Ute Barta

Erythema multiforme-like drug eruption with oral involvement after intake of leflunomide.

Leflunomide is an antirheumatic agent of the type of a ‘disease-modifying antirheumatic drug’. In rare cases, severe skin reactions up to the extreme expression of toxic epidermal necrolysis have been observed. A female patient with rheumatoid arthritis had been treated with systemic steroids and methotrexate for 2 years. Five weeks prior to admission to our hospital methotrexate was replaced by leflunomide. Three weeks after initiation of leflunomide therapy a progressive generalized erythema with blistering formation occurred accompanied by increase of body temperature, chills and erosive lesions on the lips and oral mucosa. The palmar and plantar surfaces revealed edema, erythema and pulpitis with epidermolysis. On histologic examination necrotic keratinocytes and epidermal spongiosis were observed. After administration of high-dose prednisolone and topical treatment the patient recovered within 14 days. This is one of the few cases of severe drug reaction after intake of leflunomide. Therefore, the indication of this relatively new drug should be considered carefully.

Therapie der Hyperhidrosis mittels Leitungswasseriontophorese Positive Effekte auf Abheilungszeit und Rezidivfreiheit bei Hand-Fuß-Ekzemen

ZusammenfassungHyperhidrose ist eine belästigende Folge der ekkrinen Überfunktion (autonomes Nervensystem) und ein konstitutioneller Faktor in der Ekzemunterhaltung. In einer klinischen Studie wurde bei 54 Patienten mit Hyperhidrosis manuum et pedum eine Therapie mit der Leitungswasseriontophorese mit unterbrochenem Gleichstrom durchgeführt. Nach 10 unter ärztlicher Kontrolle durchgeführten Behandlungen gaben 89% der Patienten eine Besserung der Hyperhidrose an. Zwanzig Patienten, die zugleich an einem palmoplantaren Ekzem litten und mindestens 6 Monate eine Heimbehandlung fortgeführt hatten, wurden mit einem in Alters- und Geschlechtsverteilung entsprechendem historischen Patientenkollektiv bezüglich Abheilungszeit und Rezidivfreiheit verglichen. Im Trend ergab sich eine (nicht signifikant) kürzere Abheilungszeit von durchschnittlich 20 vs. 22,3 Tagen (p>0,05). Statistisch hochsignifikant war jedoch der Vorteil bezüglich des rezidivfreien Zeitraums (24,8 vs. 8,35 Wochen; p<0,0001). Die Effekte der Leitungswasseriontophorese sind nicht allein auf die Schweißdrüsensekretion beschränkt. Aufgrund jüngerer Literaturdaten sind Capsaicin-artige Wirkungen des Gleichstromes ebenfalls zu vermuten. Es wird die Hypothese formuliert, daß der Gleichstrom der Leitungswasseriontophorese die neurogene Entzündung unterbricht, was sich auf eine verlängerte Rezidivfreiheit beim hyperhidrotischen Hand-Fuß-Ekzem positiv auswirkt.SummaryHyperhidrosis is due to an overfunction of eccrine glands (triggered by the autonomous nervous system) and may be a cofactor for palmoplantar eczema (dermatitis). Tapwater iontophoresis was used in 54 patients with hyperhidrosis manuum et pedum. After 10 applications directed by the dermatologist, 89% of patients noted an improvement in their hyperhidrosis. 20 patients suffering from palmoplantar eczema (dermatitis) who continued the treatment at home for at least 6 months were compared with a historical sex- and age-matched group of 20 eczema-patients without iontophoresis: The factors evaluated were the time needed for clearing and the relapse-free interval. Though iontophoresis-treated patients had a slightly faster clearing, this was statistically not significant (20 vs. 22.3 days; p >0.05). However, the difference for relapse-free interval between the two groups was statistically highly significant (24.8 weeks vs. 8.35 weeks; p<0.0001).Tapwater iontophoresis seems to be effective not only to control sweating. According to recently published data, galvanization seems to have a capsaicin-like effect as well. Our hypothesis is therefore, that galvanization with tapwater iontophoresis interrupts the neurogenic inflammation and prolongs the relapse-free interval in hyperhidrotic palmoplantar eczema (dermatitis).

Lupus erythematosus-associated red lunula.

BACKGROUND Red lunulae have only rarely been described in patients with lupus erythematosus. OBJECTIVE We assessed the frequency and classified the type of red lunulae in patients with definite lupus erythematosus seen in an interdisciplinary dermatorheumatologic outpatient clinic. METHODS We studied 56 patients with either systemic or cutaneous lupus erythematosus for the presence of red lunulae. RESULTS Eleven of 56 patients (19.6%) with lupus erythematosus had red lunulae. All of them showed a complete type of red lunulae, which was seen on all finger nails in 10 patients and on a single finger nail in 1 patient. Seven patients suffered from systemic lupus, the other from subacute cutaneous (n = 2) or chronic discoid cutaneous lupus (n = 2). There was no statistically significant difference in autoantibody expression or treatment regimen between patients with or without red lunulae. However, symptomatic patients had a shorter disease interval, and all but 1 showed either periungual erythema or chilblain lupus. Periungual erythema was not observed in any patient without red lunulae. CONCLUSION Red lunulae, although rarely described in the literature, are not an uncommon symptom of patients with lupus erythematosus. They seem to be associated with periungual erythema or chilblain lupus. Red lunulae should be considered in the clinical spectrum of lupus disease.

Diagnostic Odyssey of a Cutaneous Mycobacteriosis Rare in Central Europe

Cutaneous infection with Mycobacterium chelonae is an uncommon disease, although this atypical mycobacterium is an acid-fast bacillus ubiquitous in the environment. It is often misdiagnosed and treated as a fungal or common bacterial infection. We report a case of disseminated atypical mycobacterial skin infection of a 72-year-old woman who was treated with different topical and systemic antimycotic and antibiotic drugs over a period of 5 months without remarkable improvement. Eventually, repeated tissue cultures on special medium and performance of PCR led to the diagnosis of M. chelonae infection. The patient was treated successfully with oral clarithromycin within 8 weeks. In case of abscessing cutaneous infection, M. chelonae should be considered in the differential diagnosis of prolonged disease when common antibiotics are not effective after 2–4 weeks of treatment.

Acquired nevoid telangiectasia.

Background: Acquired nevoid telangiectasia (ANT) is a segmental dilatation of papillary plexus vessels. Objective: In the present study, the frequency of ANT and its associations with collagen vascular and spinal disease have been investigated. Methods: 188 unselected patients, seen at an interdisciplinary dermatorheumatologic outpatient clinic, were clinically examined for the presence of ANT and possible associations to preexisting disease. Results: ANT was seen in 17% of patients, all females. The mean age of ANT patients was 57.5 ± 8.2 years. Most common diseases were lupus erythematosus and scleroderma. Twenty-four of them suffered from generalized fibromyalgia, 8 had spondylitis deformans, 1 suffered from thoracal syringomyelia and 1 had a spine trauma. Two types of ANT have been seen: the cervicothoracal transition type and the lumbosacral transition type. Conclusions: ANT is not uncommon among patients attending a dermatorheumatologic outpatient clinic. ANT indicates spinal or neuromuscular complaints, but is not related to collagen vascular disease itself.

Nagelveränderungen bei rheumatischen Erkrankungen

ZusammenfassungDas Nagelorgan ist der klinischen Untersuchung leicht zugänglich. Im Rahmen dermatologisch-rheumatologischer Krankheitsbilder ist die Kenntnis der wichtigsten assozierten Nagelveränderungen sehr hilfreich. Für einige wichtige Erkrankungen wie der psoriatrische Osteoarthropathie einschließlich der Sonderformen, dem Morbus Reiter und den Kollagenosen finden sich typische, teils auch charakteristische Symptome. Für andere Erkrankungen wie die Rheumatoidarthritis, die Arthritis urica und die Systemvaskulitiden sind assoziierte Nagelerkrankungen nicht selten, aber von geringerer diagnostischer Spezifität. Die vorliegende Übersicht bespricht sowohl Literatur – als auch eigene, in einer dermatologisch-rheumatologischen Gemeinschaftssprechstunde erhobene Daten.SummaryClinically the nail organ ist easy to investigate. When estimating dermato-rheumatological diseases, knowledge of important associated nail symptoms is extremely helpful. In some diseases like osteoarthropathia psoriatica and special variants, Reiter’s syndrome and connective tissue disease, typical or even characteristic symptoms can be found. In other disorders like rheumatoid arthritits, goal and systemic vasculitis, associated nail disorders are not uncommon, but of less diagnostic specificity. We review data from the literature and from our dermato-rheumatological outpatient clinic.