Review of the potential photo-cocarcinogenicity of topical calcineurin inhibitors. Position statement of the European Dermatology Forum

Topical Calcineurin Inhibitors (TCIs) used for the treatment of atopic eczema modify the immune regulatory function of the skin and may have the potential to enhance immunosuppressive ultraviolet (UV) effects. Current recommendations on UV protection in eczema patients treated with PCIs are inconsistent and have given rise to uncertainty and anxiety in patients. Therefore, the European Dermatology Forum (EDF) developed a position statement which reviews critically the available data with regard to the problem, especially analysing and commenting the limitations of rodent models for the human situation. There is no conclusive evidence from rodent trials to indicate that long-term application of TCIs is photococarcinogenic. There is a need for further studies to investigate the validity of mouse models as well as long-term cohort studies in patients using TCIs. Available data suggest that long-term application of TCIs is safe, that there is no evidence of increased skin cancer risk and that it is ethical to treat patients with TCIs when indicated.

[Pigmented lesions of the genital mucosa]

Pigmented lesions of the genital mucosa are more frequent in women than in men. They represent a spectrum of different benign entities. A biopsy is always recommended when the diagnosis cannot be made with certainty on clinical examination and dermatoscopy. Differential diagnostic considerations include melanocytic nevi, blue nevi and syndromes featuring lentigines. Malignant melanomas of the penis and vulva are uncommon tumors which usually appear in elderly patients. They frequently present as painless palpable nodules at routine examination. The treatment consists of excision with histological control of the margins. An aggressive surgical approach has not been shown to prolong the poor 5-year survival. Cooperation with gynecologists and urologists is essential for the optimal management of such patients.

Zunahme der Syphilis und STD-Koinfektionen bei HIV-Infizierten in Dresden

BACKGROUND

In the past few years, increased diagnoses of syphilis and other sexually transmitted diseases (STD) have been reported in the cities of the United States and Europe, including Germany. The majority of cases identified were men who have sex with men (MSM).

PATIENTS AND METHODS

A retrospective chart review of 144 HIV-infected patients from Dresden enrolled between 2000 and October 2003 was analyzed for the prevalence of syphilis and other STDs and compared with previous data of 104 patients collected between 1993 and 1999.

RESULTS

The seroprevalence of syphilis increased from 13.5% to 17.5%, mainly due to a marked increase of active early syphilis from 0% to 7% of patients, all of whom were MSM. 63% of the patients had clinical or serological signs of other STDs.

CONCLUSION

These data confirm previous reports on the increase of syphilis among MSM. The frequent occurrence of other STDs in HIV-infected patients outlines the need for special STD screening offers and adequate counseling.

[Skin changes in diabetes mellitus]

Diabetes mellitus is the most frequent metabolic disorder. Just under 5 million people suffer from this disease in Germany. Four types of diabetes mellitus are distinguished: type 1 diabetes, type 2 diabetes, other specific diabetes forms, and gestational diabetes. Many characteristics of diabetes mellitus including skin changes are already manifest in the "prediabetic" stage when glucose tolerance is limited so that every elevation of blood sugar levels must be considered pathological. Changes in skin due to diabetes mellitus can be categorized into four disease groups: skin infections, skin diseases found overly frequently in association with diabetes mellitus, skin alterations due to diabetic complications, and reactions to antidiabetic treatment.

Risk and protective factors for sporadic basal cell carcinoma: results of a two-centre case-control study in southern Germany. Clinical actinic elastosis may be a protective factor

BACKGROUND

There are very few data regarding sun exposure behaviour of patients with basal cell carcinoma (BCC) in central Europe.

OBJECTIVES

A case-control study of patients with sporadic BCC was conducted to assess the risk of occupational and leisure-time sun exposure behaviour, precursor lesions for skin cancer and phenotypic factors on the development of sporadic BCC in Ulm and Dresden, Germany.

METHODS

A comparison was made of 213 patients with BCC (128 from Ulm, 85 from Dresden; 103 men and 110 women; median age at diagnosis 69 years) and 411 controls (237 from Ulm, 174 from Dresden; 197 men and 214 women; median age 58 years). Crude odds ratios (ORs) and corresponding 95% confidence intervals for all of 64 possible risk factors revealed strong associations in 33 items. Selection of important risk factors was performed in a multiple logistic regression.

RESULTS

For sporadic BCC, an increased risk was shown for persons with actinic cheilitis (OR 7.1), actinic keratosis (OR 2.7) and solar lentigo (OR 2.5). The only phenotypic factor indicating risk of sporadic BCC was hair colour, with a higher risk for red/fair than brown/black hair (OR 4.3). There was an increased risk for persons with BCC in first-degree relatives (OR 5.1) and those with sunburn 20 years before sporadic BCC was diagnosed (OR 3.6). Additionally, occupational ultraviolet (UV) exposure appeared to be a risk factor (OR 2.4). In contrast, clinical actinic elastosis showed a protective effect (OR 0.1).

CONCLUSIONS

In contrast to earlier reports, clinical actinic elastosis turned out to be the only protective factor for sporadic BCC. A special relationship between wrinkling and BCC risk could not be shown. For basic research, future work should be aimed at elucidating further the different forms of collagen repair processes after intermittent and/or chronic UV exposure. The data strongly support the recommendation that a change in recreational UV exposure habits in individuals, and sunburn avoidance in particular, are necessary not only because of the increased long-term risk of melanoma, but also because of the risk of other skin cancers such as sporadic BCC.

The emigration of Germany's Jewish dermatologists in the period of National Socialism

In the context of our investigation, we found information on 432 (76%) of the 569 Jewish dermatologists in Germany. There is evidence that 57 (10%) of the Jewish dermatologists were murdered in concentration camps, 61 (10.7%) died a natural death, 13 (2%) committed suicide, and 25 (4%) survived the Third Reich in Germany. After 1933, 276 (49%) Jewish dermatologists were able to leave Germany; the United States of America was the main destination and 107 (or 41%) emigrated there. A total of 34 (13%) Jewish dermatologists emigrated from Germany to Palestine and 16 to Latin America. Regarding emigration to other European countries, 20 of the Jewish dermatologists from Germany went to Great Britain (including Walter Freudenthal, 1893-1952, and Ernst Sklarz, 1894-1975), and 24 emigrated to other European countries, such as France (Rudolf Mayer, 1895-1962), Sweden (Carl Lennhoff, 1883-1963), and the Netherlands (Otto Schlein, 1895-1944).

[The treatment of atopic dermatitis in adults with topical calcineurin inhibitors]

In about 60% of cases, atopic eczema can persist in adulthood with distinctive clinical features and disease course. The introduction of the topical calcineurin inhibitors pimecrolimus 1% cream and tacrolimus 0.03 and 0.1% ointment clearly improves the long-term management of atopic eczema in adult patients; this has been shown in several large clinical studies and is confirmed by the growing practical experience with these substances. Topical calcineurin inhibitors are, even when applied for weeks and months, safe, well tolerated and efficient; they have a rapid and positive effect on pruritus and the potential--as shown in clinical studies with pimecrolimus 1% cream--to reduce the number of eczema flares, to significantly prolong the time to a first flare and to reduce or even eliminate the need for topical corticosteroids.

Demonstration of UVB-induced synthesis of 1 alpha,25-dihydroxyvitamin D3 (calcitriol) in human skin by microdialysis

Cutaneous vitamin D(3) (VD(3)) is generated by UVB-induced photolysis of 7-dehydrocholesterol (7-DHC). VD(3) then undergoes sequential hydroxylation to calcidiol (25-OHD(3)) in the liver and to hormonally active calcitriol (1 alpha,25-(OH)(2)D(3)) in the kidney. Recently, we have described the epidermal VD(3) metabolic pathway by demonstrating the autochthonous formation of calcitriol in cultured keratinocytes. In this study we sought to determine whether photolysis of 7-DHC induced by irradiation of human skin with monochromatic UVB at 300 nm results in epidermal synthesis of calcitriol in vivo. Using a microdialysis technique we demonstrated that UVB irradiation results in a dose- and time-dependent increase in the calcitriol concentration in the extracellular fluid of UVB-irradiated skin. Topical treatment of skin with an ointment containing 2% ketoconazole immediately after irradiation suppressed UVB-induced intraepidermal calcitriol synthesis. This study demonstrates for the first time UVB-triggered synthesis of calcitriol in human skin in vivo. The link between UVB irradiation and synthesis of calcitriol in the skin may be of great importance for regulation of biological processes such as cell growth, differentiation, apoptosis and immunological reactions.

[Topical treatment of psoriasis: a systematic update]

Classical topical treatment regimens in psoriasis including dithranol and corticosteroids are widely used and have been supplemented in recent years by topical vitamin D preparations, by vitamin D analogues and topical retinoids. The combination of these preparations with each other, with UV light or with systemic drugs often lead to improved effectiveness and tolerability when compared with the respective monotherapy. In private offices, the combination of calcipotriol with various corticosteroids is very commonly prescribed for patients with mild to moderate psoriasis. This combination can be sequentially applied twice daily or--in a newly introduced fixed preparation--once daily. In severe psoriasis requiring systemic treatment a concomitant effective topical treatment regimen can greatly improve the overall longtime management in affected patients.

Dynamic susceptibility contrast-enhanced echo-planar imaging of cerebral gliomas. Effect of contrast medium extravasation

PURPOSE

To assess the influence of the degree of contrast medium extravasation on different DSC EPI MR sequences for perfusion MR imaging.

MATERIAL AND METHODS

60 patients with cerebral gliomas were examined by either an FID EPI or an SE EPI DSC MR sequence. The acquired images were evaluated on a qualitative and quantitative basis. For qualitative assessment, the homogeneity of the signal time curve, image artifacts, the degree of signal drop and the degree of enhancement were evaluated. The quantitative assessment included the percentage of signal drop and the contrast-to-noise ratio of the different EPI sequences was analyzed.

RESULTS

FID EPI presented a more homogeneous signal time curve and a more pronounced susceptibility effect than the SE EPI sequence. Due to the lesser susceptibility effect, the SE EPI sequence was not as sensitive to contrast media extravasation. The signal returned to baseline in all patients. In patients with strongly enhancing lesions, the FID EPI sequence suffered from considerable T1 effects, causing problems in the quantification of perfusion data.

CONCLUSION

FID EPI sequences were preferred for perfusion MR imaging in patients without strong enhancing lesions, e.g. in ischemia or tumors with intact blood-brain barrier. In patients with suspected strong enhancing lesions, an SE EPI sequence should be used.

Dynamic susceptibility contrast-enhanced echo-planar imaging of cerebral gliomas. Effect of contrast medium extravasation

PURPOSE

To assess the influence of the degree of contrast medium extravasation on different DSC EPI MR sequences for perfusion MR imaging.

MATERIAL AND METHODS

60 patients with cerebral gliomas were examined by either an FID EPI or an SE EPI DSC MR sequence. The acquired images were evaluated on a qualitative and quantitative basis. For qualitative assessment, the homogeneity of the signal time curve, image artifacts, the degree of signal drop and the degree of enhancement were evaluated. The quantitative assessment included the percentage of signal drop and the contrast-to-noise ratio of the different EPI sequences was analyzed.

RESULTS

FID EPI presented a more homogeneous signal time curve and a more pronounced susceptibility effect than the SE EPI sequence. Due to the lesser susceptibility effect, the SE EPI sequence was not as sensitive to contrast media extravasation. The signal returned to baseline in all patients. In patients with strongly enhancing lesions, the FID EPI sequence suffered from considerable T1 effects, causing problems in the quantification of perfusion data.

CONCLUSION

FID EPI sequences were preferred for perfusion MR imaging in patients without strong enhancing lesions, e.g. in ischemia or tumors with intact blood-brain barrier. In patients with suspected strong enhancing lesions, an SE EPI sequence should be used.

[Initial scleromyxedema. Successful treatment with melphalan]

Scleromyxedema is a rare mucinous disease without thyroid dysfunction, associated with a monoclonal gammopathy. The deposits of mucin in the skin and other organs such as the cardiovasculary system, determine the prognosis of the disease. A 74-year old patient with initial scleromyxedema is described, in whom a pulse therapy with melphalan was initiated already in the early stages of the disease. Four cycles of melphalan in combination with prednisolon led to a complete and sofar stable remission of the disease.

A novel pathway for hormonally active calcitriol

Calcitriol [1alpha,25(OH)2D3], the hormonally active form of vitamin D3 (D3) is produced in both renal and extrarenal tissues. Our findings demonstrate that physiological doses of UVB radiation at 300 nm induce the conversion of 7-dehydrocholesterol (7-DHC) via preD3 and D3 into calcitriol in the pmol range in epidermal keratinocytes. The hydroxylation of photosynthesized D3 to calcitriol is strongly suppressed by ketoconazole, a known inhibitor of cytochrome P450 mixed function oxidases. The UVB-induced formation of calcitriol in human skin is demonstrable in vivo by the microdialysis technique. These results suggest that human skin is an autonomous source of hormonally active calcitriol.

[Multiple miliary osteomas of the face]

Osteoma cutis is a single or multiple ectope calcification with development of bony structures in the skin. We distinguish between primary and secondary ossification. Multiple miliary osteoma in the face has mostly been described secondary to preexisting acne vulgaris. We present a 62-year-old woman who developed multiple miliary osteoma in the face together with repeated doses of estrogen and discuss pathogenesis and therapeutic possibilities.

UVB-induced conversion of 7-dehydrocholesterol to 1alpha,25-dihydroxyvitamin D3 in an in vitro human skin equivalent model

We have previously shown that keratinocytes in vitro can convert biologically inactive vitamin D3 to the hormone calcitriol (1alpha,25-dihydroxyvitamin D3). This study was initiated to test whether the ultraviolet-B-induced photolysis of provitamin D3 (7-dehydrocholesterol), which results in the formation of vitamin D3, can generate calcitriol in an in vivo-like human skin equivalent model made of fibroblasts in a collagen matrix as the dermal component and keratinocytes as the epidermal component. Cultures were preincubated with increasing concentrations of 7-dehydrocholesterol (0.53-5.94 nmol per cm2 human skin equivalent) at 37 degrees C and irradiated with monochromatic ultraviolet B at wavelengths ranging from 285 to 315 nm (effective ultraviolet doses 7.5-45 mJ per cm2). In our in vitro model irradiation with ultraviolet B resulted in a sequential metabolic process with generation of previtamin D3 followed by the time-dependent formation of vitamin D3, 25-hydroxyvitamin D3, and ultimately calcitriol in the femtomolar range. Unirradiated cultures and irradiated cultures without keratinocytes generated no calcitriol. Irradiation of skin equivalents at wavelengths > 315 nm generated no or only trace amounts of calcitriol. The ultraviolet-B-triggered conversion of 7-dehydrocholesterol to calcitriol was strongly inhibited by ketoconazole indicating the involvement of P450 mixed function oxidases. The amount of calcitriol generated was dependent on the 7-dehydrocholesterol concentration, on wavelength, and on ultraviolet B dose. Hence, keratinocytes in the presence of physiologic concentrations of 7-dehydrocholesterol and irradiated with therapeutic doses of ultraviolet B may be a potential source of biologically active calcitriol within the epidermis.