Segmental multilayered argon plasma coagulation: effective therapy option for perianal and scrotal Hailey-Hailey disease

AIM

Hailey-Hailey disease (HHD) is a genodermatosis characterized by recurrent chronic weeping plaques at intertriginous sites. In severe cases, topical and systemic treatments are often insufficient. Extensive excisions are traumatic for patients and have a high morbidity. Superficial ablative procedures such as dermabrasion have become established, but are difficult to perform in the perianal region and scrotum. Therefore, alternative therapies are required.

METHOD

Four patients with extensive anogenital HHD were treated by argon plasma coagulation (APC). This leads to a controlled coagulation of nearly constant depth. After dividing the affected areas into segments, a multilayered APC was performed in every second segment to the upper corium. The remaining segments were treated in the same way after healing of the initially treated parts.

RESULTS

A disease-free period of up to 37 months was observed in all four patients. There was no case of reduced cutaneous sensitivity or extensive scarring.

CONCLUSIONS

Argon plasma coagulation is effective and safe for perianal and scrotal HHD. The benefits include the accessibility to difficult anatomic sites and good control of ablation. The risk of anal stenosis is minimized by the segmental two-step procedure. The rapid re-epithelialization occurs from structures not affected by the disease and allows rapid mobilization of patients.

Ichthyosis vulgaris: novel FLG mutations in the German population and high presence of CD1a+ cells in the epidermis of the atopic subgroup

BACKGROUND

Ichthyosis vulgaris (IV) is a genetic disorder with a prevalence of 1:250-1000 caused by filaggrin (FLG) mutations, which also predispose to atopic diseases.

OBJECTIVES

To study the genotype/phenotype relationship in IV and to analyse whether the suggested skin barrier defect is associated with differences of epidermal dendritic cells.

PATIENTS/METHODS

We evaluated a cohort of 26 German patients with IV, established an IV severity score and analysed epidermal ultrastructure, histology, filaggrin and CD1a antigens. Mutations were screened by restriction enzyme analysis. Particular sequencing techniques allowed the complete FLG analysis to reveal novel mutations.

RESULTS

The combined null allele frequency of R501X and 2282del4 was 67.3%. Patients also showed the mutations S3247X and R2447X as well as five novel FLG mutations: 424del17 and 621del4 (profilaggrin S100 domain), 2974delGA (repeat 2), R3766X (repeat 10(1)) and E4265X (repeat 10(2)). Their combined allele frequency in controls was <0.7%. No mutation was found in one IV patient, all in all approximately 27% were heterozygous, and the majority (approximately 69%) showed two null alleles. The IV severity score and ultrastructure showed a significant correlation with genotypes. Interestingly, CD1a cell counts showed a significant difference between nonatopic and atopic IV patients both with eczema and without eczema.

CONCLUSIONS

We confirm that the mutations R501X and 2282del4 represent the most frequent genetic cause in German IV patients. The novel mutations are probably population and family specific. The observed differences of CD1a cells support the hypothesis that there is a barrier defect that predisposes to atopic manifestations, possibly independent of atopic eczema.

A novel missense mutation in GJB2 disturbs gap junction protein transport and causes focal palmoplantar keratoderma with deafness

Gap junctions are intercellular channels that mediate rapid intercellular communication. They consist of connexins, small transmembrane proteins that belong to a large family found throughout the animal kingdom. In the skin, several connexins are expressed and are involved in the regulation of epidermal growth and differentiation. One of the skin expressed gap junction genes is GJB2, which codes for connexin 26 and is associated with a wide variety of keratinisation disorders. Here, we report on a family with a novel GJB2 mutation (p.His73Arg) causing a syndrome of focal palmoplantar keratoderma with severe progressive sensorineural hearing impairment, a phenotype reminiscent of Vohwinkel syndrome. Using fluorescent connexin fusion proteins, we show that the mutation induces a transport defect similar to that found for the Vohwinkel syndrome mutation p.Asp66His. Co-transfection into cells expressing wild type connexin26 shows that the mutant has a dominant negative effect on connexin trafficking. We suggest that there may be a weak genotype-phenotype correlation for mutations in GJB2.

Erfolgreiche Dexamethason-Pulstherapie bei großflächig erosivem perianalen Lichen ruber

A 70-year-old man presented with a 6-month history of extensive, progressive perianal erosions. In addition, he had white reticulate striae and small erosions on the penis. The clinical diagnosis of erosive lichen planus was confirmed histologically. After several topical approaches failed and his ss-blocker was stooped, 3 pulses of dexamethasone (100 mg dexamethasone i.v. on 3 consecutive days every 4 weeks) led to complete and long-lasting remission.

[Congenital melanocytic nevi--a multifaceted problem]

Congenital melanocytic nevi are specific pigmented lesions that differ from acquired melanocytic nevi in terms of the age at which they develop and, usually, also in their clinical and histological features. Their potential for malignant transformation and their association with leptomeningeal seeding of nevomelanocytic cells have long been known, at least in the case of large melanocytic nevi. In addition, significant psychosocial stigmatization may affect patients with larger congenital nevi, in particular when they appear at exposed sites. Together, these aspects, in combination with the individual reaction of the patient and his/her parents, must be considered before a therapeutic recommendation is made. In the present review, our current knowledge of this condition is summarized with the aim of helping to determine the most appropriate management for the individual affected.

Stadiengerechte Therapie der COPD

The treatment of chronic obstructive pulmonary disease (COPD) has improved substantially over recent years, and is increasingly based on evidence from prospective studies. Cessation of smoking is the most important and effective single measure which can be taken. In the early stages, intensive measures for nicotine withdrawal should be taken to prevent the catastrophic effects of disease progression. Pharmacological treatment of COPD in the earlier stages (0-II) should be symptom oriented. Asymptomatic patients at these stages do not require permanent pharmacotherapy. From Stage II, COPD patients benefit from pulmonary rehabilitation programs. Patients with stages III and IV should usually be put on long-term corticosteroid inhalation, preferably in combination with long-acting bronchodilators. Systemic corticosteroids, even at low doses, are not indicated. They are useful only for the short-term treatment of acute exacerbations. These treatment modalities improve the quality of life and morbidity of COPD patients. They also decrease exacerbations and hospitalization rates, which should help to reduce mortality due to this important disease.

Die Behandlung des parapneumonischen Ergusses und des Pleuraempyems

Pleural effusions of infectious origin usually present as a complication of pneumonia, or, more rarely, of thoracic surgical procedures. Treatment is based upon the clinical picture, the appearance of the pleural fluid, on certain laboratory parameters, and upon the success of therapeutic interventions. The initial antibiotic regimen should cover the causative organisms that may empirically be expected in the individual setting of the patient. Similar to the situation in pneumonias, the spectrum of organisms in community-acquired effusions or empyemas differs substantially from that in hospital-acquired pleural infections. The management of pleural empyemas should follow an interdisciplinary strategy which involves the pulmonologist and the thoracic surgeon. The single most important intervention is the early and effective drainage of the pleural cavity. Loculated effusions that do not promptly improve after drainage can additionally be treated by a trial of intrapleural fibrinolysis for a period of approximately three days. However, the precise role of fibrinolytics in the setting of complicated pleural effusions and empyemas remains to be better defined. Early definitive surgical treatment, preferentially by video-assisted thoracoscopic surgery (VATS), should be the goal in all patients who do not promptly respond to drainage and/or intrapleural fibrinolytic therapy and who qualify for a surgical intervention.