Diagnosis and treatment of malignant eyelid tumors

BACKGROUND

Malignant tumors of the eyelid are much less frequent than benign eyelid alterations. These are frequently incidental findings without symptoms which are often overlooked or misinterpreted by patients.

OBJECTIVE

This article gives an overview of clinical aspects, diagnostics and treatment of the five most common malignant eyelid tumors and exemplarily explains the essential principles of evidence-based treatment of malignant eyelid tumors.

METHODS

This narrative review was prepared based on a selective literature search. The depiction of the treatment of eyelid tumors is supported by illustrations of clinical cases.

RESULTS

The medical history and inspection provide initial indications of malignancy. Every eyelid change suspected of being malignant should be examined histologically to confirm a diagnosis. By far the most common malignant eyelid tumor in Europe is basal cell carcinoma, which metastasizes only in exceptional cases. Squamous cell carcinomas, sebaceous adenocarcinomas, melanomas and Merkel cell carcinomas occur much less frequently. In these cases, potential metastasis in particular must be considered when making the diagnosis and staging has to be initiated. Surgical excision into healthy tissue with tumor-free margins is the gold standard for malignant eyelid tumors. Non-surgical adjuvant or neoadjuvant forms of evidence-based treatment can be initiated based on the individual case to minimize the risk of recurrence and metastasis.

CONCLUSION

It is essential to recognize eyelid changes at an early stage, to classify them correctly and to initiate the appropriate treatment. The interaction between the general condition and the personal needs of a patient as well as state of the art medicine are the keys to a good personalized treatment.

Immune checkpoint inhibition and targeted therapy for melanoma: A patient‐oriented cross‐sectional comparative multicenter study

BACKGROUND

Choosing the adequate systemic treatment for melanoma is driven by clinical parameters and personal preferences.

OBJECTIVE

Evaluation of the impact of disease and treatment on the daily life of patients receiving systemic therapy for melanoma.

METHODS

A German-wide, cross-sectional comparative study was conducted at 13 specialized skin cancer centres from 08/2020 to 03/2021. A questionnaire was distributed to assess patients' perception of disease and symptoms, the impact of their current treatment on quality of life (QOL) and activities, adverse events (AEs), therapeutic visits, as well as believe in and satisfaction with their current systemic melanoma treatment. Patient-reported outcomes (PROs) were rated on a continuous numerical rating scale or selected from a given list.

RESULTS

Four hundred and fourteen patients with systemic melanoma therapy were included. 359 (87%) received immune checkpoint inhibition (ICI) and 55 (13%) targeted therapy (TT). About 1/3 of patients were adjuvantly treated, the remaining because of unresectable/metastatic melanoma. In subgroup analyses, only in the adjuvant setting, TT patients reported a significant decrease in their treatment associated QOL compared to patients with ICI (p = 0.02). Patients with TT were 1.9 times more likely to report AEs than patients with ICI, a difference being significant just for the adjuvant setting (p = 0.01). ICI treatment intervals differed significantly between adjuvant and unresectable/metastatic setting (p = 0.04), though all patients, regardless of their specific ICI drug, evaluated their treatment frequency as adequate. TT patients with dabrafenib/trametinib (n = 37) or encorafenib/binimetinib (n = 15) did not differ regarding the strain of daily pill intake. Patients older than 63 years rated various PROs better than younger patients.

CONCLUSIONS

Patients evaluated their treatment mainly positively. ICI might be preferred over TT regarding QOL and patient-reported AEs in the adjuvant setting. Older melanoma patients appeared to be less impacted by their disease and more satisfied with their treatment.

Proposal for a 6-step-approach for differential diagnosis of neonatal erythroderma

The broad differential diagnosis of neonatal erythroderma often poses a diagnostic challenge. Mortality of neonatal erythroderma is high due to complications of the erythroderma itself and the occasionally severe and life-threatening underlying disease. Early correct recognition of the underlying cause leads to better treatment and prognosis. Currently, neonatal erythroderma is approached by a case by case basis. The purpose of this scoping review was to develop a diagnostic approach in neonatal erythroderma. After a systematic literature search in Embase (January 1990 - May 2020, 74 cases of neonatal erythroderma were identified, and 50+ diagnoses could be extracted. Main causes were the ichthyoses (40%) and primary immunodeficiencies (35%). Congenital erythroderma was present in 64% (47/74) of the cases, predominantly with congenital ichthyosis (11/11; 100%), Netherton syndrome (12/14, 86%), and Omenn syndrome (11/23, 48%). Time until diagnosis ranged from 102 days to 116 days for cases of non-congenital erythroderma and congenital erythroderma respectively. Among the 74 identified cases a total of 17 patients (23%) died within a mean of 158 days and were related to Omenn syndrome (35%), graft versus host disease (67%), and Netherton syndrome (18%). Disease history and physical examination are summarized in this paper. Age of onset and a collodion membrane can help to narrow the differential diagnoses. Investigations of blood, histology, hair analysis, genetic analysis and clinical imaging are summarized and discussed. A standard blood investigation is proposed and the need for skin biopsies with Lympho-Epithelial Kazal-Type related Inhibitor-staining is highlighted. Overall, this review shows that diagnostic procedures narrow the differential diagnosis in neonatal erythroderma. A 6-step flowchart for the diagnostic approach for neonatal erythroderma during the first month of life is proposed. The approach was made with the support of expert leaders from international multidisciplinary collaborations in the European Reference Network Skin-subthematic group Ichthyosis.

Human Papillomavirus-type distribution in anogenital lesions of prepubertal children

BACKGROUND

In contrast to adults, only limited data are available on the human papillomavirus (HPV)-type spectrum in anogenital warts (AGW) of children.

OBJECTIVE

This study aimed to evaluate the HPV-type spectrum in AGW of prepubertal children.

MATERIALS & METHODS

In a retrospective German multicentre study, HPV genotyping was performed in AGW biopsies of 55 1- to 12-year-old children using HPV group-specific PCRs followed by hybridization with type-specific probes or sequence analysis.

RESULTS

Human papillomavirus-DNA was found in 53 of the 55 AGW. In 58.5% (31/53) of the HPV-positive AGW, mucosal HPV types were detected. HPV6 (27/53, 50.9%) was the predominant type. 43.4% (23/53) of the lesions were induced by cutaneous HPV types (HPV2, HPV27, HPV57). Mucosal HPV types were significantly more common in children under 5 years of age than in children 5 years of age and older (22/25, 88.0% [95% CI: 70.0-95.8] vs. 9/28, 32.1% [95% CI: 17.9-50.7], P < 0.001). In contrast, cutaneous HPV types were significantly more prevalent in the 5- to 12-year age group (4/25, 16.0% [95% CI 6.4-34.7] vs. 19/28, 67.9% [95% CI 49.3-82.1], P < 0.001).

CONCLUSION

Anogenital warts in 5- to 12-year-old children are frequently associated with cutaneous HPV types, possibly due to horizontal transmission. HPV typing, in addition to comprehensive clinical and psychosocial evaluation, can potentially help in the assessment of these cases.

Man against machine reloaded: performance of a market-approved convolutional neural network in classifying a broad spectrum of skin lesions in comparison with 96 dermatologists working under less artificial conditions

BACKGROUND

Convolutional neural networks (CNNs) efficiently differentiate skin lesions by image analysis. Studies comparing a market-approved CNN in a broad range of diagnoses to dermatologists working under less artificial conditions are lacking.

MATERIALS AND METHODS

One hundred cases of pigmented/non-pigmented skin cancers and benign lesions were used for a two-level reader study in 96 dermatologists (level I: dermoscopy only; level II: clinical close-up images, dermoscopy, and textual information). Additionally, dermoscopic images were classified by a CNN approved for the European market as a medical device (Moleanalyzer Pro, FotoFinder Systems, Bad Birnbach, Germany). Primary endpoints were the sensitivity and specificity of the CNN's dichotomous classification in comparison with the dermatologists' management decisions. Secondary endpoints included the dermatologists' diagnostic decisions, their performance according to their level of experience, and the CNN's area under the curve (AUC) of receiver operating characteristics (ROC).

RESULTS

The CNN revealed a sensitivity, specificity, and ROC AUC with corresponding 95% confidence intervals (CI) of 95.0% (95% CI 83.5% to 98.6%), 76.7% (95% CI 64.6% to 85.6%), and 0.918 (95% CI 0.866-0.970), respectively. In level I, the dermatologists' management decisions showed a mean sensitivity and specificity of 89.0% (95% CI 87.4% to 90.6%) and 80.7% (95% CI 78.8% to 82.6%). With level II information, the sensitivity significantly improved to 94.1% (95% CI 93.1% to 95.1%; P < 0.001), while the specificity remained unchanged at 80.4% (95% CI 78.4% to 82.4%; P = 0.97). When fixing the CNN's specificity at the mean specificity of the dermatologists' management decision in level II (80.4%), the CNN's sensitivity was almost equal to that of human raters, at 95% (95% CI 83.5% to 98.6%) versus 94.1% (95% CI 93.1% to 95.1%); P = 0.1. In contrast, dermatologists were outperformed by the CNN in their level I management decisions and level I and II diagnostic decisions. More experienced dermatologists frequently surpassed the CNN's performance.

CONCLUSIONS

Under less artificial conditions and in a broader spectrum of diagnoses, the CNN and most dermatologists performed on the same level. Dermatologists are trained to integrate information from a range of sources rendering comparative studies that are solely based on one single case image inadequate.

Die Klinik und Poliklinik für Dermatologie und Venerologie der Universitätsmedizin Rostock – von Fischschuppenerkrankungen, Mondscheinkindern und viel, viel Mee(h)r!

Die Universität Rostock und die Universitätsmedizin als Gründungsfakultät ist die drittälteste Alma Mater in Mitteleuropa – 2019 hat sie ihr 600-jähriges Bestehen gefeiert. Die Klinik und Poliklinik für Dermatologie und Venerologie der Universitätsmedizin Rostock kann auf eine ähnlich lange Tradition zurückblicken – sie ist das drittälteste Ordinariat nach Breslau und der Charité in Berlin. Gemäß dem universitären Motto „Traditio et Innovatio“ hat sich aus dieser Tradition, begründet durch angesehene Ordinarien wie Wolters, Frieboes oder auch Flegel zu DDR-Zeiten, in den letzten 4 Jahren eine moderne universitäre Dermatologische Universitätsklinik (DUK) mit hoher Entwicklungsdynamik und einem Masterplan DUK2030 für alle Bereiche der Krankenversorgung, Forschung und Lehre entwickelt. Unter einem Dach sind stationäre, teilstationäre, ambulante und operative Patientenversorgung zusammen mit dem histologischen und klinischen Labor und den Forschungslaboren vereint. Unter anderem durch Zentrumsgründungen vor Ort (Hautkrebszentrum, Immuntherapiezentrum, Allergologisches Zentrum, Gefäß- und Wundzentrum, Zentrum für Seltene (Haut-) Erkrankungen) und auf europäischer Ebene (Europäisches Referenznetzwerkzentrum für seltene Hauterkrankungen) hat diese interdisziplinäre Zusammenarbeit die Klinik lokal und überregional sehr gut vernetzt. Ein junges, hochengagiertes und noch expandierendes Team hat diese bisherige Entwicklung ermöglicht. Dafür kann allen Beteiligten nicht genug gedankt werden. Dieser und die folgenden Artikel geben einen Einblick in die dermatologische Welt der Universitätsmedizin Rostock.

Experimentelle Forschung an der Klinik und Poliklinik für Dermatologie und Venerologie

Seit Antritt von Prof. Dr. med. Steffen Emmert als Ordinarius der Klinik und Poliklinik für Dermatologie und Venerologie im Jahr 2015 konnte das dermatologische Forschungslabor sukzessive aufgebaut und erweitert werden. Im Einklang mit dem onkologischen Schwerpunkt der Universitätsmedizin Rostock sowie dem von der Landesregierung forcierten „Gesundheitsland Mecklenburg-Vorpommern“ wird grundlagenorientierten und translationalen Projekten nachgegangen. Das vorwiegend drittmittelfinanzierte und stetig wachsende Forschungsteam bearbeitet diverse Fragestellungen in den Bereichen der Dermato-Onkologie, Plasmamedizin und seltenen Hauterkrankungen. Inzwischen auf einem soliden Fundament stehend, befindet sich der Forschungsbereich weiterhin in einem dynamischen Entwicklungsprozess. Nicht nur personell, sondern auch thematisch und methodisch wird er derzeit durch die Integration weiterer Arbeitsgruppen unter der Leitung von Ärzten aus der Klinik ergänzt und ausgebaut. Diverse Kollaborationen an der Universitätsmedizin Rostock und im Land zeugen von einem freundlichen, unterstützenden und kollegialen Umfeld, das die Integration am Standort befördert hat.

Etablierung des Schwerpunktes Psoriasis an der Universitätshautklinik Rostock und eine praxisbezogene Übersicht über die Biologikatherapie der Psoriasis

Die Diagnostik und Behandlung der Psoriasis stellt einen Schwerpunkt an der Universitätshautklinik Rostock dar. Aufgrund des breiten Spektrums verfügbarer Biologikatherapien für die Behandlung der Psoriasis werden in diesem Artikel praxisbezogene Ratschläge für diese Therapieform gegeben. Dabei wird aufgezeigt, wie das optimale Biologikum für einen individuellen Patienten unter Berücksichtigung möglicher Kontraindikationen, krankheitsspezifischer Aspekte und unerwünschter Wirkungen ausgewählt werden kann. Außerdem wird ein mögliches Vorgehen bei Unterbrechung, Wiederaufnahme oder Umstellung von Biologika erwähnt.

Genetisch bedingte Hauterkrankungen – Xeroderma pigmentosum und das CEDNIK-Syndrom

Die Rostocker Hautklinik ist Europäisches Referenznetzwerkzentrum für seltene Hauterkrankungen mit den besonderen Schwerpunkten Xeroderma pigmentosum und Ichthyosen. Diese Themen vertreten wir auch in der medizinischen Grundlagenforschung.

Xeroderma pigmentosum (XP) ist eine seltene, autosomal-rezessive Erkrankung, die entsprechend der Gendefekte in 7 Komplementationsgruppen – XP-A bis XP-G sowie die sog. XP-Variante (XP-V) – eingeteilt wird. XP ist ein Nukleotid-Exzisions-Reparatur-Defektsyndrom und äußert sich v. a. durch vorzeitige Hautalterung und frühzeitige Entwicklung von Hauttumoren.

Das seltene, neurokutane CEDNIK-Syndrom ist eine autosomal-rezessive Erkrankung, der eine Loss-of-Function-Mutation in SNAP29 zugrunde liegt. SNAP29 ist ein SNARE-Protein und an intrazellulären Membranfusionen beteiligt. CEDNIK ist ein Akronym für den mit dem Syndrom assoziierten Symptomkomplex aus zerebraler Dysgenese, Neuropathie, Ichthyose und Palmoplantarkeratosen. CEDNIK-Patienten weisen neben der Ichthyose zudem Gedeihstörungen, eine psychomotorische Retardierung und faziale Dysmorphien auf.

Aquagener Pruritus als Warnzeichen eines inneren Tumorleidens – eine Fallvorstellung und Literaturübersicht

Aquagener Pruritus (AP), d. h. Jucken, Kribbeln, Brennen nach Wasserkontakt, ist ein häufiges Symptom bei Polycythaemia vera und anderen myeloproliferativen Neoplasien, kann aber auch unabhängig davon auftreten. Wie andere Formen des Pruritus schränkt AP die Lebensqualität der Betroffenen häufig ein und kann zu einem hohen Leidensdruck führen. Zur Pathogenese existieren unterschiedliche Erklärungsansätze, jedoch kein einheitliches Konzept. Passend dazu sprechen Patienten auch nur zum Teil auf vorhandene Therapien an, die überwiegend off label sind. In dieser Literaturübersicht zum AP werden beschriebene Pathomechanismen diskutiert und mögliche Therapieformen genannt. Ein verbessertes Verständnis von AP soll dazu beitragen, dieses Symptom zu erkennen und an mögliche zugrunde liegende Erkrankungen, insbesondere an ein inneres Tumorleiden, zu denken.

[Current indications for plasma therapy in dermatology]

BACKGROUND

Plasma medicine is gaining increasing interest and provides a multitude of dermatological applications. Cold atmospheric pressure plasma (CAP) can be used in clinical applications without harming the treated tissue or in a tissue destructive manner. It consists of a complex mixture of biologically active agents, which can act synergistically on the treated material or tissue.

OBJECTIVES

A summary of the current research findings regarding dermatological applications of CAP is provided.

METHODS

Literature on CAP applications in dermatology has been screened and summarized.

RESULTS

CAP exerts antimicrobial, tissue-stimulating, blood-flow-stimulating but also pro-apoptotic effects. By exploiting these properties, CAP is successfully applied for disinfection and treatment of chronic ulcerations. Furthermore, positive effects of CAP have been shown for the treatment of tumors, actinic keratosis, scars, ichthyosis, atopic eczema as well as for alleviation of pain and itch.

CONCLUSIONS

While the use of CAP for disinfection and wound treatment has already moved into clinical practice, further applications such as cancer treatment are still exploratory.

[Increased revenues from secondary diagnoses : A comparison from dermatology, ophthalmology, and infectious diseases]

BACKGROUND

Hospital revenues generated by diagnosis-related groups (DRGs) are in part dependent on the coding of secondary diagnoses. Therefore, more and more hospitals trust specialized coders with this task, thereby relieving doctors from time-consuming administrative burdens and establishing a highly professionalized coding environment. However, it is vastly unknown if the revenues generated by the coders do indeed exceed their incurred costs.

METHODS

Coding data from the departments of dermatology, ophthalmology, and infectious diseases from Rostock University Hospital from 2007-2016 were analyzed for the effects of secondary diagnoses on the resulting DRG, i. e., hospital charges.

RESULTS

Ophthalmological case were highly resistant to the addition of secondary diagnoses. In contrast, adding secondary diagnoses to cases from infectious diseases resulted in 15% higher revenues. Although dermatological and infectious cases share the same sensitivity to secondary diagnoses, higher revenues could only rarely be realized in dermatology, probably owing to a younger, less multimorbid patient population.

CONCLUSION

Except for ophthalmology, trusting specialized coders with clinical coding generates additional revenues through the coding of secondary diagnoses which exceed the costs for employing these coders.

Xeroderma pigmentosum – Fakten und Perspektiven

Die Nukleotid-Exzisions-Reparatur (NER) ist für die Beseitigung von ultraviolett (UV) -induzierten DNA-Schäden und damit zur Vermeidung von Hautkrebs essenziell. Menschen mit einem genetischen Defekt in der NER, Xeroderma pigmentosum (XP) -Patienten, sind äußerst sonnenempfindlich. Sie entwickeln bereits in den ersten Lebensjahren Zeichen der vorzeitigen Hautalterung mit einem deutlich erhöhten Risiko zur Entwicklung von UV-induzierten kutanen Karzinomen. DNA-Reparaturdefektsyndrome werden vorrangig in der Klinik diagnostiziert und auf molekularer Ebene bestätigt. Für die seltene, rezessiv vererbte Erkrankung XP steht zum jetzigen Zeitpunkt leider noch keine kausale Therapie zur Verfügung, weshalb eine frühe Diagnosestellung umso bedeutsamer ist. Durch frühzeitige sowie konsequente UV-protektive Maßnahmen und eine regelmäßige Überprüfung der Haut im Zuge der Hautkrebsfrüherkennung werden sowohl die Prognose als auch Krankheitsverlauf maßgeblich verbessert.

Molekulare Mechanismen der kutanen Photokarzinogenese: ein Update

UV-Strahlung gilt als primäre Ursache der Photokarzinogenese und trägt somit zur Entwicklung von kutanen Hautkrebsentitäten wie Plattenepithelkarzinom, Basalzellkarzinom und Melanom bei. Durch UV-Strahlung entstehen einerseits typische DNA-Photoprodukte und andererseits indirekte DNA-Schäden durch reaktive Sauerstoffspezies. UV-bedingte DNA-Schäden werden durch die Nukleotid-Exzisions-Reparatur behoben, die somit der Bildung von Mutationen und der Hautkrebsentwicklung entgegenwirkt. Durch Mutationen werden Tumorsuppressorgene inaktiviert und wachstumsfördernde Signalwege aktiviert, die die normale Zellzyklusprogression stören. Abhängig von der jeweilig zugrunde liegenden Hautkrebsentität, sind bestimmte Gene häufiger betroffen als andere. Basalzellkarzinome weisen häufig Patched- oder Smoothened-Mutationen auf, die den Sonic hedgehog-Signalweg beeinflussen. Plattenepithelkarzinome zeigen vermehrt TP53-Mutationen. Weitere Mutationen umfassen den epidermalen Wachstumsfaktorrezeptor, RAS, FYN und CDKN2A. In Melanomen konnten vor allem UV-induzierte Mutationen in TP53 und CDKN2A nachgewiesen werden. Zudem tragen UV-induzierte Entzündungsprozesse zur Photokarzinogenese bei. Neuere Studien konnten einen Einfluss von Zitrusfruchtkonsum, Alkoholkonsum, Hormonersatztherapien und oralen Kontrazeptiva auf die Photokarzinogenese feststellen. Präventive Maßnahmen gegen UV-bedingte Karzinogenese beinhalten den adäquaten Gebrauch von Sonnenschutz und regelmäßige Hautkrebsvorsorgeuntersuchungen.

Electromagnetic-radiation absorption by water

Why does a microwave oven work? How does biological tissue absorb electromagnetic radiation? Astonishingly, we do not have a definite answer to these simple questions because the microscopic processes governing the absorption of electromagnetic waves by water are largely unclarified. This absorption can be quantified by dielectric loss spectra, which reveal a huge peak at a frequency of the exciting electric field of about 20 GHz and a gradual tailing off toward higher frequencies. The microscopic interpretation of such spectra is highly controversial and various superpositions of relaxation and resonance processes ascribed to single-molecule or molecule-cluster motions have been proposed for their analysis. By combining dielectric, microwave, THz, and far-infrared spectroscopy, here we provide nearly continuous temperature-dependent broadband spectra of water. Moreover, we find that corresponding spectra for aqueous solutions reveal the same features as pure water. However, in contrast to the latter, crystallization in these solutions can be avoided by supercooling. As different spectral contributions tend to disentangle at low temperatures, this enables us to deconvolute them when approaching the glass transition under cooling. We find that the overall spectral development, including the 20 GHz feature (employed for microwave heating), closely resembles the behavior known for common supercooled liquids. Thus water's absorption of electromagnetic waves at room temperature is not unusual but very similar to that of glass-forming liquids at elevated temperatures, deep in the low-viscosity liquid regime, and should be interpreted along similar lines.

Dynamics of protein hydration water

We present the frequency- and temperature-dependent dielectric properties of lysozyme solutions in a broad concentration regime, measured at subzero temperatures, and compare the results with measurements above the freezing point of water and on hydrated lysozyme powder. Our experiments allow examining the dynamics of unfreezable hydration water in a broad temperature range. The obtained results prove the bimodality of the hydration shell dynamics. In addition, we find indications of a fragile-to-strong transition of hydration water.

A novel mutation in the XPA gene results in two truncated protein variants and leads to a severe XP/neurological symptoms phenotype

BACKGROUND

The nucleotide excision repair (NER) pathway repairs UV-induced DNA lesions in an accurate fashion and prevents UV-irradiated areas of the skin from tumour formation. The XPA protein plays a major role in DNA damage demarcation as well as stabilization of other NER factors and was found to be defective in xeroderma pigmentosum (XP) complementation group A patients.

OBJECTIVE

Characterization of four new XP-A patients.

METHODS

Genomic and cDNA sequencing, post-UV cell survival of living cells, host-cell reactivation of patients' fibroblasts and Western blotting.

RESULTS

One of the four investigated patients shows a novel mutation leading to two different truncated protein variants. Three patients contain the already described p.R228X mutation. All patient cell lines exhibit a strong UVC sensitivity and reduced NER capability. In most of the cases stable protein expression was detected.

CONCLUSION

We discovered four new XP-A patients and a novel XPA mutation resulting in two diverse patient alleles.

[Palmoplantar dermatoses: when should genes be considered?]

BACKGROUND

Palmoplantar dermatoses are common. They can be both functionally debilitating and markedly stigmatize the patient because they are so visible. Dermatoses on the hands and feet often go along with palmoplantar hyperkeratosis. Such palmoplantar keratoses (PPK) can be classified into acquired (non-hereditary) and hereditary (monogenetic) PPK.

OBJECTIVES

A considerable proportion of PPK develop on the grounds of gene defects. As these diseases constitute a heterogeneous group of quite uncommon single entities, the treating physician must know when to entertain the diagnosis of a hereditary PPK and which causative genes should be considered.

METHODS

We summarize the common causes of acquired and hereditary PPK based on a review of the latest literature.

RESULTS

The most common causes of acquired PPK are inflammatory dermatoses like psoriasis, lichen planus, or hand and feet eczema. Also irritative-toxic (arsenic poisoning, polycyclic aromatic hydrocarbons) and infectious causes of PPK (human papilloma viruses, syphilis, scabies, tuberculosis, mycoses) are not uncommon. Genetically caused PPK may occur isolated, within syndromes or as a paraneoplastic marker. The clinical/histological classification discerns diffuse, focal, or punctuate forms of PPK with and without epidermolysis. A new classification based on the causative gene defect is starting to replace the traditional clinical classification.

CONCLUSIONS

Knowledge about the large, but heterogeneous group of hereditary PPK is important to adequately counsel and treat patients and their families.

Alleviation of chronic venous leg ulcers with a hand-held dielectric barrier discharge plasma generator (PlasmaDerm(®) VU-2010): results of a monocentric, two-armed, open, prospective, randomized and controlled trial (NCT01415622)

BACKGROUND

Cold atmospheric plasma (CAP, i.e. ionized air) is an innovating promising tool in reducing bacteria.

OBJECTIVE

We conducted the first clinical trial with the novel PlasmaDerm® VU-2010 device to assess safety and, as secondary endpoints, efficacy and applicability of 45 s/cm(2) cold atmospheric plasma as add-on therapy against chronic venous leg ulcers.

METHODS

From April 2011 to April 2012, 14 patients were randomized to receive standardized modern wound care (n = 7) or plasma in addition to standard care (n = 7) 3× per week for 8 weeks. The ulcer size was determined weekly (Visitrak® , photodocumentation). Bacterial load (bacterial swabs, contact agar plates) and pain during and between treatments (visual analogue scales) were assessed. Patients and doctors rated the applicability of plasma (questionnaires).

RESULTS

The plasma treatment was safe with 2 SAEs and 77 AEs approximately equally distributed among both groups (P = 0.77 and P = 1.0, Fisher's exact test). Two AEs probably related to plasma. Plasma treatment resulted in a significant reduction in lesional bacterial load (P = 0.04, Wilcoxon signed-rank test). A more than 50% ulcer size reduction was noted in 5/7 and 4/7 patients in the standard and plasma groups, respectively, and a greater size reduction occurred in the plasma group (plasma -5.3 cm(2) , standard: -3.4 cm(2) ) (non-significant, P = 0.42, log-rank test). The only ulcer that closed after 7 weeks received plasma. Patients in the plasma group quoted less pain compared to the control group. The plasma applicability was not rated inferior to standard wound care (P = 0.94, Wilcoxon-Mann-Whitney test). Physicians would recommend (P = 0.06, Wilcoxon-Mann-Whitney test) or repeat (P = 0.08, Wilcoxon-Mann-Whitney test) plasma treatment by trend.

CONCLUSION

Cold atmospheric plasma displays favourable antibacterial effects. We demonstrated that plasma treatment with the PlasmaDerm® VU-2010 device is safe and effective in patients with chronic venous leg ulcers. Thus, larger controlled trials and the development of devices with larger application surfaces are warranted.

Melanoma thickness: the role of patients' characteristics, risk indicators and patterns of diagnosis

BACKGROUND

Factors associated with early vs. late diagnosis of cutaneous melanoma remain poorly understood.

OBJECTIVE

To identify factors with a significant impact on melanoma thickness.

METHODS

Patients with previous melanoma (n = 347, median age at diagnosis: 56.5 years, 44.7% female, 55.3% male) were recruited for this monocentre, non-randomized, observational study between April 2012 and March 2013. All patients were assessed by means of a structured interview and systematic clinical and dermoscopic full-body examination. Melanoma thickness in association with patients' characteristics, risk indicators and patterns of diagnosis was submitted to statistical analyses.

RESULTS

Univariate analyses revealed associations between a statistically significant lower Breslow thickness and participation in specialized dermoscopic screening programs, personal history of more than one previous melanoma, diagnostic examination with a dermatoscope, diagnostic examination by board certified dermatologist, high number of common and/or atypical nevi, younger age at time of diagnosis, higher level of education, or superficial spreading or lentigo maligna melanoma subtype (all P ≤ 0.01). In a multivariate regression analysis only three of these criteria: (i) participation in specialized screening programs (P < 0.0001); (ii) melanoma subtype (P < 0.0001); and (iii) diagnostic examination with a dermatoscope (P = 0.040) and one interaction term ('younger age' x 'female sex', P < 0.0001) showed an independent influence on a significantly lower melanoma thickness.

CONCLUSIONS

The screening of patients in specialized surveillance programs resulted in melanoma detection at significantly earlier stages. The use of dermoscopy, SSM or LMM histotype and younger age in connection with female sex were also characteristics that were independently associated with significantly thinner melanomas in multivariate analyses.

A novel selective small-molecule PI3K inhibitor is effective against human multiple myeloma in vitro and in vivo

Developing effective therapies against multiple myeloma (MM) is an unresolved challenge. Phosphatidylinositol-3-kinase (PI3K) activation may be associated with tumor progression and drug resistance, and inhibiting PI3K can induce apoptosis in MM cells. Thus, targeting of PI3K is predicted to increase the susceptibility of MM to anticancer therapy. The lead compound of a novel class of PI3K inhibitors, BAY80-6946 (IC50=0.5 nM against PI3K-α), was highly efficacious in four different MM cell lines, where it induced significant antitumoral effects in a dose-dependent manner. The compound inhibited cell cycle progression and increased apoptosis (P<0.001 compared with controls). Moreover, it abrogated the stimulation conferred by insulin-like growth-factor-1, a mechanism relevant for MM progression. These cellular effects were paralleled by decreased Akt phosphorylation, the main downstream target of PI3K. Likewise, profound antitumoral activity was observed ex vivo, as BAY80-6946 significantly inhibited proliferation of freshly isolated myeloma cells from three patients (P<0.001 compared with vehicle). In addition, BAY80-6946 showed convincing in vivo activity against the human AMO-1 and MOLP-8 myeloma cell lines in a preclinical murine xenograft model, where treatment with 6 mg/kg every other day for 2 weeks reduced the cell numbers by 87.0% and 69.3%, respectively (P<0.001 compared with vehicle), without overt toxicity in treated animals.

[X-linked recessive ichthyosis (XRI), cerebellar ataxia and neuropsychiatric symptoms]

X-Linked ichthyosis (XRI) is a keratinisation disorder caused by a mutation of the steroid sulfatase gene. An association with mental retardation and epilepsy has been reported earlier. Here, we report on a patient suffering from cerebellar symptoms such as yes/yes head tremor, scanning dysarthria, pronounced dysmetria and intention tremor, without any abnormalities of the cerebellum in MRI, in addition to XRI proven by molecular genetics. Furthermore, the patient suffered from anxiety disorder, depression, and a male pattern baldness. One of the patient' s brothers and a nephew showed a similar clinical presentation. Because of the fact that several members of the patient's family suffered from similar symptoms, we consider a syndromic link between XRI and cerebellar disorder to be possible.

Expanding the keratin mutation database: novel and recurrent mutations and genotype-phenotype correlations in 28 patients with epidermolytic ichthyosis

BACKGROUND

Epidermolytic ichthyosis (EI) is a hereditary keratinization disorder caused by mutations in the keratin 1 (KRT1) or keratin 10 (KRT10) genes. In most cases of severe EI, heterozygous single point mutations are found at the highly conserved helix boundary motifs of KRT1 and KRT10 that play a critical role in filament formation. The presence of palmoplantar keratoderma suggests KRT1 mutations, whereas KRT10 mutations in most instances give rise to the nonpalmoplantar variants.

OBJECTIVES

To identify the underlying mutations in patients with EI and to correlate genotype and phenotype.

METHODS

Mutation analysis was performed in 28 patients with EI by direct sequencing of KRT1 and KRT10 genes.

RESULTS

We identified 14 different mutations, of which four have not been published previously.

CONCLUSIONS

Identification of novel mutations and genotype-phenotype correlations in EI allows improved understanding of disease pathogenesis as well as better patient management.

CEDNIK syndrome results from loss-of-function mutations in SNAP29

BACKGROUND

CEDNIK (cerebral dysgenesis, neuropathy, ichthyosis and keratoderma) syndrome is a rare genodermatosis which was shown 5 years ago in one family to be associated with a loss-of-function mutation in SNAP29, encoding a member of the SNARE family of proteins. Decrease in SNAP29 expression was found to result in abnormal lamellar granule maturation leading to aberrant epidermal differentiation and ichthyosis.

OBJECTIVES

To delineate the molecular consequences of disease-causing mutations in SNAP29.

METHODS

We used direct sequencing, in vitro mutagenesis and three-dimensional organotypic cell cultures.

RESULTS

We identified a novel homozygous insertion in SNAP29 (c.486insA) in two sibs presenting with ichthyosis and dysgenesis of the corpus callosum. In vitro transfection experiments indicated that this mutation results in SNAP29 loss-of-function. Further substantiating this notion, we could replicate histological features typical for CEDNIK syndrome in three-dimensional primary human keratinocyte organotypic cell cultures downregulated for SNAP29.

CONCLUSIONS

The identification of a second mutation in SNAP29 in the present study definitely establishes a causal relationship between defective function of SNAP29 and the pleiotropic manifestations of CEDNIK syndrome. Our present and previous data position SNAP29 as an essential component of the epidermal differentiation machinery.

Functional DNA repair system analysis in haematopoietic progenitor cells using host cell reactivation

Deficiencies in individual DNA repair systems are involved in both de novo and therapy-related acute myeloid leukaemia (t-AML), as indicated by genetic markers involving nucleotide excision repair (NER gene polymorphisms), double-strand-break (DSB) or mismatch repair (microsatellite instability (MSI)). We modified a host cell reactivation (HCR) assay for functional DNA repair system analysis of living primary haematopoietic cells; 2 x 10(5) normal peripheral blood lymphocytes (PBLs) and cord blood CD34+ progenitor cells were cryopreserved, thawed and transfected with 75-250 ng luciferase reporter plasmid (pCMVLuc) using DEAE-dextran (0.1 mg/mL) in a transfection volume of 250 microL. We obtained luciferase activities of approximately 300-fold above background in CD34+ progenitor cells and approximately 2000-fold in PBLs, thus rendering these cells applicable for DNA repair analysis. We then evaluated the NER (UV-irradiated pCMVLuc) and DSB repair capacity (linearized pCMVLuc) of normal lymphocytes and several leukaemic cell lineages. Kasumi-1 and HL-60 AML cells exhibited a reduced NER capacity compared to normal GM03715 lymphocytes, PBLs and CD34+ progenitor cells (6.2 +/- 0.9%, 6.5 +/- 0.9% vs. 12.3 +/- 1.8%, 13.5 +/- 0.7% and 13.5 +/- 2.0%, respectively). Kasumi-1 AML tells exhibited a reduced DSB repair capacity compared to AG10107 and GM03715 normal lymphocytes as well as CEM acute T-cell lymphoblastic leukaemia cells (6.4 +/- 0.8% vs. 10.8 +/- 0.7%, 27.3 +/- 1.1% and 20.5 +/- 1.6%, respectively). The modified HCR assay can be used for functional DNA repair analysis in living cells of patients with pre- and post-leukaemic conditions as well as in leukaemic blasts to elucidate the role of DNA repair in de novo and t-AML leukaemogenesis and to determine the individual susceptibility to t-AML prior to chemotherapy.

Forty-two novel COL7A1 mutations and the role of a frequent single nucleotide polymorphism in the MMP1 promoter in modulation of disease severity in a large European dystrophic epidermolysis bullosa cohort

BACKGROUND

Dystrophic epidermolysis bullosa (DEB) is a severe genetic skin blistering disorder caused by mutations in the gene COL7A1, encoding collagen VII. Recently, the MMP1 promoter single nucleotide polymorphism (SNP) rs1799750, designated as 1G 2G, was shown to be involved in modulation of disease severity in patients with recessive DEB (RDEB), and was proposed as a genetic modifier.

OBJECTIVES

To identify the molecular basis of DEB in 103 individuals and to replicate the results of the MMP1 promoter SNP analysis in an independent patient group, as verification is necessary in such a rare and heterogeneous disorder.

METHODS

To determine the molecular basis of the disease, we performed COL7A1 mutation screening, reverse transcription-polymerase chain reaction (PCR) and real-time quantitative PCR. The status of the MMP1 SNP was analysed by PCR and restriction enzyme digestion and verified by sequencing.

RESULTS

We disclosed 42 novel COL7A1 mutations, including the first large genomic deletion of 4 kb affecting only the COL7A1 gene, and three apparently silent mutations affecting splicing. Even though the frequency of the high-risk allele was increased in patients with RDEB, no statistically significant correlation between disease severity and genotype could be made. Also, no correlation was observed with development of squamous cell carcinoma, a severe complication of DEB.

CONCLUSIONS

Taken together, the results suggest that the MMP1 SNP is not the sole disease modifier in different forms of DEB, and other genetic and environmental factors contribute to the clinical phenotype.

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.

Acroangiodermatitis Mali resulting from arteriovenous malformation: report of a case of Stewart-Bluefarb syndrome

We describe the rare Stewart-Bluefarb syndrome in a 15-year-old boy. This syndrome presents as a congenital arteriovenous malformation of the lower leg with multiple arteriovenous shunts accompanied by the benign acroangiodermatitis of Mali (pseudo-Kaposi's sarcoma). The clinical features of this disorder and the treatment options are reviewed.

[Dronabinol for supportive therapy in patients with malignant melanoma and liver metastases]

BACKGROUND

Loss of appetite and nausea can reduce the quality of life of patients with malignant melanoma and liver metastases. Often established antiemetic drugs fail to bring relief. Tetrahydrocannabinol (THC, Marinol), which is the active agent of Indian hemp, has been used successfully in this situation for other malignant tumors.

PATIENTS AND METHODS

We treated 7 patients with hematogenous metastatic melanoma and liver metastases suffering from extensive loss of appetite and nausea supportively with dronabinol (Marinol. All of these patients had previously received standard antiemetic therapy without adequate relief. Dronabinol is a synthetic Delta-tetrahydrocannabinol. The drug was administered in capsule form. We evaluated the palliative effects of dronabinol with a special patient evaluation form, which was filled out at the beginning of the therapy and again after 4 weeks.

RESULTS

The majority of patients described a significant increase in appetite and decrease in nausea. These effects remained for some weeks, but then decreased as metastases progressed and the general condition worsened. All of the patients experienced slight to moderate dizziness, but it was not sufficiently troubling to cause interruption or termination of therapy.

CONCLUSION

Loss of appetite and nausea due to liver metastases of malignant melanoma can be treated in individual cases supportively with Dronabinol.

Ultraviolet light selection assay to optimize oligonucleotide correction of mutations in endogenous xeroderma pigmentosum genes

Various oligonucleotide (ODN)-based approaches have been proposed for their ability to correct mutated genes at the normal chromosomal locations. However, the reported gene correction frequencies of these approaches have varied markedly in different experimental settings, including when different tissues or cell types are targeted. In order to find the optimal ODN-based approach for a specific target tissue, an assay system that allows direct comparison of the different methods on that tissue is necessary. Herein, we describe an XP-UVC selection assay that can be used to evaluate and compare gene correction frequencies in different cell types obtained from a xeroderma pigmentosum (XP) patient, following treatment by different ODN-based approaches. As an experimental example, the XP-UVC selection assay was used to assess the ability of chimeric RNA/DNA ODN to correct point mutations in the XPA gene. This assay can be used to assess and evaluate other types of ODN-based approaches, and to further optimize them.

Extracorporeal photochemotherapy for the treatment of exanthematic pityriasis rubra pilaris

Pityriasis rubra pilaris (PRP) is a rare papulosquamous skin disease of unknown aetiology that has been categorized into five clinical types based on age at onset, cutaneous features and prognosis. We present a patient with chronic exanthematic type II atypical adult PRP, whose skin status was significantly improved with monthly extracorporeal photochemotherapy (ECP). Various therapeutic regimens including narrow-band UV-B, bath PUVA therapy, systemic fumaric acid esters and systemic cyclosporin had failed. Oral retinoids could not be administered due to a type IIa hyperlipoproteinemia with profound hepatic steatosis and elevated liver transaminases. The observed clinical benefit may encourage future clinical studies analysing the effectiveness of ECP in otherwise unresponsive cases of type II PRP.

Results of a surveillance programme for patients at high risk of malignant melanoma using digital and conventional dermoscopy

Patients with a high number of atypical naevi and a personal and/or family history of melanoma are at high risk of malignant melanoma. The objective of this study was to design a special documentation and surveillance programme using epiluminescence microscopy (ELM) and digital epiluminescence microscopy (DELM) to improve the surveillance of these patients. High-risk patients (n=212) were categorized by the number and phenotype of their naevi and their personal and family history of melanoma. Then patients were screened by the unaided eye, conventional photography, ELM and, in selected cases of atypia, DELM. Median follow-up was 18 months, and 2939 pigmented lesions were followed by DELM. Examination on the first visit identified 17 cutaneous melanomas. During the following observation period, another 17 melanomas were identified. Fifteen of these follow-up melanomas were exclusively identified based upon DELM. In these cases, subtle lesional changes occurred over time, and ELM diagnostic algorithms for differentiating benign melanocytic lesions from melanoma did not score a suspicion of melanoma. All melanomas, either pre-existing or developing during follow-up, were identified in an early, curable phase of tumour growth. We conclude that DELM follow-up for patients at high risk allows the early detection of melanomas that have not yet acquired melanoma-typical ELM features.

Inefficacy of vindesine monotherapy in advanced stage IV malignant melanoma patients previously treated with other chemotherapeutic agents

The anti-melanoma activity of vindesine as a single or polychemotherapeutic agent has been reported previously in adjuvant and first-line melanoma treatment. In this study, we investigated the usefulness of vindesine monotherapy as salvage therapy in stage IV melanoma patients after failure of other chemotherapies. Thirteen patients with progressive disease were treated with 3 mg/m2 vindesine every 2 weeks (median age, 61 years). Previous systemic treatment consisted of polychemotherapy or combined chemo-immunotherapy. All 13 patients suffered from visceral metastases (three lung, one liver, one adrenal gland and eight multiple visceral metastases). A median of three vindesine treatments was administered. Despite the various pre-treatments, the toxicity of vindesine was mild. In all 13 patients, vindesine treatment was stopped due to disease progression. The median survival after primary tumour diagnosis was 42 months (8-151 months), the survival after entering stage IV was 11 months (3-35 months), and the survival after starting vindesine therapy was 4 months (1-22 months). We conclude that vindesine monotherapy is ineffective in stage IV melanoma patients previously treated with other chemotherapeutic agents.

[Improved scar formation after using a medical surgical zipper for wound closure under tension]

BACKGROUND AND OBJECTIVE

The objective of the study was to evaluate the use of a medical surgical zipper (Medizip) for wound closure under tension in comparison to conventional cutaneous sutures. The surgical zipper is supposed to reduce wound tension by approximating of the wound edges via epidermal traction.

PATIENTS/METHODS

This prospective study included patients with a wound diameter of more than 1 cm. 45 patients were treated with the surgical zipper, 38 were randomized into a control group with conventional wound closure. Scars were assessed after 6-18 months focusing on aesthetic and functional aspects.

RESULTS

The average length of the scars in both groups was 9 cm, but after a observation time of at least 6 month, there were differences in the width of the scars. The group with the surgical zipper showed significantly thinner scars (2.74 mm versus 4.24 mm, p=0.0008). Only 17% of the Medizip patients developed unaesthetic rope ladder-like scars versus 65% in the control group. This observation was statistically significant (p<0.0001).

CONCLUSIONS

Wound stabilization by approximation of the wound edges via surgical zipper results in improved scar formation in wounds with moderate tension. Using the Medizip trade mark in wounds under heavy tension is not recommended because of the possible development of to tension bullae under the zipper.