The clinical spectrum of syphilitic balanitis of Follmann: report of five cases and a review of the literature

BACKGROUND

Eugène Follmann first described syphilitic balanitis as a manifestation of primary syphilis in 1948 and since then it has been known as syphilitic balanitis of Follmann (SBF). So far, SBF has rarely been described in literature.

OBJECTIVES

We are reporting five additional cases of SBF considering the broad differential diagnosis of balanitis.

METHODS

A review of the available literature of SBF was performed and five additional cases analyzed.

RESULTS

In our case series, the clinical appearance of SBF shows a heterogeneous spectrum varying from painful oedematous balanoposthitis with beginning paraphimosis to superficial erosive balanitis and even to painless induration of the glans.

CONCLUSIONS

SBF might be seen more frequently than has been described due to misinterpretation. Therefore primary syphilis should be included in the differential diagnosis of balanitis and balanoposthitis.

[Non-gonococcal infectious urethritis : pathogen spectrum and management]

For many years an increase in cases of urethritis has been observed in western Europe. In order to be able to combat this continuous rise, the perception of sexually transmitted diseases must be promoted, the clarification and screening must be intensified and therapy must be rapidly and correctly carried out. In addition to the commonest pathogens causing urethritis, namely chlamydia and gonococci, many other pathogenic microbes must be taken into consideration in the diagnostics. With respect to therapy, apart from the increasing resistance formation of Mycoplasma genitalium, the decreasing effectiveness of standard forms of treatment of other microbes must be emphasized. For chronic and recurrent urethritis in particular a broad clarification of the pathogen should be carried out to enable targeted treatment and also partner treatment. Priority must again be given to primary prevention.

[Differential diagnosis and management of balanitis]

Balanitis is a descriptive diagnosis for a heterogeneous group of infectious or inflammatory dermatoses which have to be differentiated from malignant conditions. Balanitis is caused not only by Candida spp. and bacterial infections, including anaerobic bacteria: viral infections, parasites and other sexually transmitted infections (STI) also have to be considered. Lichen planus, psoriasis and contact dermatitis can characteristically lead to inflammatory conditions of the glans penis. In addition to a complete skin examination, a thorough patient history with respect to topically applied products and sexual behavior is essential. Infections must be treated and the glans penis should be kept dry. It is important to ensure a balanced genital hygiene in patients. As a last resort therapeutic circumcision can be considered for most forms of chronic balanitis.

Rare human skin infection with Corynebacterium ulcerans: transmission by a domestic cat

Corynebacterium ulcerans is mainly known for its ability to cause animal infections. Some strains of C. ulcerans produce diphtheria toxin, which can cause life-threatening cardiopathies and neuropathies in humans. Human cutaneous C. ulcerans infection is a very rare disease that mimics classical cutaneous diphtheria. We present a very rare case of a C. ulcerans skin infection caused by a non-diphtheria toxin-producing strain of C. ulcerans that resolved after 3 weeks of therapy with amoxicillin-clavulanate. A pet cat was the probable source of infection. The presence of C. ulcerans in the mouth of the cat was confirmed by 16S rRNA gene analysis and the API Coryne system. In cases of human infection with potentially toxigenic corynebacteria, it is important to determine the species and examine the isolate for diphtheria toxin production. If toxigenicity is present, diphtheria antitoxin should be administered immediately. Carriers and potential infectious sources of C. ulcerans include not only domestic livestock but also pet animals. For the primary prevention of disease caused by diphtheria toxin-producing corynebacteria, vaccination with diphtheria toxoid is recommended.

Irradiation-induced morphea: x-rays as triggers of autoimmunity

We report on 3 females with breast cancer who developed morphea at the site of post-surgery radiotherapy. One was suffering from other autoimmune skin diseases before the diagnosis and treatment of breast cancer. Postirradiation morphea is a potential complication after radiotherapy, particularly radiotherapy for cancer. This troublesome skin disease can occur months to years after treatment, and is associated with remarkable morbidity and pain, and also cosmetic aspects. Therefore, it is crucial to be aware of this condition, and to try to identify patients who might be at an increased risk of developing morphea.

European guideline for the management of genital herpes, 2010

This is the guideline for genital herpes simplex virus (HSV) management for the IUSTI/WHO Europe, 2010. They describe the epidemiology, diagnosis, clinical features, treatment and prevention of genital HSV infection. They include details on the management of HSV in pregnancy, those who are immunocompromised and the clinical investigation and management of suspected HSV-resistant disease.

European guideline for the management of chancroid, 2011

Chancroid is a sexually acquired disease caused by Haemophilus ducreyi. The infection is characterized by one or more genital ulcers, which are soft and painful, and regional lymphadenitis which may develop into buboes. The infection may easily be misidentified due to its rare occurrence in Europe and difficulties in detecting the causative pathogen. H. ducreyi is difficult to culture. Polymerase chain reaction (PCR) can demonstrate the bacterium in suspected cases. Antibiotics will usually be efficient for curing chancroid.

Incidence of bullous pemphigoid and pemphigus in Switzerland: a 2-year prospective study

BACKGROUND

Bullous pemphigoid (BP), pemphigus vulgaris (PV) and pemphigus foliaceus (PF) are autoimmune bullous diseases characterized by the presence of tissue-bound and circulating autoantibodies directed against disease-specific target antigens of the skin. Although rare, these diseases run a chronic course and are associated with significant morbidity and mortality. There are few prospective data on gender- and age-specific incidence of these disorders.

OBJECTIVES

Our aims were: (i) to evaluate the incidence of BP and PV/PF in Swiss patients, as the primary endpoint; and (ii) to assess the profile of the patients, particularly for comorbidities and medications, as the secondary endpoint.

METHODS

The protocol of the study was distributed to all dermatology clinics, immunopathology laboratories and practising dermatologists in Switzerland. All newly diagnosed cases of BP and pemphigus occurring between 1 January 2001 and 31 December 2002 were collected. In total, 168 patients (73 men and 95 women) with these autoimmune bullous diseases, with a diagnosis based on clinical, histological and immunopathological criteria, were finally included.

RESULTS

BP showed a mean incidence of 12.1 new cases per million people per year. Its incidence increased significantly after the age of 70 years, with a maximal value after the age of 90 years. The female/male ratio was 1.3. The age-standardized incidence of BP using the European population as reference was, however, lower, with 6.8 new cases per million people per year, reflecting the ageing of the Swiss population. In contrast, both PV and PF were less frequent. Their combined mean incidence was 0.6 new cases per million people per year. CONCLUSIONS; This is the first comprehensive prospective study analysing the incidence of autoimmune bullous diseases in an entire country. Our patient cohort is large enough to establish BP as the most frequent autoimmune bullous disease. Its incidence rate appears higher compared with other previous studies, most likely because of the demographic characteristics of the Swiss population. Nevertheless, based on its potentially misleading presentations, it is possible that the real incidence rate of BP is still underestimated. Based on its significant incidence in the elderly population, BP should deserve more public health concern.

Precalcaneal congenital fibrolipomatous hamartomas: report of 3 additional cases and discussion of the differential diagnosis

We report 3 cases of otherwise healthy infants with nodules on their soles. The nodules were present at birth or developed in early childhood. This condition has first been described in 1977 and was termed precalcaneal congenital fibrolipomatous hamartoma (PCFH). Since then the same entity has been reported under various denominations. The incidence of PCFH is underestimated, and it is important to recognize the benign nature of this disorder.

Assessment of a real-time PCR test to diagnose syphilis from diverse biological samples

OBJECTIVES

To investigate the contribution of a real-time PCR assay for the detection of Treponema pallidum in various biological specimens with the secondary objective of comparing its value according to HIV status.

METHODS

Prospective cohort of incident syphilis cases from three Swiss hospitals (Geneva and Bern University Hospitals, Outpatient Clinic for Dermatology of Triemli, Zurich) diagnosed between January 2006 and September 2008. A case-control study was nested into the cohort. Biological specimens (blood, lesion swab or urine) were taken at diagnosis (as clinical information) and analysed by real-time PCR using the T pallidum 47 kDa gene.

RESULTS

126 specimens were collected from 74 patients with primary (n = 26), secondary (n = 40) and latent (n = 8) syphilis. Among primary syphilis, sensitivity was 80% in lesion swabs, 28% in whole blood, 55% in serum and 29% in urine, whereas among secondary syphilis, it was 20%, 36%, 47% and 44%, respectively. Among secondary syphilis, plasma and cerebrospinal fluid were also tested and provided a sensitivity of 100% and 50%, respectively. The global sensitivity of T pallidum by PCR (irrespective of the compartment tested) was 65% during primary, 53% during secondary and null during latent syphilis. No difference regarding serology or PCR results was observed among HIV-infected patients. Specificity was 100%.

CONCLUSIONS

Syphilis PCR provides better sensitivity in lesion swabs from primary syphilis and displays only moderate sensitivity in blood from primary and secondary syphilis. HIV status did not modify the internal validity of PCR for the diagnosis of primary or secondary syphilis.

Swiss recommendations for the management of varicella zoster virus infections

Infections with varicella zoster virus (VZV) are common viral infections associated with significant morbidity. Diagnosis and management are complex, particularly in immunocompromised patients and during pregnancy. The present recommendations have been established by a multidisciplinary panel of specialists and endorsed by numerous Swiss medical societies involved in the medical care of such patients (Appendix). The aim was to improve the care of affected patients and to reduce complications.

Swiss recommendations for the management of varicella zoster virus infections

Infections with varicella zoster virus (VZV) are common viral infections associated with significant morbidity. Diagnosis and management are complex, particularly in immunocompromised patients and during pregnancy. The present recommendations have been established by a multidisciplinary panel of specialists and endorsed by numerous Swiss medical societies involved in the medical care of such patients (Appendix). The aim was to improve the care of affected patients and to reduce complications.

Retrospective analysis of varicella zoster virus (VZV) copy DNA numbers in plasma of immunocompetent patients with herpes zoster, of immunocompromised patients with disseminated VZV disease, and of asymptomatic solid organ transplant recipients

BACKGROUND

Varicella zoster virus (VZV) causes significant morbidity and mortality in immunocompromised patients. Subclinical reactivation has been described in solid organ recipients and has been associated with graft versus host disease in bone marrow transplantation. Newer studies assessing the prevalence and impact of subclinical VZV reactivation in solid organ transplant (SOT) recipients are lacking.

METHODS AND RESULTS

In a first step we developed a highly sensitive quantitative polymerase chain reaction (qPCR) assay for VZV DNA with a detection limit of < or = 20 copies/mL. Using this assay, we retrospectively analyzed plasma samples of different patient groups for VZV DNA. VZV DNA was found in 10/10 plasma samples of immunocompetent patients with herpes zoster (VZV copy numbers/mL: mean+/-SEM 1710+/-1018), in 1/1 sample of a human immunodeficiency virus-infected patient with primary VZV disease (15,192 copies/mL) and in 4/4 plasma samples of immunocompromised patients with visceral VZV disease (mean of first value 214,214+/-178,572). All 108 plasma samples of asymptomatic SOT recipients off any antiviral therapy, randomly sampled over 1 year, were negative for VZV DNA.

CONCLUSION

Our qPCR assay proved to be highly sensitive (100%) in symptomatic VZV disease. We did not detect subclinical reactivation in asymptomatic SOT recipients during the first post-transplant year. Thus, subclinical VZV reactivation is either a rare event or does not exist. These data need to be confirmed in larger prospective trials.

17-jähriger Mann mit akuten Bauchschmerzen, Hämatochezie und Exanthem

A 17-year old adolescent presented with abdominal pain, petechial lesions, arthralgia, and hematochezia. Abdominal ultrasound showed a suspicious ileocecal region and a lower endoscopy revealed the picture of an ileitis terminalis. The diagnosis of Purpura Henoch Schoenlein was made and confirmed by skin-biopsy showing a leucocytoclastic vasculitis. This case report demonstrates the various clinical symptoms of Purpura Henoch Schoenlein and its clinical course.

Aquagenic syringeal acrokeratoderma (transient reactive papulotranslucent acrokeratoderma)

In 1996, English and McCollough described an unusual entity in 2 sisters characterized by a transient and recurrent keratoderma exclusively on the palms after water exposure. The condition developed 3-5 min after exposure to water and resolved within a short time after drying. This finding was associated with a tightening sensation. Yan et al. coined the term 'aquagenic palmoplantar keratoderma', and the designation 'aquagenic syringeal acrokeratoderma' was suggested by MacCormack et al. Until now, a total of 8 cases have been reported. We documented 2 new cases with acquired aquagenic syringeal acrokeratoderma. A 25-year-old female had observed within the last 3 months a burning sensation on the palms after some minutes of water contact. Physical examination revealed a perfectly normal skin on the palms. Three minutes after water immersion of 20 degrees C, a whitish discoloration appeared on the palms and a thickening of the palmar skin was visible. In addition, the eccrine pores were much more prominent. Few minutes after drying the skin, the situation returned to a normal state. The second patient, a 33-year-old female noticed a painful whitish discoloration of the skin on the palms after a short period of water immersion. Sometimes the white skin could be peeled off. In the last year, hyperhidrosis developed, and a more reddish aspect of the palms appeared. In our office after rinsing the hands with water at room temperature, a whitish discoloration in the center of the palms appeared which was associated with a painful sensation. After drying, the whitish lesions disappeared almost completely within 30 min. Aquagenic palmar keratoderma describes an acquired and transient condition which occurs after brief exposure to water and disappears after drying within minutes to an hour. Only rarely may a slight hyperkeratosis remain for a longer time. The possible pathophysiology and treatment options are discussed.

Cold agglutinin disease--the importance of cutaneous signs

We present the case of a woman where the diagnosis of cold agglutinin disease could be made after we had noticed slight cutaneous manifestations during a routine examination. Leading symptoms were livedo reticularis of the thighs and a history of acrocyanosis and Raynaud's phenomenon upon cold exposure. The current knowledge about the etiology, clinical presentation and treatment of the disease is briefly discussed.

Cowden syndrome-diagnostic skin signs

Cowden syndrome is a rare autosomal dominant familial cancer syndrome with a high risk of breast cancer. The most important clinical features include carcinomas of the breast and thyroid, and hamartomatous polyps of the gastrointestinal tract. There are characteristic mucocutaneous features which allow early recognition of the disease and are generally present before internal malignancies develop. We report on a woman in whom the diagnosis of Cowden syndrome was first made after she had been treated for both breast cancer and melanoma.

The heterogeneous clinical spectrum of genital herpes

BACKGROUND AND OBJECTIVE

Most data of genital herpes have been collected in STD clinics in the USA where unrecognized forms accounted for 80% of HSV-2 infections. Our aim was to study the clinical features in an outpatient clinic of dermatology.

METHODS

The charts of 170 patients, previously monitored prospectively for a HIV prevalence study, with culture-confirmed genital herpes or herpetic infection with HSV-2 at any other site presenting between 1995 and 1999 were analyzed.

RESULTS

111 (65%) men and 59 (35%) women were identified with a mean age of 44 years. Only 49% had a typical cluster of genital lesions. Eighty-six (51%) presented with either lesions at extragenital sites [mostly the buttocks 33/170 (19%), thigh 10/170 (6%), anal region 9/170 (5%) and fingers 8/170 (5%)] or showed morphologically atypical forms of isolated genital lesions [single ulcer 16/170 (9%), erosion 6/170 (4%), crust 3/170 (2%) and fissure, edema or erythema each 1/170 (1%)]. Women significantly presented more often with extragenital infections of HSV-2 [36/59 (61%)] than men [18/111 (16%)].

CONCLUSIONS

More than half of the patients with genital herpes of a mainly immunocompetent population presented with atypical manifestations. The underdiagnosis of genital herpes seems largely due to misinterpretation of atypical genital and extragenital lesions.

Contact dermatitis after temporary henna tattoos--an increasing phenomenon

Four patients developed contact dermatitis to black henna tattoos on holiday in the Middle East and Asia. Two to ten days after skin painting an itchy, reddish swelling developed at the site of the tattoo exactly following its sharply demarcated borders. Histological investigation of the lesions revealed spongiotic dermatitis with dense lymphohistiocytic infiltrates. Patch testing in all patients showed a strong reaction to p-phenylenediamine (PPD). The other tests, including standard series and henna powder, were all negative. Healing time after application of topical class III and IV steroids was prolonged. These reports show an impressive side effect of temporary tattoos with possible long-term damage. Rather than henna, the causative agent in the pastes used for temporary tattoos appears to be PPD, a widely used dye that is added to the pastes in high concentrations to produce a darker shade. The growing incidence of this complication requires close observation, while practitioners should be aware of this sensitisation and of possible subsequent allergic reactions, especially after hair colouring with dyes based on PPD.

Contact dermatitis after temporary henna tattoos--an increasing phenomenon

Four patients developed contact dermatitis to black henna tattoos on holiday in the Middle East and Asia. Two to ten days after skin painting an itchy, reddish swelling developed at the site of the tattoo exactly following its sharply demarcated borders. Histological investigation of the lesions revealed spongiotic dermatitis with dense lymphohistiocytic infiltrates. Patch testing in all patients showed a strong reaction to p-phenylenediamine (PPD). The other tests, including standard series and henna powder, were all negative. Healing time after application of topical class III and IV steroids was prolonged. These reports show an impressive side effect of temporary tattoos with possible long-term damage. Rather than henna, the causative agent in the pastes used for temporary tattoos appears to be PPD, a widely used dye that is added to the pastes in high concentrations to produce a darker shade. The growing incidence of this complication requires close observation, while practitioners should be aware of this sensitisation and of possible subsequent allergic reactions, especially after hair colouring with dyes based on PPD.

Reticulate, patchy and mottled pigmentation of the neck. Acquired forms

Besides the inherited forms of mottled and reticulate pigmentation, a vast number of diseases and trigger mechanisms can lead to acquired pigmentation of the neck. Nonhereditary variants of reticulate and mottled pigmentation can affect the neck as a typical site and therefore may give a diagnostic clue or it can occur sporadically on the neck as well as on other sites. A well-known and important factor in the pathogenesis is exposure to sunlight. Sun-induced pigmentation often presents on the neck and may result from phototoxic, photoallergic and cumulative actinic damage. Frequent forms comprise berloque dermatitis, Riehl's melanosis, poikiloderma of Civatte and tanning bed lentigines. Different infections may also lead to this distinct skin alteration as pediculosis capitis, pityriasis versicolor and syphilis II. Treatment-induced irregular pigmentations may occur after applications of topical agents (e.g. diphenylcyclopropenone), systemic medication (e.g. 5-fluorouracil, chlorpromazine), as a complication of laser resurfacing or as a chronic graft-versus-host reaction. Different neoplasms may also involve the neck. Widespread pigmented basal cell carcinoma, cutaneous T-cell lymphoma, syringolymphoid hyperplasia and histiocytic diseases may lead to reticulated pigmentation. Various other infrequent conditions as connective tissue diseases, malnutrition, lichen planus pigmentosus and others are summarized. The neck, a readily accessible site to medical inspection, may have an underestimated value for the diagnosis of different skin diseases.

Palmoplantar keratoderma and leukokeratosis anogenitalis: the second case of a new disease

An increasing number of syndromes with palmoplantar keratoderma (PPK) with associated diseases are being identified, representing a wide spectrum of distinct entities. At present only one case report has described the combination of marked anogenital leukokeratosis with diffuse PPK evolving in a collodion baby. We report a patient with a diffuse, nonprogressive PPK in combination with an intermittently pruritic, slowly progressive anogenital leukokeratosis. Hyperkeratosis of the perineal area was most pronounced and extended to the distal portion of the anal mucosa. The opalescent lesion was also visualized at the margin of the major labia. Vulvar structures were not otherwise involved or dystrophic. There were no signs or symptoms of ectodermal dysplasia. Specifically, the nails were normal and showed no signs of pachyonychia congenita. Other differential diagnoses included dyskeratosis congenita and white sponge nevus, which may be associated with anogenital leukokeratosis, but a keratoderma is not associated with these entities. Keratin immunocytochemistry showed marked expression of suprabasal K17 and absence of K6 and K16. Further examination of the initial case described by Itin and Rufli demonstrated the same expression pattern and supports the contention that these two cases represent the same entity.

Genodermatosis with reticulate, patchy and mottled pigmentation of the neck--a clue to rare dermatologic disorders

Reticulate pigmentation of the neck is a common finding in numerous genodermatoses and acquired diseases. As the neck is readily accessible to medical inspection, it may serve as a diagnostic window for various dermatoses. Several entities out of the spectrum of ectodermal dysplasia present with reticulate or mottled pigmentation on the upper trunk and neck. The most impressive genodermatoses with punctate and reticulate pigmentation affecting the neck are the Naegeli-Franceschetti-Jadassohn syndrome, dermatopathia pigmentosa reticularis and dyskeratosis congenita. Reticulate pigmented anomaly of the flexures and lentiginosis, disorders of cornification and related entities are further genodermatoses which may involve the neck. In our review we have integrated inherited dermatoses which do not obligatorily affect the neck but have been well documented to do so. Our work should give the clinician a checklist on genodermatoses which may produce reticulate and mottled pigmentation on the neck.

[The diabetic foot--examination of the skin]

A thorough dermatologic examination permits early identification of an increased risk for ulceration. This is of central importance in any plan to prevent amputation. Investigation should focus on the color of the skin, alteration of the texture, temperature and presence of swelling. Attention should be paid to callosities, indicating increased foot pressures, and to breaks in the skin, which may be followed by bacterial penetration. In addition, a variety of nail changes exists associated with diabetes mellitus requiring correct diagnosis and appropriate therapy.

[Grain mites. A small epidemic caused by Pyemotes species]

Pyemotes mites, of which the grain itch mite is the most important for human medicine, are ectoparasites of many insect species. Human infestation occurs only accidentally and temporally. The source materials are most often grain, straw and plant-based foods. Bites produce an intensely itching urticarial wheal capped by pin-point vesicles, which often are destroyed by scratching. Pyemotes dermatitis favours the back, the abdomen and the flexor side of the forearms. The mites are barely visible to the naked eye and reside only briefly on humans and thus are not found by physicians during clinical examination. When itching starts, the parasites have usually left their hosts. Therefore it is important to investigate the patient's environment and to identify the infested materials. We describe an outbreak of Pyemotes dermatitis in at least 16 persons, most of them warehouse workers in a hobby mail-order house. Infested decorative wheat was the source of the problem. Successful eradication was achieved by fumigation of the storage facilities with the insecticide methylbromide. Our cases demonstrate the importance of examination of environmental specimens for ectoparasites in cases of unexplained dermatoses. Biological agriculture avoiding insecticides may cause reappearance of this almost forgotten skin disease.

Cutaneous manifestations of Paecilomyces lilacinus infection induced by a contaminated skin lotion in patients who are severely immunosuppressed

BACKGROUND

New opportunistic fungal infections cause significant morbidity and death in patients who are severely immunocompromised. Cutaneous lesions may be the first clinical manifestation and give the clue to early diagnosis.

OBJECTIVE

The purpose of this study was to describe the clinical and histologic manifestations of Paecilomyces lilacinus infection in patients who are severely immunosuppressed.

METHODS

Within a 3-month period, we observed 5 patients with allogenic bone marrow transplantation and 4 patients with aplasia after chemotherapy for hematologic malignancies who developed skin eruptions caused by invasive P lilacinus.

RESULTS

The skin lesions began in 7 cases during or shortly after recovery of pancytopenia. Most of the skin lesions were located on the lower extremities. The cutaneous manifestations were highly variable including erythematous macules, nodules, pustules, vesicular lesions, and necrotic crusts. In 3 biopsy specimens, histologic examination revealed hyphae in periodic acid-Schiff-stained sections. In all patients P lilacinus was isolated from skin tissue samples. P lilacinus was identified from all lesions either by skin biopsy or needle aspiration from clinically evident lesions. In 3 additional cases, the patient's hands were colonized without skin lesions. The source of the epidemic outbreak was finally traced down to several contaminated lots of a topical moisturizing agent. Two patients died; one patient had septic lesions in the eye and kidney as the result of P lilacinus.

CONCLUSION

Clinical and histologic findings of P lilacinus infection with cutaneous manifestations in patients who are severely immunosuppressed are summarized. P lilacinus is resistant to all systemic antimycotics available, and in general, recovery of immunosuppression is necessary to eradicate the mold. Contaminated topical dermatologic agents should be included in the differential diagnosis as a source for severe epidemic cutaneous manifestations of fungal infection in patients who are severely immunosuppressed. This fact implies that additional safety guidelines are necessary for topical dermatologic agents used for patients who are severely immunosuppressed.

Lower and upper extremity atrophy associated with a giant congenital melanocytic nevus

Giant congenital melanocytic nevi (GCMN) may be associated with a variety of malformations. Recently, atrophy of the underlying extremity was reported for the first time. We observed two patients with GCMN on the extremities with marked atrophy of the underlying tissue without functional impairment. According to the definition of hamartoma, it seems possible that one component of tissue has decreased. Dermatologists treating patients with such nevi in the first weeks of life with dermabrasion, laser, or curettage need to know that the natural course of GCMN may lead to atrophy and that this does not necessarily result from the treatment regimen.

Viral lesions of the mouth in HIV-infected patients

Viral lesions of the mouth in patients with HIV infection are common and these diseases any be a marker for HIV and disease progression. We review the spectrum of oral viral manifestations and discuss treatment modalities. The most common Epstein-Barr virus (EBV)-induced disorder in HIV-infected patients is oral hairy leukoplakia. EBV-related oral B-cell and T-cell lymphoma in AIDS patients has been described repeatedly. Herpes virus type 1 and rarely type 2 may lead to painful and resistant oral ulcers, and systemic treatment with acyclovir, valaciclovir or famciclovir is indicated. In acyclovir-resistant cases foscarnet is the treatment of choice. In recent years it has been documented that Kaposi's sarcoma, which often affects oral mucosa, is probably induced by herpesvirus type 8. Cytomegalovirus was found in 53% of cases with herpesviridae-induced mucosal ulcers as the only ulcerogenic viral agent in AIDS patients. In severe cytomegalovirus infection treatment with ganciclovir is helpful. Viral warts induced by different HPV may occur in the mouth. Several physical treatment modalities are possible in the oral mucosa. In AIDS patients mollusca contagiosa may occur as large and atypical lesions in the face and lips and rarely in the oral cavity. Cryotherapy is a bloodless treatment in such patients.

[Skin manifestations of graft-versus-host reaction following bone marrow transplantation]

We review the cutaneous manifestations of acute and chronic graft versus host disease (GvHD). Acute GvHD is characterized by initial itching, pain on pressure and erythema which begins on posterior auricular skin, palms and soles. The disease evolves into a typical but nonspecific maculopapular rash. Confluent rashes and follicular erythema may occur. Erosive oral lesions usually develop. The most severe variant of GvHD is toxic epidermal necrolysis, which often has a fatal outcome. The onset of chronic GvHD usually occurs more than 100 days after bone marrow transplantation and may be preceded by the acute form. The spectrum of skin changes includes lichenoid pruritic lesions with violaceous color and scleroderma-like skin involvement. Investigation of unknown rashes in these patients includes skin biopsy, which clearly differentiates leukocytoclastic vasculitis and erythema exsudativum multiforme with lymphocytic vasculitis from cutaneous manifestations of GvHD. Special stains may reveal bacteria and fungus in septicemic patients. The therapeutic options are discussed.

[Correlation between chronic urticaria and depression/somatization disorder]

In a multicenter study, 100 patients with chronic urticaria were examined with a standardized personality test (Giessen test), a standardized symptom questionnaire (Giessener Beschwerdebogen) and a specially developed questionnaire concerning symptoms, history and behaviour during symptomatic periods. Almost one third of the patients showed elevated scores both for depression and for symptoms that are often associated with depression. It therefore seems worth-while examining such persons more specifically and possibly treating them by psychosomatic methods. The present results do not allow the classification of chronic urticaria as a somatization disorder. Since one-third of the patients had symptoms of depression, combined dermatological and psychosomatic approach may make it possible to offer them an appropriately targeted treatment.

Lymphoproliferative responses to Borrelia burgdorferi in patients with erythema migrans, acrodermatitis chronica atrophicans, lymphadenosis benigna cutis, and morphea

BACKGROUND AND DESIGN

Specific humoral and cell-mediated immune responses play an important role in the pathogenesis of Lyme borreliosis. Several previous studies demonstrated that a specific cellular immune response to Borrelia burgdorferi can occur independently of a diagnostic humoral response. Little is known about T-cell reactivities against B burgdorferi in early and late cutaneous manifestations of Lyme borreliosis. We studied the lymphoproliferative response of peripheral blood mononuclear cells to B burgdorferi antigen from 99 patients (25 with erythema migrans, 16 with acrodermatitis chronica atrophicans, 13 with lymphadenosis benigna cutis, and 45 with localized scleroderma) and 21 control subjects. The results are expressed as a stimulation index (SI) (mean count per minute of triplicate cultures with stimulant divided by mean count per minute without stimulant). The serum samples from all patients and control subjects were tested for antibodies to B burgdorferi by indirect immunofluorescence assay.

RESULTS

The 21 healthy seronegative controls had an SI of 3.3 +/- 2.0 (mean +/- SD). Compared with that of control subjects, the SIs were significantly elevated in patients with erythema migrans (9.8 +/- 9.1), acrodermatitis chronica atrophicans (11.8 +/- 8.2), and lymphadenosis benigna cutis (7.2 +/- 6.2). The 45 patients with localized scleroderma had elevated proliferative responses, with an SI of 6.5 +/- 7.3, but these responses did not significantly differ from those of controls. Elevated titers of antibodies to B burgdorferi were present in six (24%) of 25 patients with erythema migrans, five (38%) of 13 patients with lymphadenosis benigna cutis, and 13 (29%) of 45 patients with localized scleroderma. All 16 patients with acrodermatitis chronica atrophicans had markedly elevated antibody titers.

CONCLUSIONS

Our findings show that a significant lymphoproliferative response to B burgdorferi occurs in the majority of patients with cutaneous manifestations of Lyme borreliosis. The lymphocyte proliferation assay may be of diagnostic value in patients in whom Lyme borreliosis is strongly clinically suspected and who have nondiagnostic levels of antibodies against B burgdorferi.

Palmoplantar keratoderma and associated syndromes

This article focuses on the current state of knowledge concerning the characterization and classification of palmoplantar keratoderma and associated syndromes. In addition, therapeutic options are discussed. Exact diagnosis enables dermatologists to give patients accurate genetic counseling and may help to detect underlying defects or proneness to cancer. Furthermore, precise classification of this disease facilitates the use of the most efficient therapeutic modalities. Important criteria for the classification of palmoplantar keratoderma are the mode of transmission, age at onset, and distribution of the keratoderma. The disorder may be diffuse or focal; it may be restricted to the palms and soles or also involve the dorsal aspects of the hands and feet. Psoriatic-like lesions in other parts of the body may occur in certain variants. The association of other signs and symptoms may provide diagnostic clues. Ultrastructural investigation will show diagnostic features in some types of palmoplantar keratoderma, and biochemical analysis may be helpful in the classification of keratoderma. In the future, the most accurate diagnosis will be the identification of the genetic defect and its chromosomal localization.

Zosteriform metastases in melanoma

Zosteriform metastasis is a rare form of tumor spread to the skin that most often arises from an internal carcinoma or a hematologic malignancy. We describe a 29-year-old woman with malignant melanoma of the back in whom zosteriform metastases developed along the fifth thoracic dermatome.

[Skin changes in HIV infections]

The spectrum of dermatologic findings related to human immunodeficiency virus includes a variety of cutaneous and mucocutaneous disorders. The most frequent diagnoses are oral candidiasis, seborrheic dermatitis, pyodermas and Kaposi's sarcoma. Distinctive skin lesions occur at various stages of HIV infection. Especially herpes zoster, seborrheic dermatitis and oral candidiasis may act as indicators, and their recognition is of particular importance for the early diagnosis of HIV infection and for the prevention of further opportunistic infections. In addition, some dermatologic findings as mollusca contagiosa and Kaposi's sarcoma occur mostly as late manifestations and may constitute a cutaneous correlate of advanced cellular immune deficiency.

Mutations of keratinocyte transglutaminase in lamellar ichthyosis

Lamellar ichthyosis is a severe congenital skin disorder characterized by generalized large scales and variable redness. Affected individuals in three families exhibited drastically reduced keratinocyte transglutaminase (TGK) activity. In two of these families, expression of TGK transcripts was diminished or abnormal and no TGK protein was detected. Homozygous or compound heterozygous mutations of the TGK gene were identified in all families. These data suggest that defects in TGK cause lamellar ichthyosis and that intact cross-linkage of cornified cell envelopes is required for epidermal tissue homeostasis.