Stephan Nobbe

IL-31 expression by inflammatory cells is preferentially elevated in atopic dermatitis.

Interleukin-31 (IL-31) is a recently discovered cytokine expressed in many human tissues, and predominantly by activated CD4(+) T cells. IL-31 signals through a heterodimeric receptor consisting of IL-31 receptor alpha (IL-31RA) and oncostatin M receptor beta (OSMR). Earlier studies have shown involvement of IL-31 and its receptor components IL-31RA and OSMR in atopic dermatitis, pruritus and Th2-weighted inflammation at the mRNA level. The aim of this study was to investigate IL-31 protein expression in skin of such conditions. Immunohistochemical staining for IL-31, IL-31RA and OSMR was performed in formalin-fixed paraffin-embedded biopsy specimens. IL-31 expression was increased in the inflammatory infiltrates from skin biopsies taken from subjects with atopic dermatitis, compared with controls (p ≤ 0.05). IL-31, IL-31RA and OSMR protein immunoreactivity was not increased in biopsies from subjects with other Th2-weighted and pruritic skin diseases. Our results confirm, at the protein level, the relationship between IL-31 expression and atopic dermatitis. Our results do not support a general relationship between expression of IL-31/IL-31R and pruritic or Th2-mediated diseases.

Martorell Hypertensive Ischemic Leg Ulcer A Model of Ischemic Subcutaneous Arteriolosclerosis

OBJECTIVES To better define the diagnosis and treatment of Martorell hypertensive ischemic leg ulcer (HYTILU) and to compare Martorell HYTILU with calciphylaxis (calcific uremic arteriolopathy) and nonuremic forms of calciphylaxis. DESIGN Retrospective study from 1999 through 2007. SETTING Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland. PARTICIPANTS Of 330 patients with leg ulcers, 31 had a clinical diagnosis of Martorell HYTILU confirmed by dermatopathologic examination. MAIN OUTCOME MEASURES Clinical features, suspected diagnosis at initial presentation, cardiovascular risk factors, findings from vascular examination and histologic analysis, specific medical and surgical management, and outcome. RESULTS Of the 31 patients, all presented with 1 or multiple painful necrotic skin ulcers on the laterodorsal part of the leg, with bilateral involvement in 16 of 31 cases (52%), and 16 were referred with suspected pyoderma gangrenosum. All patients had arterial hypertension, and 18 (58%) had diabetes. All patients had subcutaneous stenotic arteriolosclerosis on histologic analysis, with medial calcification in 22 of 31 of cases (71%). Martorell HYTILU, calciphylaxis, and nonuremic forms of calciphylaxis shared identical histologic features. Of the 31 patients, 29 (94%) were successfully treated with surgical debridement and split-thickness skin grafting. Three patients (9%) died of sepsis, 2 of whom were undergoing immunosuppressive treatment for wrongly diagnosed pyoderma gangrenosum. CONCLUSIONS Ischemic subcutaneous arteriolosclerosis is the hallmark of Martorell HYTILU, calciphylaxis, and the nonuremic forms of calciphylaxis. All patients are hypertensive and approximately 60% are diabetic. Martorell HYTILU can easily be confused with pyoderma gangrenosum, which can be detrimental, since the 2 diseases require a completely different treatment strategy.

Marie Antoinette syndrome.

Bchetnia, Charfeddine, Kassar, Boubaker, and Mokni. Drafting of the manuscript: Bchetnia, Charfeddine, and Mokni. Critical revision of the manuscript for important intellectual content: Abdelhak, Kassar, Zribi, Tounsi Guettiti, Ellouze, Cheour, Boubaker, Dhahri-Ben Osman, and Mokni. Obtained funding: Abdelhak and Mokni. Administrative, technical, or material support: Bchetnia, Charfeddine, and Kassar. Study supervision: Abdelhak, Boubaker, and Mokni. Financial Disclosure: None reported. Funding/Support: This work was supported by the Tunisian Ministry of Higher Education and Scientific Research (Molecular Investigation of Genetic Orphan Disorders Research Unit and Hereditary Keratinisation Disorders Research Unit) and the Ministry of Health. Additional Contributions: We are especially grateful to the patients and their family members for their interest and cooperation in this study.

Herpes simplex virus reactivation as a complication of photodynamic therapy

We report the case of an 81‐year‐old male patient who developed a reactivation of herpes simplex virus localized to the right forehead, where photodynamic therapy (PDT) for actinic keratosis was performed. Considering the wide use of PDT, herpes virus infection or reactivation as well as other infections seem to be a very rare but potentially serious complication that has to be distinguished from common inflammatory reactions after PDT. Further applications of PDT under antiviral prophylaxis were well tolerated by our patient, with no further herpetic reactivation and successful treatment of actinic keratoses.

Split skin graft ""from scalp to scalp"" for repairing large surgical defects

Given the rise in life expectancy among the population, there is an increase in older and very old patients with androgenetic alopecia who present with extensive centroparietal field cancerization. Men are more frequently affected, but women with androgenetic alopecia may also develop skin cancer on the scalp. Cutaneous squamous cell carcinoma represents the most common tumor type (approximately 70 % of all scalp tumors), followed by basal cell carcinoma (approximately 20 % of all scalp tumors), and finally primary cutaneous melanoma of the lentigo maligna melanoma type (approximately 10 %). The occurrence of these lesions may require partial or complete scalping [1]. In the first step, malignant scalp tumors (Figure 1a, b) are resected down to the loose connective tissue layer between the galea aponeurotica and the periosteum of the cranium (Figure 2). Depending on the consistency of the scalp and galea, spindle-shaped surgical defects up to a width of 1-3 cm may be closed directly. Once reconstruction becomes more complex, histological examination of surgical margins is required. The various histological methods for examining surgical margins have been described in JDDG [2]. In the authors’ opinion, with respect to larger scalp lesions, examination of surgical margins on formalin-fixed and paraffin-embedded tissue has proven most successful (“Tübinger Torte” method) [2]. During the waiting period of approximately 24 hours until the histology report becomes available, the extensively exposed periosteum can dry up and become devitalized. In order to avoid this, the surgical defect must be covered with a hydrogel and a semi-occlusive dressing. If the surgical margins at the base are not tumor-free, the periosteum has to be excised and the external lamina (table) removed in thin layers using a bone chisel. As long as the area of exposed cranial bone is small (1-2 cm in diameter), secondary intention healing may be considered. Since 2010, we have been treating deep scalp wounds with a plant-based oil spray made from neem oil and St. John’s wort oil, which results in secondary intention healing in approximately 80 % of scalp defects associated with exposed cranial bone [3]. One option for larger wounds is immediate split skin grafting onto the well-vascularized diploë of the cranial bone. Very frequently performed today, the alternative procedure includes using a collagen matrix (to grow new skin) onto which the split skin graft is placed three weeks later [4]. In the following, we focus on a – rather obvious and elegant – method of split skin grafting for larger scalp defects. As donor site, we use the supraauricular scalp area [5].

Images in clinical medicine. Papillomatosis cutis lymphostatica.

An 88-year-old man presented with a 7-year history of asymptomatic, enlarging papules on his feet and toes. He had a 30-year history of chronic venous insufficiency and chronic leg edema.

Disseminated ulcerating lupus panniculitis emerging under interferon therapy of hairy cell leukemia: treatment- or disease-related?

We report a 43‐year‐old woman, who underwent therapy with interferon‐α for hairy cell leukemia. During interferon‐α therapy she developed multiple subcutaneous swellings, accompanied by fever and fatigue. A skin biopsy revealed lobular, T‐cell lymphocytic panniculitis. In conjunction with the clinical and immunological findings, the diagnosis of lupus panniculitis was made and interferon‐α therapy stopped. Initially, she responded well to oral prednisone and hydroxychloroquine, but after several months she became resistant to it. Her condition worsened, she developed skin ulcers in the inflamed regions. Only with the leukemia‐targeted therapy using cladribine and rituximab her skin condition could be controlled, suggesting hairy cell leukemia as an additional trigger of the lupus panniculitis. Our report is the first one to show induction of lupus panniculitis under interferon therapy of hairy cell leukemia and its presumable sustentation by the latter.

Spalthautverpflanzung „von Skalp zu Skalp“ zur Rekonstruktion großer Exzisionsdefekte der Kopfhaut

Mit steigender Lebenserwartung der Bevölkerung sehen wir zunehmend ältere und sehr alte Patienten, welche mit einer ausgedehnten zentroparietalen Feldkanzerisierung bei androgenetischer Alopezie vorstellig werden. Männer sind häufiger betroffen, aber auch Frauen mit einer androgenetischen Alopezie können an der Kopfhaut Hautkrebs entwickeln. Am häufigsten sehen wir dort kutane Plattenepithelkarzinome (ca. 70 % aller Tumoren der Kopfhaut), gefolgt von Basalzellkarzinomen (ca. 20 % aller Tumoren der Kopfhaut) und schließlich primäre kutane Melanome vom Typ des Lentigo-maligna-Melanoms (ca. 10 %). Diese Situationen können eine Teilskalpierung oder vollständige Skalpierung der Kopfhaut erfordern [1]. Maligne Tumoren der Skalphaut (Abbildung 1a, b) werden im ersten Schritt bis auf die lockere Bindegewebeschicht zwischen der Galea aponeurotica und dem Periost des Schädelknochens reseziert (Abbildung 2). Spindelförmige Exzisionsdefekte können je nach Festigkeit der Kopfhaut und der Galea bis zu einer Breite von 1–3 cm noch direkt verschlossen werden. Sobald die Rekonstruktion aufwändiger wird, muss eine histologische Schnittrandkontrolle vorausgesetzt werden. Über die unterschiedlichen histologischen Methoden der Schnittrandkontrolle wurde in JDDG berichtet [2]. Für größere Skalp-Exzidate bewährt sich in unserer Hand die Schnittrandkontrolle am formalinfixierten und in Paraffin eingebetteten Gewebe (Tübinger Torte) [2] am besten. In den rund 24 Stunden Wartezeit bis zum Vorliegen der Histologie kann das großflächig exponierte Periost austrocknen und untergehen. Um dies zur verhindern, muss der Exzisionsdefekt mit einem Hydrogel und einem semiokklusiven Deckverband geschützt werden. Wenn der basale Exzidatrand tumorbefallen ist, müssen das Periost exzidiert und die Tabula externa mit einem Knochenmeissel dünnschichtig abgetragen werden. Solange der Schädelknochen eher kleinflächig (1–2 cm Defektdurchmesser) exponiert ist, kann eine sekundäre Wundheilung angestrebt werden. Seit 2010 behandeln wir tiefe Skalpwunden mit einem pflanzlichen Ölspray aus Neemöl und Johanniskrautöl, das bei Skalphautdefekten mit exponiertem Schädelknochen in etwa 80 % der Fälle zur Abheilung führt [3]. Bei Wunden größeren Durchmessers kann entweder direkt auf die reichlich durchblutete Spongiosa der Diploe des Schädelknochens Spalthaut transplantiert werden, oder – was heute sehr häufig durchgeführt wird – als Zwischenschritt eine Neodermis aus einer Kollagenmatrix aufgebaut werden, bevor drei Wochen später Spalthaut verpflanzt wird [4]. Im Folgenden fokussieren wir uns auf eine besonders naheliegende und elegante Form der Spalthautverpflanzung auf größere Exzisionsdefekte am Skalp. Als Spenderareal verwenden wir die supraaurikuläre Skalphaut [5].

Sudden Painless Nail Shedding

A 7-year-old girl presented to the dermatology clinic with a 4-week history of progressive nail changes. Her mother reported a sudden onset of brittle nails with cracks followed by painless sloughing of nails. Initially only the fingernails had been affected, but the toenails soon showed the same pathology. The family was concerned and suspected an internal disease or vitamin deficiency. The child was otherwise well and no previous skin or nail conditions were known. On clinical examination, most fingernails showed semilunar whitish grooves in the middle of the nail plate (Figure, A). The toenails had transverse partial cracks of the proximal nail plate with distal onycholysis but normal proximal nail growth (Figure, B). Quiz at jamapediatrics.com WHAT IS YOURDIAGNOSIS? A. Drug intake B. Kawasaki syndrome C. Vaccination reaction D. Hand-foot-and-mouth disease A B

Ulcère hypertensif de Martorell

L’ulcere hypertensif de Martorell fait partie des causes les plus frequentes de plaies chroniques au niveau de la jambe. Toutefois, le diagnostic correct n’est souvent pas pose et une pyodermite gangreneuse ou une vascularite est souvent diagnostiquee a tort.