A new hope in the treatment of onychogryphosis due to acquired malalignment of great toenails due to: intramatrix dexpanthenol injection

Onychogryphosis is a form of nail deformity characterized by a distorted, yellowish-brown thickened nail plate that is skewed, grossly thickened, and partly curved like a ram's horn. Although onychogryphosis has been described for more than one hundred years, there is no curative treatment for onychogryphosis. Nonsurgical conservative procedures and nail avulsion with or without matricectomy are the common treatment procedures. The recurrence rate is high, so patients' needs are not met in many cases. Herein, we report for the first time the intramatrix injection of dexpanthenol in the treatment of onychogryphosis with excellent result.

EROSIVE PUSTULAR DERMATOSIS OF THE SCALP (EPDS) - A CASE SERIES AND SHORT REVIEW

Erosive pustular dermatosis of the scalp (EPDS) is an uncommon and possibly underreported chronic inflammatory skin disease within the spectrum of neutrophilic disorders. Although it has been reported in all ages, elderly people are more common affected. The surrounding skin often shows symptoms of chronic actinic damage. Histopathology is rather unspecific. The pustules and lakes of pus are sterile. Treatment includes anti-septic, anti-inflammatory topical therapy, in more severe cases oral steroids. Rarely systemic antibiosis or surgery are necessary. EPDS is an important differential diagnosis of non-melanoma skin cancer, bullous autoimmune disease, and soft tissue infections by bacteria or fungi. When untreated, scarring alopecia develops. We report on or own case series and present a narrative review on published cases since 2010.

UPPER ARM CONTOURING - A NARRATIVE REVIEW

Disfigurement of upper arms is a common esthetic problem. All soft tissues contribute with skin and subcutaneous adipose tissue as the major targets of medical intervention. This narrative review describes the complex pathogenesis of upper arm ptosis and its classification. Surgical and non-surgical methods to improve upper arm contour are discussed. With the broad spectrum of available treatments, a tailored approach is possible to address the individual patient's needs.

SYMPTOMATOLOGY AND TREATMENT OF COVID-19 AFFECTING SKIN APPENDAGES: A NARRATIVE REVIEW BEYOND COVID-TOES

SARS-CoV-2 is the cause of COVID-19 disease and responsible for a pandemic since the 2020. Multiple organ involvement has been described including cutaneous symptoms. Affection of skin appendages, however, seems to be under-reported except for COVID-toes. We performed a PUBMED research for "COVID-19" OR "SARS-CoV-2" AND "skin appendages", "hair", "nails", and "skin glands" from January 2020 to April 2022. COVID toes were excluded since this symptom had extensively been discussed. The focus of this narrative review was laid on clinical presentation, association to the course of COVID-19 disease and treatment options. Skin appendages can be affected by COVID-19 disease beyond COVID-toes, both by symptomatic and asymptomatic course. Telogen effluvium, androgenetic alopecia, and alopecia areata are the most common hair disorders in COVID-19 patients. Nails are less commonly affected by COVID-19 than hair. Splinter hemorrhages and leukonychia are the most frequent findings. While sebaceous glands seem to be uninvolved, SARS-CoV-2 spike proteins have been identified in eccrine sweat glands. Alopecia areata is often seen among asymptomatic COVID-19 patients while telogen effluvium is observed in symptomatic and asymptomatic patients. The half-moon sign on the nails could be a red flag for a more severe course of COVID-19. Treatment options are summarized. Skin appendages are not spared by COVID-19. Their knowledge will help to identify asymptomatic patients and patients at risk for a more severe course of the viral disease.

SEVERE LEUKOCYTOCLASTIC VASCULITIS AFTER COVID-19 VACCINATION - CAUSE OR COINCIDENCE? CASE REPORT AND LITERATURE REVIEW

Vaccination has been the most powerful tool to fight the COVID-19 pandemic while the specific treatment options in clinical practice have been under review for approval and authorization by regulatory bodies. After registration of different vaccines, it is important to ensure a post-marketing surveillance to identify potential risks not observed in controlled trials. Authors report on the case of an 80-year-old male patient who developed severe leukocytoclastic vasculitis of skin and oral mucous membrane after receiving the second dose of COVID-19 mRNA vaccine. He was treated successfully with prednisolone. We also provide a literature review on other reported cases of COVID-19 vaccine induced vasculitis. This type of an adverse reaction seems to be rare. Fortunately, most cases were temporary and well controlled by corticosteroids. The majority of vaccine-associated vasculitis cases have been observed in association with BONT162b2 mRNA vaccine although other vaccines also may cause the event. The knowledge of this possible adverse event is important for early diagnosis and intervention.

JUXTA-ARTICULAR ADIPOSIS DOLOROSA IN LIPEDEMA PATIENTS

Both lipedema and juxta-articular adiposis dolorsa are painful disorders of subcutaneous adipose tissue. We investigated 297 female patients with lipedema treated at our department for the presence of juxta-articular adiposis dolorsa. Occurrence of both disorders was identified in 4.4% of lipedema patients. The common presence of both disorders was observed only in more advanced lipedema (grade II and III). Juxta-articular adiposis dolorosa of the knees is seen exclusively on the inner knees, and it presents neither bruising nor creases or hypothermia. Choices of surgical treatment are either microcannula liposuction or dermolipectomy. Recurrences have not been observed.

PIGMENTED NODULAR CYSTIC HIDRADENOMA OF THE ANKLE

Solid-cystic hidradenoma is a benign cutaneous tumor that is most commonly found in the head, neck, trunk, and upper extremity regions of patients in the middle to older aged groups. Presentation on lower extremities and in particular on the foot is uncommon. Nodular hidradenomas represent a dermatological pitfall, being difficult to differentiate from basal cell carcinoma and melanoma. We report on a 53-year-old male patient with a pigmented nodular hidradenoma on his ankle that was surgically removed. We discuss histopathology and differential diagnosis of this eccrine tumor of skin. This is the second reported case in the English literature.

LONG-PULSED ND:YAG LASER TO TREAT TELANGIECTASIA OF THE NOSE: A COMPREHENSIVE 5-YEAR SINGLE CENTER STUDY

Telangiectases of the nose are of esthetic concern and treatment is warranted. The study provides the results of 5 years of treatment of telangiectases of the nose region with the long-pulsed Nd:YAG 1,064 nm laser. A retrospective analysis was conducted in patients of Fitzpatrick skin type II-V. Exclusion criteria were patients with a previous history of treatment of the nose region, pregnant or lactating patients or patients with unrealistic expectations regarding the treatment risks, limitations and results. Standardized photographs were obtained before each session and at least 2 months after the last treatment session. A long-pulsed Nd:YAG 1,064 nm laser was used with a spot size of 2.5mm, fluence of 100 - 175 J/cm2, pulse duration of up to 135ms and repetition rate of 2-4 Hz. The follow-up ranged from 2 months to 5 years. The number of laser sessions varied from 1 to 5 monthly. Assessment was made by comparing pre-treatment and post-treatment photographs by two independent specialists and also by the patients' own assessment. All patients presented improvement of the vascular alterations. Evaluation of independent specialists as well as the evaluation of the patients themselves showed a high degree of satisfaction with the treatment. The treatment presented only few transitory side effects. Treatment of telangiectasia on the nose skin with the long-pulsed Nd:YAG 1,064 nm laser demonstrated to be safe and effective even in darker pigmented skin. The major limitation of this study is its retrospective nature.

[New botulinum toxins for aesthetic dermatology : A comprehensive review]

Facial rejuvenation is gaining immense popularity among patients and clinicians. Botulinum toxins derived from bacteria are well-tolerated options as minimally invasive interventions for facial rejuvenation or other aesthetic procedures. These products have revolutionized aesthetic treatments. Several types of botulinum toxins (BoNT) are available. Currently type A and B are clinically used and only BoNT‑A products are approved for use for cosmetic indications in the Germany and the United States. Each product is unique in terms of its composition. Understanding the various BoNT‑A products is essential in choosing the optimal treatment for our patients. In this article we discuss different BoNT‑A products used for aesthetic intervention.

Approach to skin malignancies in COVID-19 pandemic days

COVID-19 pandemic emerged as a condition that changed our entire life and led us to develop new perspectives on diseases. Cancers are generally additional risk factors for COVID-19, and this has implications also for skin cancer patients. Those patients require special attention, due to situations such as an increased risk of infection as a result of visiting the hospital for treatment. It is imperative that the diagnosis and treatment of patients who have a cancer that progresses rapidly, such as malignant melanoma, high-risk squamous cell carcinoma and a high risk of metastasis, are delayed. Due to the relatively long-lasting nature of basal cell carcinoma and, as almost no metastasis would be expected, its treatment may be postponed, except for those that occur in areas such as the eyes and mouth. Diagnosis and treatment of skin cancers is a process that requires many procedures. Throughout this process, physicians should take appropriate precautions that are sufficient to protect both the patient and themselves in the best way without leading to any delay in the procedures.

IMPROVEMENT OF HYPERTROPHIC SCARS WITH INTRALESION INJECTIONS OF HYALURONIDASE

In contrast to intra-urine wounds, extra-uterine wounds will heal with a scar. A number of conservative and surgical methods have been developed, aiming at improving unsightly and hypertrophic scars. The authors report on their experience with intralesional injection of the enzyme hyaluronidase to improve hypertrophic scars. Hyaluronidase produces low-molecular weight fragments during digestion of high-molecular weight hyaluronic acid. These fragments are known to stimulate angiogenesis and to activate mesenchymal stem cells. The manuscript presents a clinical review of series of patients with hypertrophic scars, mainly resulted from tumor resection, who were treated by this technique.

GIANT PEDUNCULATED TUMORS OF SKIN

The clinical appearance of a skin tumor is of major importance for clinical diagnosis of both benign and malignant neoplasias. Pedunculated growth pattern is unusual to exceptionally rare, depending on a tumor type. A necessary prerequisite for pedunculated growth is a well vascularized stem. We provide a review on large and giant pedunculated tumors of skin to serve as an additional guidance for the clinicians to avoid diagnostic errors and mistreatment. The knowledge of unusual growth pattern of cutaneous neoplasia is an essential not only in outpatient care, but also in care of hospital-admitted patients.

DIFFERENTIAL DIAGNOSIS OF ANNULAR SKIN LESIONS - A CLINICAL REVIEW

Annular lesions are a peculiar type of presentation of various skin disorders. The primary efflorescence can be either macule, papule, plaque, urticaria or vesicle. Depending on the primary efflorescence involved, the differential diagnoses can be delimited. It is important to identify secondary features such as scaling and discolorations. Additional symptoms may include pruritus, burning sensations or hypoesthesia. Depending on the clinical findings and medical history, confirmation of suspected working diagnosis is achieved by laboratory work-up, including histology and microbiology (mycology) studies.

LOCALIZED CUTANEOUS NON-TOXIC DIPHTHERIA (CASE REPORT)

The authors report on a clinical case of 91-year-old female patient presented with a two-year history of an enlarging forehead lesion with exudation and bleeding, suspicious of squamous cell carcinoma. Histology ruled out the suspected diagnosis, however the microbiology culture and polymerase chain reaction assay identified non-toxic Corynebacterium diphtheriae. Therefore the diagnosis of localized cutaneous diphtheria was confirmed. The patient was treated with penicillin regimen V 3 x 1 mio IU/ day for 10 days in complex with topical povidone-iodine. The chosen treatment achieved complete healing of the ulcer and no relapse has been reported during the 9-month follow-up. Cutaneous non-healing chronic ulcers can be caused by diphtheroid corynebacteria. Immediate diagnosis is important to exclude toxic variants, which need patient isolation and treatment of persons in close contact.

HYPERCALCEMIA DUE TO POLYMETHYLMETHACRYLATE INJECTIONS? (LITERATURE REVIEW AND CASE REPORTS)

Hypercalcemia is a common feature of malignancy, bone metabolic conditions and granulomatous disorders. In the latter, hypercalcemia is usually calcitriol-related. As eventual association of silicone and polymethylmethacrylate (PMMA) injections with granulomatous disease and hypercalcemia the condition has become an issue of recent interest. Authors report on two cases of calcitriol-related hypercalcemia where PMMA injections had been previously administered. The association, even though intriguing, requires additional confirmation by follow-up studies.

The PARACELSUS score: a novel diagnostic tool for pyoderma gangrenosum

BACKGROUND

The lack of objective diagnostic criteria renders pyoderma gangrenosum (PG) a diagnosis of exclusion. The diagnostic approaches proposed to date have not been systematically evaluated. Thus, PG remains a challenging and frequently misdiagnosed disorder.

OBJECTIVES

To develop and assess a comprehensive, yet clinically practicable, sensitive diagnostic scoring system for PG.

METHODS

Clinical history and images of a total of 60 participants with previously confirmed PG located on the lower extremity and a control cohort of 50 patients with venous leg ulcers were retrospectively evaluated by expert teams at two tertiary dermatological centres specializing in wound care using a newly developed diagnostic scoring system composed of 10 criteria.

RESULTS

The three major diagnostic criteria are rapidly progressing disease, assessment of relevant differential diagnoses and a reddish-violaceous wound border (prevalent in 98% of patients with PG). Minor criteria (evident in 61-95% of patients with PG) include amelioration by immunosuppressant drugs, characteristically irregular shape of ulceration, extreme pain > 4/10 on a visual analogue scale and localization of lesion at the site of the trauma. Three additional criteria (observed in up to 60% of patients with PG) encompass suppurative inflammation in histopathology, undermined wound borders and systemic disease associated. A total score value of 10 points or higher indicates a high likelihood of PG and differentiates PG from venous leg ulcers. The initial letters of the above-listed criteria form the acronym PARACELSUS.

CONCLUSIONS

The PARACELSUS score represents a novel, easily implementable, effective and sensitive diagnostic tool for PG.

CUTANEOUS POLYPOID MELANOMA OF HEAD AND NECK

Cutaneous polypoid melanoma is an uncommon subtype of malignant melanoma. The clinical behavior of this subtype has been described as aggressive. Tumors can be sessile or pedunculated. The typical patient is a younger adult. Authors have analyzed the case histories of patients with polypoid melanomas of the head and neck region treated at our clinic from 2001 to 2018. We identified 3 female patients with tumors of the neck and cheek. In contrast to other reports, all patients were older than 80-years of age. None of them had a metastatic spread at the time of diagnosis. Treatment was delayed Mohs surgery. Polypoid melanomas of the head and neck region can occur in elderly patients without an aggressive course. In those patients a number of differential diagnoses have to be considered including Merkel cell carcinoma, metatypical basal cell carcinoma, squamous cell carcinoma and tumor metastases.

CALCIUM HYDROXYLAPATITE MICROSPHERES - BIOCOMPATIBILITY AND CLINICAL EFFECTS

Soft tissue fillers are used in aesthetic medicine for volumizing and for contouring. Calcium hydroxylapatite (CaHA) is a fully biodegradable biostimulatory filler. The study presents results of in vitro biocompatibility and cytotoxicity investigations performed on CaHA and illustrates its clinical effects. We used a human cell culture model for in vitro studies with HaCaT keratinocytes and human dermal fibroblasts, known to be a sensitive cell type for biocompatibility and cytotoxicity. Cells were exposed to different concentrations of CaHA (Radiesse®). Cell proliferation was calculated by luminometric adenosine triphosphate (ATP) measurement using the ATPLiteTM-M Assay. Possible cytotoxic effects were detected by the calorimetric Cytotoxicity Detection Kit. Clinical data were obtained from our own treatment files. CaHA did neither inhibit cell proliferation nor cause cytotoxicity. Clinical data suggest an excellent tolerability and long-term efficacy superior to hyaluronic acid-based fillers. CaHA is a versatile and well-tolerated biodegradable and biostimulatory filler.

BASAL CELL CARCINOMA OF THE FOOT - TWO CASE REPORTS AND LITERATURE REVIEW

Basal cell carcinoma (BCC) is considered the most common skin cancer in men. BCC of the foot, however, is very rare, and may occur on dorsal surface of the foot, foot sole or nail apparatus. Diagnosis is often delayed due to the location at an unusual site. We report on two patients: a 61-year-old female with an ulcerated BCC of the sole and dorsum of the foot on a leg with Klippel-Trénaunay syndrome and a 61-year-old male with an ulcerated BCC of the foot sole. Histologic tumor types were either metatypic or mixed solid and morphea-like with partial glandular infiltration. Perineural invasion was evident in both patients indicating the aggressive tumor behavior in the particular region. Authors also provide a review of the literature with a focus on the years 2000 through 2017.

UNILATERAL FRONTALIS MUSCLE PARALYSIS: MANAGEMENT WITH BOTULINUM TOXIN A (CASE REPORTS)

Unilateral frontalis muscle palsy is a debilitating disease with a heterogeneous etiology. Congenital or acquired unilateral paralysis of the frontalis muscle causes ipsilateral brow ptosis and contralateral hypermobility of the non-paralytic frontalis muscle, resulting in a bizarre asymmetry and emotional embarrassment. We present five patients with unilateral frontal muscle paralysis, two males and three females, aged between 32 and 68, treated with botulinum toxin A injection to the contralateral (non-affected) side. A total dose between 10 to 30 U botulinum toxin A (onabotulinum or incobotulinum toxin A) successfully improve symmetry and facial esthetics without any adverse events. Botulinum toxin A is an alternative to facial palsy surgery but may also be used as an adjunct after the surgical procedure to optimize the outcome.

Acral lentiginous melanoma: a skin cancer with unfavourable prognostic features. A study of the German central malignant melanoma registry (CMMR) in 2050 patients

BACKGROUND

Acral lentiginous melanoma (ALM) is one of the four major subtypes in cutaneous melanoma (CM). Although ALM has a poorer prognosis than other CM subtypes, the prognostic factors associated with ALM have only been verified in small-sized cohorts because of the low incidence of ALM worldwide.

OBJECTIVES

To investigate the clinical characteristics of ALM and to evaluate their prognostic values based on a large dataset from the Central Malignant Melanoma Registry (CMMR) of the German Dermatologic Society.

METHODS

The Kaplan-Meier method was used to estimate the potential influence of clinical and histological parameters on ALM disease-specific survival (DSS) curves, which were compared using the log-rank test. A Cox proportional hazards model was used to identify independent prognostic factors for DSS.

RESULTS

In total, 2050 patients with ALM were identified from 58 949 patients with CM recorded by the CMMR with follow-up data. In multivariate analyses, age (P = 0·006), ulceration (P = 0·013), tumour thickness (P < 0·001) and tumour spread (P < 0·001) turned out to be significant prognostic factors for DSS in ALM whereas sex, nevus association and level of invasion were not independent factors.

CONCLUSIONS

ALM has the same prognostic factors as other subtypes of melanoma. Unfavourable prognosis probably derives from the delay in diagnosis in comparison with other melanoma subtypes.

KERATOACANTHOMA OF THE UPPER LIP: REVIEW OF THE LITERATURE AND REPORT OF CASE WITH CENTRAL UPPER LIP RECONSTRUCTION

Keratoakanthoma (KA) is a common non-melanoma skin tumor of sun-exposed skin. Recently it has been classified as a highly differentiated squamous cell carcinoma, based on the evidence of local destruction, tissue invasion and malignant transformation with metastatic spread described in the medical literature. Lower lip KA is not uncommon on lower lip, and quite rare on upper lip. The authors present a case of 78-year-old Caucasian male patient with a rapidly growing keratotic tumor of the central region of upper lip. After complete surgical excision, single-stage reconstruction of the defect was performed by modified Goldstein's bilateral advancement myocutaneous vermilion flap. The histologic examination confirmed KA with excision margins within healthy tissue. Healing was unremarkable and functional and esthetic outcomes were very good. KA of the upper lip is a rare tumor that warrants complete surgical excision. Reconstruction of the central part of the upper lip is a challenge, but bilateral advancement myocutaneous vermilion flap resulted in good outcome.

PHOTODYNAMIC TREATMENT WITH NANOEMULSIFIED 5-AMINOLEVULINIC ACID AND NARROW BAND RED LIGHT FOR FIELD CANCERIZATION DUE TO OCCUPATIONAL EXPOSURE TO ULTRAVIOLET LIGHT IRRADIATION

Actinic keratosis (AK) is a premalignant epithelial disease that develops on skin chronically exposed to ultraviolet-light. For outdoor workers, AK is an occupational hazard with a potential for malignant transformation into squamous cell carcinoma. Various topical treatments are used to treat AK's. Photodynamic therapy (PDT) promises the highest cure rates. We performed a prospective single center trial evaluating effects of PDT treatment for field cancerization due to occupational exposure to ultraviolet light irradiation in patients unresponsive to the treatment regimen with topical diclofenac gel. For PDT, a nanoemulsified 5-aminolevulinic acid (5-ALA) formulation was combined with narrow band red light irradiation with a peak wavelength of 635 nm and a total light intensity of 37 J/cm2. Clearance rate and adverse events were recorded. Thirty patients with a mean age of 77±10.5 years (26 males and 4 females) were included in the trial. They received between one and nine PDT sessions. Mean pain during PDT was scored at 6.8±2.8 using the visual analogue scale. Patients exhibited a mild immediate erythema after PDT. Among the patients, who tolerated PDT, a complete clearance was achieved in 93.3%, and >90% clearance - in 6.7%. Pain management was performed by cold-air analgesia. In conclusion, PDT with nanoemulsified 5-ALA and narrow band red light irradiation is an effective and safe treatment for occupational field cancerization without systemic toxicity. Adherence to this treatment is much better than to topical treatment.

The role of subcutaneous adipose tissue in psoriasis

It is widely accepted that obesity is a systemic comorbidity factor in psoriasis. At the same time, there is rapidly growing evidence that the adipose tissue is not only systemically but also locally involved in the pathophysiology of psoriasis and in response to successful anti-psoriatic treatment.

Wirkungsphysiologische Aspekte des therapeutischen Ultraschalls in der Wundbehandlung

Therapeutischer Ultraschall (US) besitzt im Kontext der Wundheilung als hoch- (1-4 MHz) und als niederfrequenter US (20-120 kHz) Relevanz. Beim hochfrequenten US dominieren thermische Effekte, beim niederfrequenten mechanische. Wirkungsphysiologische Hypothesen fokussieren Stoffwechselsteigerung, Durchblutungsverbesserung und Auflösung von Hautveränderungen (Wundgebiet) vornehmlich mit niederfrequentem US. Die therapeutische Wirksamkeit des US wird von seiner Dosis (W/cm2) und Dosierung (Applikationshäufigkeit) bestimmt.

In vitro konnte der proliferative Effekt (Biostimulation) auf Fibroblasten, Osteoblasten und Monoyzten sowie eine Steigerung der Proteinbiosynthese (z. B. von Kollagen) und der Zytokinproduktion für hoch- und niederfrequenten US bei adäquater Dosierung nachgewiesen werden. Mechanische Wirkungen des niederfrequenten US implizieren transiente Kavitationen im Wundgebiet, die Wundreinigung und Granulationsanregung bedingen. Im Kanon eines multimodalen Therapiekonzeptes für die Wundheilung ist US eine effektive und sinnvolle Option.

ANALYSIS OF TISSUE OXYGENATION IN CHRONIC LEG ULCERS BY COMBINATION OF A MULTI-SPECTRAL CAMERA AND A HYPER-SPECTRAL PROBE

Objective evaluation of chronic wounds, such as leg ulcers, by the use of non-invasive techniques is of importance for diagnosis, monitoring treatment response, and probably leads to improved treatment strategies. We performed a feasibility study for the combined use of a multi-spectral camera and a hyper-spectral probe to evaluate chronic leg ulcers with a focus on tissue oxygenation. Sixty patients - 40 females and 20 males were enrolled in the study. The age range was 46 to 85 years for males (mean 65.8 years, median 73.0 years) and 51 to 91 years for females (mean 74.4 years, median 77.0 years). Measurements were performed by hyper-spectral wound (HySkinII) probe and multi-spectral (DeMuk) camera on wounds and surrounding skin. The investigation results demonstrate a high variability of oxygenation within ulcers and the surrounding tissue. The methods allow an investigator to independently assess of tissue oxygenation in superficial and deeper layers. Non-invasive multi- and hyper-spectral imaging techniques offer new opportunities of an objective assessment of chronic wounds.

MIXED TYPE BASAL CELL CARCINOMA OF THE AURICLE - SINGLE STAGE RECONSTRUCTION AFTER R0-RESECTION BY A MODIFIED ANTIA-BUCH FLAP (CLINICAL CASE REPORT)

Basal cell carcinoma (BCC) is the most common neoplasia in Caucasians with a pre-dominance for the sun-exposed anatomical areas including the auricle. The treatment of choice is surgery achieving an R0-resection status. On the other hand, functional and aesthetic results are of importance. We report a case of 79-year-old Caucasian man with a BCC of the helical rim that was treated surgically using a modified Antia-Buch flap for single stage reconstruction. Article is discussing peculiarities of BCC on the auricle and options for auricular reconstruction.

Consensus statement on prevention and management of adverse effects following rejuvenation procedures with hyaluronic acid-based fillers

Facial fillers play an important role in the correction of facial changes associated with ageing. They offer quick treatments in the outpatient setting with minimal subsequent downtime that provide predictable, natural-looking, long-lasting results. Adverse reactions after hyaluronic acid injections tend to be mild or moderate and rather temporary. However, as with all injected or implanted biomaterials, severe adverse events can occur and patients must be fully informed of potential risks prior to undergoing treatment. A panel of experts from Germany (D), Austria (A) and Switzerland (CH) developed recommendations, and this study provides the 'DACH Consensus Recommendations' from this group specifically on the use of hyaluronic acid fillers. The aim is to help clinicians recognize potential risks and to provide guidance on how best to treat adverse events if they arise. Contraindications to hyaluronic acid fillers are also detailed, and ways to prevent adverse events occurring are discussed. Hyaluronic acid-based products are claimed to be very close to an ideal tissue augmentation agent; nevertheless, profound medical, anatomical and product knowledge are of paramount importance to minimize the occurrence of adverse reactions.

PEMETREXED-INDUCED PSEUDOCELLULITIS - A RARE CUTANEOUS ADVERSE REACTION TO MULTI-TARGETED ANTIFOLATE THERAPY

Pemetrexed is a multi-targeted folate antagonists approved for non-small cell lung cancer and other malignancies. Adverse cutaneous reactions have been reported in up to 1/3 of patients treated. A rare cutaneous adverse reaction is pseudocellulitis. We report about a 62-year-old male patient treated with a combination of cisplatin and pemetrexed for non-small cell lung cancer stage IV who developed about 4 months after initiation of treatment painful, non-febrile erythematous lesions on feet and lower legs. There was no lymphadenopathy and no general malaise. Laboratory investigations detected increased level of C-reactive protein but normal values of procalcitonin. A skin biopsy revealed a mild interface dermatitis. Antifolate treatment was stopped and he received oral and topical corticosteroids, compression therapy and supplementation with folate and vitamin B. A complete remission of skin eruptions was achieved. Pemetrexed-induced pseudocellulitis is a possible, but rare complication of treatment that oncologists and dermatologists should know. Systemic antibiosis is unnecessary.

RESULTS OF MINIMAL INVASIVE TREATMENT IN LOCALIZED ACQUIRED CUTIS LAXA TYPE 1 AND TYPE 2 - CASE REPORT AND DISCUSSION

Cutis laxa is a disease of premature ageing. While the congenital type is characterized by mutations of genes involved in extracellular matrix turnover, acquired cutis laxa is a rare disease that can be induced by a variety of exogenous factors. We present a case of acquired type 2 cutis laxa of the neck due to excessive exposure to natural sunlight and a type 1 facial acquired cutis laxa, both significantly improved by minor invasive procedures. The etiology, prevention and treatment options are discussed.

History of venous leg ulcers

To retrieve the history of venous ulcers and of skin lesions in general, we must go back to the appearance of human beings on earth. It is interesting to note that cutaneous injuries evolved parallel to human society. An essential first step in the pathogenesis of ulcers was represented by the transition of the quadruped man to Homo Erectus. This condition was characterized by a greater gravitational pressure on the lower limbs, with consequences on the peripheral venous system. Furthermore, human evolution was characterized by an increased risk of traumatic injuries, secondary to his natural need to create fire and hunt (e.g. stones, iron, fire, animal fighting). Humans then began to fight one another until they came to real wars, with increased frequency of wounds and infectious complications. The situation degraded with the introduction of horse riding, introduced by the Scites, who first tamed animals in the 7th century BC. This condition exhibited iliac veins at compression phenomena, favouring the venous stasis. With time, man continued to evolve until the modern age, which is characterized by increased risk factors for venous wounds such as poor physical activity and dietary errors (1, 2).

Laser treatment of leg ulcers: selected concepts

An overview on different laser devices, available for the treatment of the different phases of wound healing: debridement, wound repair and scars correction.

DERMAL ADIPOSE TISSUE IN HAIR FOLLICLE CYCLING: POSSIBLE APPLICATIONS IN ALOPECIA?

Cross-talk between the hair follicles (HFs) in different stages of their cycling and adjacent adipose tissue is a new important topic which is of both theoretical and practical interest. Objective - to analyze available data on possible interrelationship of dermal adipose tissue and hair follicle cycling. Experimental results obtained in rodents clearly demonstrate that HFs cycling is connected to adjacent dermal adipose tissue. Recently uncovered adipocyte-myofibroblast transition can be significantly involved in miniaturization of HFs and be an important pathophysiological step in androgenetic alopecia. Improvement of adipogenic environment of HFs can be important both in treatment of alopecia and in surgical hair restoration procedures.

APLASIA CUTIS CONGENITA TYPE I - A CASE SERIES

Aplasia Cutis Congenita is a rare disorder with circumscribed, partial or widespread absence of skin and subcutaneous soft tissue; in about 20% it also causes skull defects. The disease is heterogeneous in its clinical presentation with nine major subtypes. Type I represents nonsyndromic Aplasia Cutis Congenita. We report 5 infants with skin defects of the scalp and limbs presented to dermatologists. Pediatric workup ruled out any other malformations or genetic disorders. All patients were treated by conservative wound and skin care without complications. In one case the formation of milia has been observed - an outcome not described before. Therapeutic approach and differential diagnoses are described. Topical wound and skin care resulted in complete closure of the defects. Skin appendages did not recover, leaving hairless areas on the scalp and limbs. Aplasia Cutis Congenita type I is a rare disorder in newborns with >85% of all solitary lesions occurring on the scalp. Conservative treatment is a simple and safe option in many cases. Exposed large veins and sagittal plexus demand urgent surgical approaches to prevent fatal hemorrhages or infections.

ILVEN - COMPLETE REMISSION AFTER ADMINISTRATION OF TOPICAL CORTICOSTEROID (CASE REVIEW)

Inflammatory linear verrucous epidermal nevus (ILVEN) is a relatively rare disorder with an onset at early age, consisting of pruritic linear papules and/or plaques and histologic features resembling psoriasis or lichenoid dermatitis. The disease is a version of mosaicism caused by somatic mutations. ILVEN belongs to the heterogeneous group of congenital hamartomas of embryonal ectodermal origin, as a variant of verrucous epidermal nevus, representing approximately 5% of all epidermal nevi, with predominance in females and with general therapeutic resistance. We report on an 18-month-old female patient with ILVEN, who failed to respond to topical tacrolimus, but achieved complete resolution with topical application of momethasone furoate 0.1% under occlusion for 2 weeks, with no signs of recurrence to date. Consequent topical therapy can provide excellent results in young children.

CARCINOSARCOMA OF SKIN (SARCOMATOID CARCINOMA) - A RARE NON-MELANOMA SKIN CANCER (CASE REVIEW)

Non-melanoma skin cancer incidence is rising worldwide. The leading neoplasias are basal cell carcinoma and squamous cell carcinoma. We report on an 88-year-old female patient with a rapidly grown, symptomless, exophytic tumor of the supraclavicular area. Examination at the dermatology department has revealed a firm, exophytic, reddish tumor covered by crusts, about 4 cm in diameter and easily movable to the ground. The tumor was removed by delayed Mohs surgery (R0 resection). The resulting defect was closed by tissue expansion. Nodal metastases were ruled out by ultrasound. Histologic investigation revealed a biphasical nodular tumor composed of partly fibrous spindle cellular elements, partly myxoid and chondroid mesenchymal components with cellular atypia, atypical mitoses and focal necrosis. Some multinucleated tumor cells were noted. Trabecular and island-like solid epithelial tumor components demonstrated increased mitotic activity and cellular atypia. There was no vascular invasion. The diagnosis of a basaloid carcinosarcoma was confirmed. Basaloid carcinosarcoma is an extremely rare cutaneous neoplasia with less than 30 patients reported. Complete wide excision or Mohs surgery are the favored treatment options.

SCLEROSING MICROCYSTIC ADNEXAL CARCINOMA OF THE SCALP (CASE REPORT)

Microcystic adnexal carcinoma is a rare malignant sweat gland tumor. We present the case report of a 63 year old male patient who developed this malignancy on the scalp, which is an uncommon site. The tumor has been removed by delayed MOHS technique with no relapse. The differential diagnoses and treatment options are discussed.

[Disseminated necrobiotic xanthogranuloma]

Necrobiotic xanthogranuloma is a rare non-Langerhans-cell histiocytosis. A 62-year-old woman presented with yellowish erythematous plaques, nodules, and papules in the periorbital region and the extremities. She had a nodular tumor grown on the left upper lid that clinically resembled a keratoacanthoma. Histologically it was a xanthogranulomatous lesion. She suffered from monoclonal gammopathy of unknown significance of κ‑type. Treatment was realized with a combination of systemic dapsone/prednisolone and topical corticosteroids.

[Complex decongestive therapy]

The amount of physical pressure plays an important role in complex decongestive therapy (CDT). As a function of pressure, microcirculation takes place between blood vessels and tissue. As part of the total lymphatic system, lymphatic vessels transport the lymphatic load from the interstitial space to the blood stream. The lymphatic vessel system, characterized by specific anatomical conditions like initial lymphatic vessels, precollectors, collectors, and lymphatic strains, is the therapeutic target of complex decongestive therapy. Components of CDT include manual lymphatic drainage, compression therapy, decongestive kinesitherapy, and good skin care, which increase the transport capacity of the lymphatic vessel system. Currently, CDT is acknowledged as the main conservative treatment of lymphedema of primary and secondary genesis, lipolymphedema, and phlebolymphedema. In clinical practice, we are increasingly confronted with edema of multifactorial genesis requiring a critical discussion and stocktaking of comprehensive clinical findings in terms of the indication for CDT. Therapeutic success depends on a joint application of all CDT components and patient compliance. To an increasing extent, medical research tries to combine successfully CDT with adjunct treatment options.

CELLULAR FIBROUS DERMATOFIBROMA OF THE SOLE

Cellular fibrous dermatofibroma is a rare variant of dermatofibroma/histiocytoma. We present a 61 years old female with a slow-growing, firm tumor on the sole of her right foot. The tumor was removed by slow Mohs surgery within 2 cm negative margin. Histopathologic investigation revealed a nodular encapsulated tumor composed of spindle and some epithelioid cells in a storiform growth pattern. Minimal mitotic activity was reported, however without evidence of atypical mitoses. Tumor cells expressed CD10, focally smooth muscle antigen and desmin, but remained negative for S100 protein and CD34. The diagnosis of cellular fibrous dermatofibroma was confirmed. The defect was closed by full thickness skin graft.