–5 years) and rarely, adults.1–3 MC clinically presents as waxy, dome-shaped umbilicated papules (Fig 1). The synonyms are epithelioma contagiosum and dimple warts.1 Descriptions of MC have been in the medical literature since 1817. In 1905, the viral nature of MC was discovered by Juliusberg.4 Molluscum contagiosum virus (MCV) is a large, double-stranded DNA orthopoxvirus of the family Poxviridae or an unclassified poxvirus.4–6 MCV is strictly epidermotropic (not scarring) and relatively large at 240–320 nm. MCV replicates in the cytoplasm of host epithelial cells, producing cytoplasmic inclusions, and may cause enlargement of infected cells.5,6 Transmissions are from person to person or autoinoculation. MC affects both sexes equally. The actual virus reservoir is not known. The incubation period is 2–8 weeks for year.5 The virus enters the skin directly via small epithelial defects or indirectly via clothing, towels, or handkerchiefs.7 MC in adults is most typically a sexually transmitted disease (STD), occurring in 10–20% of HIV-seropositive patients and in patients with immunosuppressive conditions. MC may be spread by “autoinoculation”— scratching or touching a lesion and transferring the virus from location to location. They are usually localized on the trunk, arms, and in the armpits. Genital area involvement is much more often seen in adults.

Treatment of cutaneous leishmaniasis with 20% paromomycin ointment.

Cutaneous leishmaniasis is an infectious disease caused by flagellate protozoa of the genus Leishmania. In Mediterranean countries, the most common causative agents are Leishmania (L.) major, L. infantum and L. tropica. In Croatia, cutaneous leishmaniasis is a rare disease, the last case being reported in 1988. Our patient was a 5‐year‐old boy with a left cheek skin lesion in the form of papule with central exulceration, hyperkeratotic crust and erythema of a 6‐month duration. The diagnosis of cutaneous leishmaniasis was based on history data (stay in the southernmost region of Croatia and multiple mosquito bites), light microscopic histology (dense infiltrates of large histiocytes with extracellular bodies), and positive Montenegro (leishmanin) test. A new therapy with aminosidine (paromomycin), an aminoglycoside antibiotic, in the form of ointment at a concentration of 20%, was for the first time used in Croatia. Four‐week therapy resulted in complete regression of the skin lesions with residual hyperpigmentation. During therapy, no local or systemic side effects were observed. Thus, topical therapy with paromomycin could be considered an efficient therapeutic alternative in the management of cutaneous leishmaniasis.

Unusually low prevalence of Mycoplasma genitalium in urine samples from infertile men and healthy controls: a prevalence study

Objective To detect Mycoplasma genitalium in urine samples of infertile men and men without any signs of infection in order to investigate whether M. genitalium and other genital mycoplasmas (Mycoplasma hominis and Ureaplasma spp) are found more often in urine samples of infertile men than in asymptomatic controls and to determine resistance to macrolides. Methods The study included first void urine samples taken from 145 infertile men and 49 men with no symptoms of urethritis. M. genitalium, Chlamydia trachomatis and Neisseria gonorrhoeae were detected by commercial PCR. Trichomonas vaginalis was detected by microscopy and culture. M. hominis and Ureaplasma spp were detected by culture. M. genitalium was detected by in-house conventional and real-time PCR. Results Two M. genitalium positive samples were found among samples obtained from infertile men. All asymptomatic men were M. genitalium negative. Macrolide resistance was not found in either of the two positive samples. Conclusions In comparison with reported data, an unusually low prevalence of M. genitalium was found in infertile men. The reasons for this unexpected result are not known; possibly, local demographic and social characteristics of the population influenced the result. Further studies to investigate M. genitalium in infertile and other groups of patients are needed.

Mollusca contagiosa: from paediatric dermatology to sexually transmitted infection.

ZusammenfassungMollusca contagiosa (MC) sind eine häufig auftretende, durch das Molluscum-contagiosum-Virus verursachte Hautinfektion, sie kann Kinder und Erwachsene betreffen. Sie ist relativ häufig bei 1- bis 5-Jährigen und kann an fast allen Körperstellen auftreten. Bei Erwachsenen gelten MC als sexuell übertragbare Infektion (STI). Das Molluscum-contagiosum-Virus kann direkt von Mensch zu Mensch übertragen werden oder durch Autoinokulation. Bei Erwachsenen finden sich MC typischerweise in der Genitalregion. Extragenitaler Befall tritt häufiger auf unter Immunsuppression, besonders bei HIV-Infektion. Bei HIV-positiven Patienten können MC als Teil eines immunrekonstitutionellen inflammatorischen Syndroms (IRIS) verstanden werden. Bei Kindern sind vermutlich beide Geschlechter gleich häufig betroffen, bei Erwachsenen scheint die Prävalenz unter Männern höher zu sein. Hinsichtlich einer Behandlung bestehen zwar Kontroversen, sie kann aber sehr hilfreich sein bei der Prävention. Bisher gibt es keine kausale Therapie, die meisten Behandlungsoptionen sind mechanischer Art, andere sind nicht hinreichend evidenzbasiert. Besondere Beachtung sollte einem extragenitalen Befall bei Erwachsenen geschenkt werden, dann sollte ein HIV-Test empfohlen werden. Zur Prävention von Übertragung und Autoinokulation sollten sowohl Kinder als auch Erwachsene mit MC angehalten werden, Hautkontakt und Kratzen zu vermeiden. Erwachsene MC-Patienten sollten einem Screening auf andere sexuell übertragbare Infektionen unterzogen und entsprechend beraten werden.AbstractMolluscum contagiosum (MC) is a common cutaneous infection caused by the molluscipox virus (MCV) and can affect both children and adults. Molluscum contagiosum is relatively frequent in children aged 1-5 years old and can be localized almost anywhere on the body, but in adults it is regarded as a sexually transmitted infection (STI). MCV can be transmitted directly from person to person or by autoinoculation. MC in adults characteristically involves the genital area but extragenital appearance can be more typically seen in patients with immunosuppressive conditions, especially in HIV/AIDS. The onset of MC in HIV-positive individuals can be regarded as a part of the immune reconstitution inflammatory syndrome (IRIS). MC probably affects both sexes equally in children, whereas it seems that in adults the incidence is more prevalent in males. Therapy is controversial but may be considerably beneficial in preventing transmission or autoinoculation. At present there is no aetiological treatment of MC and most treatment options are mechanical sometimes causing discomfort or are not sufficiently evidence-based. Attention should be given to the extragenital site of involvement in adults and HIV testing should be recommended. Both children and adults with MC should be educated to avoid scratching and skin contact with others to prevent transmission and autoinoculation. Adult patients with MC should be carefully screened for other STIs and appropriately counseled.Molluscum contagiosum (MC) is a common cutaneous infection caused by the molluscipox virus (MCV) and can affect both children and adults. Molluscum contagiosum is relatively frequent in children aged 1-5 years old and can be localized almost anywhere on the body, but in adults it is regarded as a sexually transmitted infection (STI). MCV can be transmitted directly from person to person or by autoinoculation. MC in adults characteristically involves the genital area but extragenital appearance can be more typically seen in patients with immunosuppressive conditions, especially in HIV/AIDS. The onset of MC in HIV-positive individuals can be regarded as a part of the immune reconstitution inflammatory syndrome (IRIS). MC probably affects both sexes equally in children, whereas it seems that in adults the incidence is more prevalent in males. Therapy is controversial but may be considerably beneficial in preventing transmission or autoinoculation. At present there is no aetiological treatment of MC and most treatment options are mechanical sometimes causing discomfort or are not sufficiently evidence-based. Attention should be given to the extragenital site of involvement in adults and HIV testing should be recommended. Both children and adults with MC should be educated to avoid scratching and skin contact with others to prevent transmission and autoinoculation. Adult patients with MC should be carefully screened for other STIs and appropriately counseled.

Paederus dermatitis featuring chronic contact dermatitis

Paederus dermatitis is a distinct variant of acute irritant contact dermatitis caused by mucocutaneous contact with the specific toxin of an insect belonging to the genus Paederus. It is characterized by the sudden onset of erythema and vesiculobullous lesions on exposed skin, with special predilection for the periorbital region. Paederus species have been mostly identified in Africa, Asia, Australia, and Central/South America. We report a 51-year-old woman who experienced 4 recurrences of periorbital erythema and edema in the previous year. No consistent etiology could be established at the beginning. Only after taking a detailed medical history was it discovered that 1 year before our examination, the patient had traveled to Kenya, where she had experienced contact with the insect. This fact led us to the diagnosis of Paederus dermatitis. After appropriate treatment, a complete regression was observed over a 3-week period.

An overview: the changing face of cutaneous infections and infestations

Our intention was to point out the importance of cutaneous infections and infestations in resolving this dermatological problems. Modern way of life and fast communications enable the spread of this conditions in all age groups and in all parts of the world. The main role of dermatologist is not only in the recognition and treatment, but also in the prevention of infections and infestations of the skin. Finally, investigation, prevention, and continuous education on infections and infestations in dermatology will provide healthier population in every environment.