Acrally distributed dermatoses: Vascular dermatoses (purpura and vasculitis)

Purpuric lesions appear in acral distribution in a variety of conditions and often provide clues to the clinical diagnosis. Purpuric means "hemorrhagic"-that is, the lesions do not blanch from pressure. This review focuses on dermatoses that produce hemorrhagic lesions in acral distribution from the large groups of the vasculitic diseases and their mimics. Cutaneous small vessel vasculitis is confined to the skin, involves mainly postcapillary venules, and has the hallmark manifestation of palpable purpura. Henoch-Schönlein purpura is an immune complex-mediated systemic vasculitis of the small vessels with manifestations from the skin, joints, kidneys, and gastrointestinal system. Only cases where the immune complexes contain immunoglobulin A type are classified as Henoch-Schönlein purpura. Cryoglobulinemic vasculitis is induced by the deposition of cold-precipitated immune complexes in the small vessels. Urticarial vasculitis comprises a spectrum of conditions with the characteristic course of chronic urticaria, with wheals that persist longer than 24 hours, leave hyperpigmentation, and have leukocytoclastic vasculitis on histologic examination. Polyarteritis nodosa is a rare multisystem, segmental necrotizing vasculitis of mainly the medium-sized vessels. Pigmented purpuric dermatoses are chronic benign dermatoses characterized by petechiae, purpura, and increased skin pigmentation. The hallmark of pigmented purpuric dermatoses is their orange-brown, speckled, cayenne pepper-like discoloration.

Methods for the Assessment of Barrier Function

Due to the ease of skin accessibility, a large variety of invasive and noninvasive in vitro and in vivo methods have been developed to study barrier function. The measurement of the transepidermal water loss (TEWL) is most widely used in clinical studies. The different methods of determining TEWL, as well as skin hydration, skin pH, tape stripping and other modern less widely used methods to assess skin barrier function, are reviewed, including Raman spectroscopy and imaging methods such as optical coherence tomography and laser scanning microscopy. The modern imaging methods are important developments in the last decades which, however, determine the structure and, hence, cannot replace the measurement of TEWL in questions related to function.

[Morbus Behçet or inflammatory bowel disease--a diagnostic and therapeutic dilemma]

We present the case of a 43-year old caucasian male suffering from a condition initially diagnosed as colitis ulcerosa. For 2 years Azathioprine and anti-TNF-alpha antibodies were used for treatment without convincing benefit but with serious adverse events. After the first occurrence of complex accompanying symptoms like oral and scrotal ulcerations, arthritis and scratch-induced skin lesions the differential diagnosis of a Morbus Adamantiades-Behçet with intestinal evolvement was considered. After introduction of a parenteral Ciclosporin medication, which was later switched to Tacrolimus and Azathioprin, a remission could be achieved that lasted for several months. When a drug-induced acute kidney injury occurred, the regime was changed to Golimumab and a delayed but significant improvement was achieved. To separate Morbus Adamantiades-Behçet from inflammatory bowel disease is of some difficulty, demands interdisciplinary cooperation and is the basis for a successful therapy.

Hand dermatitis: a review of clinical features, prevention and treatment

Hand dermatitis is a socially significant health problem. This review provides a discussion on the clinical features and patterns as well as the differential diagnosis of hand dermatitis, because these are essential for proper diagnosis in clinical practice. The morphology, however, is poorly related to the etiology in chronic cases. In all cases of chronic hand dermatitis, a full diagnostic examination should be undertaken and the etiology should be clarified and addressed in the treatment concept, instead of just moving directly from a morphological diagnosis to therapy. Preventive measures should be included in the treatment concept according to etiology. A stepwise approach for escalating therapy is advised, including basic topical therapy, topical corticosteroids, calcineurin inhibitors, as well as phototherapy and systemic therapy with corticosteroids, alitretinoin, cyclosporine, methotrexate, azathioprine, and others.

Development of a standardized testing procedure for assessing the irritation potential of occupational skin cleansers

BACKGROUND

Frequent skin cleaning fulfils the definition of occupational 'wet work'. Standardized methods are required to assess the irritation potential of workplace cleansers.

OBJECTIVES

To develop a standardized procedure for testing the irritation potential of occupational skin cleansers.

METHODS

In this single-blind, single-centre trial in 25 healthy volunteers, the irritation potential of five generic reference cleansers was tested by three-times-daily washing with an automated skin cleaning device for 4 days, and quantification of cumulative skin barrier damage was performed by visual scoring, chromametry, transepidermal water loss TEWL, and corneometry. For two cleansers, reproducibility of the irritancy assessment was assessed. Furthermore, the irritation induced by four commercial workplace skin cleansers was studied.

RESULTS

Whereas no significant changes were observed for any of the tested cleansers by either visual scoring or chromametry, significant increases in TEWL and significant decreases in stratum corneum hydration were found for all cleansers. Cleansers differed significantly in their irritation potential. On retesting of two cleansers, the first results were confirmed. Among the four commercial cleansers, one that was claimed to be mild was found to be disproportionally irritant.

CONCLUSIONS

The presented model for testing cleansing preparations allows a highly controlled, practically relevant and reproducible irritancy assessment of occupational skin cleansers.

Teaching interventions in contact dermatitis

Prevention of occupational contact dermatitis is of utmost significance for both insurers and legislators because it can preserve the individual's ability to work and result in decreased costs for public health. In the last 20 years, many concepts for educational interventions and a multitude of teaching aids have been developed by insurance associations and public institutions from different countries (eg, the United States, Sweden, Denmark, Switzerland, and Germany). For didactic purposes, terms of different levels of prevention have been inaugurated in northern Europe in the context of occupational dermatology. This review presents different educational interventions in the fields of primary, secondary, and tertiary prevention as well as evaluation studies of these measures, especially among health care workers, hairdressers, metalworkers, and bakers' apprentices. Special emphasis is put on the prevention of allergic contact dermatitis.

Psoriatic erythroderma associated with enalapril

A 59-year-old man with a 35-year personal and positive family history of psoriasis was admitted to our department for treatment of psoriatic erythroderma. The patient had commenced therapy with enalapril 10 mg b.i.d. for the treatment of hypertension approximately 6 weeks before hospitalization. Five weeks after the initiation of enalapril, his psoriasis began to flare, and for a period of about 1 week it reached the extent of erythroderma. The patient did not associate the psoriatic flare with other factors such as infections, trauma, or stress. The patient presented with diffuse erythema and pronounced desquamation covering his entire trunk, scalp, and extremities (Figure). Nearly 100% of the body surface area was involved. The palms and soles were also affected, displaying erythema, hyperkeratosis, and painful fissures. The nails showed pits, oil spots, and subungual hyperkeratosis. The patient also had psoriatic arthritis affecting the interphalangeal joints of his fingers. Laboratory tests revealed an elevated erythrocyte sedimentation rate, an elevated creatinine level of 180 mmol/L, a blood urea nitrogen level of 10.8 mmol/L, and a uric acid level of 716 mmol/L. Urinalysis showed proteinuria of 1.5 g/24 h. The patient's renal condition was diagnosed as chronic tubulointerstitial nephritis, most probably related to his dermatologic disease. Allopurinol and dietary measures were recommended. Following treatment with methotrexate and replacement of enalapril therapy, the erythema and scaling gradually subsided and became confined to his pre-eruptive chronic plaques (approximately 5% of body surface area). Rechallenge with enalapril was not performed.

Drug-induced lupus erythematosus

Among the numerous idiopathic immune-mediated diseases that can be drug-induced, such as pemphigus, psoriasis, lichen, etc, drug-induced lupus is the most widely commented upon and investigated. The terms drug-induced lupus (DIL) and drug-induced lupus erythematosus (DILE) are preferred, but other ones are also used--drug-related lupus, lupus-like syndrome, and lupus erythematosus medicamentosus. This review discusses the general issues in DILE, such as pathogenic mechanisms, clinical forms, and diagnostic criteria, and provides more detailed information for some of the implicated drugs: minocycline, statins, terbinafine, etc.