A study on serum IgE and clinical symptomatology of atopy in patients suffering from the lysosomal storage disorder Fabry disease

BACKGROUND

Lysosomal storage disorders may impair intracellular lysosomal processing of antigen with consequences for antibody production [e.g. immunoglobulin E (IgE)] and atopic disease status.

AIMS

Serum concentration of total IgE as well as clinical symptoms of atopic disorders as an indirect consequence of lysosomal impairment of antigen processing were studied in male and female Fabry disease (FD) patients with and without replacement of the missing lysosomal enzyme, alpha-galactosidase A (alpha-Gal A).

METHODS

Observational study in 31 adult FD patients with measurements of total serum IgE concentration. Questionnaire-derived data were obtained for atopic eczema (AE) skin lesions, allergic rhinoconjunctivitis (RCA) and allergic asthma (AA) at present or in the past.

RESULTS

Among 12 FD males under enzyme replacement therapy (ERT), 2 showed total IgE concentrations above 100 kU/L. Clinical symptoms for AA were found in 2, RCA and AE in 1, respectively. Among 10 FD females under ERT, 4 showed total IgE concentrations above 100 kU/L. Clinical symptoms for AA were found in 4, RCA in 2 and AE in 2. Among 9 females without ERT, 2 showed total IgE concentrations above 100 kU/L. Clinical symptoms for AA were found in 2, RCA in 2 and AE in none.

CONCLUSIONS

FD patients may demonstrate an increased total serum IgE concentration and may show symptoms of atopic disorders (AA, RCA, AE) in a prevalence rate comparable to international experience for individuals without FD. There was no difference between patients with and without ERT. Lack of detection of AE in females without ERT is suggested to be caused by the small sample size. FD patients without any alpha-Gal A activity prior to initiation of ERT should be in the focus of future studies.

Allergy to peanut oil--clinically relevant?

The increasing prevalence of food allergies (especially allergy to peanuts) has led to a discussion of how safe topical preparations containing peanut oil are with respect to allergy. The major allergens from peanuts are proteins that have been characterized at a molecular level and cloned. Clinical signs of peanut allergy symptoms can be observed on the skin (urticaria), or in the gastrointestinal and/or respiratory tract culminating in cardiovascular symptoms and anaphylactic reactions. In most cases, symptoms are elicited by oral uptake; rarely, a contact urticaria has been described. In vegetable oils, the contents of protein differ depending on the production process: crude oils contain approximately 100 times more proteins than refined oils. This has clear-cut implications for allergic individuals. Quantitative data are available regarding elicitation of symptoms in allergic individuals with a threshold dose of 0.1-1 mg peanut allergen in oral provocation tests. There are anecdotal reports of adverse reactions after topical use of peanut oils. In one epidemiological trial, an association between topical use of skin care products containing peanut oil and the development of peanut allergy was observed; however, the data reflect a retrospective analysis without specifying skin care products containing peanut oil and also without analysing the quantity of topicals used. In contrast, oral tolerance was prevented and allergic sensitization was enhanced in a mouse model using high concentrations of peanut protein. So far, no reliable data are available regarding doses required to induce sensitization against peanut allergen via the epidermal route. A possible induction of sensitization against peanut proteins through contact with the skin via skin care products and the respective protein concentrations is a matter of speculation. Patients with atopic diseases, namely eczema, need appropriate skin care because of the disturbed skin barrier function. The benefit of avoiding damage to skin barrier functions of atopic individuals by the use of peanut protein-containing skin care products seems to outweigh possible risks of sensitization and/or allergy induction against substances contained in those products containing refined peanut oil.

Atopic eczema: what's new?

Atopic eczema (AE) is a chronic inflammatory skin disease characterized by recurrent intense pruritus and a typical age-related distribution of skin lesions. Several new aspects with regard to the pathogenetic background as well as strategies for prevention, diagnosis and treatment of AE have emerged. There are ongoing studies on genetic susceptibility loci, as well as environmental and nutritional factors associated with an increase or a decrease of AE lesions. The atopy patch test is now available for identification of allergens in aeroallergen-triggered AE. New topical therapies, such as the calcineurin inhibitors, have broadened the therapeutic armamentarium substantially. In order to increase knowledge and coping strategies, patient education programs have been launched. Learning objective Upon completing this paper, the reader should be aware of new developments in AE, especially on nomenclature, prevention strategies, diagnostic tests, as well as therapeutic options.

[Tattoos and permanent make-up: background and complications]

Tattoos and permanent make-up have enjoyed great popularity during recent years. However, a careful consideration of the risks is made only rarely before each procedure. Above all the undefined pigment compositions create unforeseeable health and appearance problems. The family physician should be familiar with the techniques, materials, as well as the possible risks of tattoos and permanent make-up when advising patients. Medical complications include, among other things, infections, allergies, keloid and granuloma formation.

The course of eczema in children aged 5-7 years and its relation to atopy: differences between boys and girls

BACKGROUND

The role of atopy in the pathophysiology of eczema is still under debate. The concept and analyses of the nonatopic and atopic subtypes of eczema have gained increasing interest in recent studies. The course of these subtypes and differences between boys and girls have not been investigated so far.

OBJECTIVES

To examine the course of nonatopic and atopic eczema in preschool children from Germany with regard to sex.

METHODS

Repeated cross-sectional studies were performed in 5-7-year-old preschool children from Germany between 1994 and 2000. Individuals with eczema were identified by a dermatological examination. In addition to a questionnaire, skin prick tests and analyses of serum IgE antibodies against seven and five environmental allergens, respectively, were performed. Atopy was defined by sensitization to at least one of five common aeroallergens (birch, grass and mugwort pollen, house dust mites, cat dander). In part of the study population investigations of spare time behaviour and skin function were carried out (including stratum corneum hydration and skin surface pH).

RESULTS

A total of 2693 girls and 2783 boys underwent a full dermatological examination of the skin and determination of sensitization. Among the girls, 8.7% demonstrated eczema clinically at the day of investigation in contrast to 6.1% of the boys. In girls, early onset eczema (< 2 years of age) was strongly related to atopy at age 5-7 years [odds ratio (OR) 3.7; 95% confidence interval (CI) 2.7-5.1], whereas late-onset eczema (> or = 2 years of age) was not (OR 1.0; 95% CI 0.7-1.5). Boys were more often atopic at the age of 5-7 years than girls (28.3% vs. 20.6%), and early and late-onset eczema were related to atopy without such a difference (OR 2.8, 95% CI 2.0-4.0; OR 1.9, 95% CI 1.3-2.8, respectively). The excess of current eczema in 5-7-year-old girls compared with boys was related to the nonatopic type. The higher susceptibility of girls in that age group to develop eczema was reflected by the skin physiological examination: even girls without eczema had significantly higher skin surface pH and lower stratum corneum hydration than boys. Additionally, questionnaire data revealed that girls more often than boys predominantly played indoors, which was associated with more eczema.

CONCLUSIONS

Atopy and eczema develop differently in boys and girls. Boys are more often atopic, whereas girls suffer significantly more often from eczema without relation to atopy. The nonatopic type of eczema in preschool girls is noticed predominantly after their second birthday. Genetic and lifestyle factors may contribute to this difference.

[Cost-of-illness study in patients suffering from atopic eczema in Germany]

BACKGROUND

Atopic eczema is one of the most common skin diseases. In Germany, the economic burden is estimated to be EUR 1.2-3.5 billion yearly. The aim of this study was to show the resource utilization and costs for outpatient care and the out-of-pocket expenses for the patients.

PATIENTS AND METHODS

This study was a multi-center, retrospective and prospective cost-of-illness study. Patient characteristics and data on resource utilization were collected with a semi-structured patient questionnaire and by chart abstraction. 193 patients filled in the patient questionnaire; data from 169 patients were obtained by chart abstraction.

RESULTS

Average direct medical costs of a disease flare were EUR 123 per patient. Average annual total costs were EUR 1,425 per patient, increasing with severity from EUR 956 (mild) to EUR 2,068 (severe).

CONCLUSION

Prolongation of flare-free time and reduction in severity are not only desirable for the patients but also of economic interest.

[Acquired effluvium of head hair: common conditions in women]

Acquired disorders of hair growth in women may present clinically either as effluvium or alopecia. The relevant pathologies include androgenetic alopecia, postpartum effluvium, tinea capitis, trichotillomania and alopecia areata.

[Inflammatory bowel diseases--associated lesions affecting the skin and mucous membranes]

Crohn's disease or ulcerative colitis may be preceded, followed or accompanied by a variety of extra-intestinal diseases affecting the skin and mucous membranes. Amongthe most important of these associated lesions are, for example, erythema nodosum and pyoderma gangrenosum.

[Diabetes mellitus: Cutaneous and mucosal marker lesions]

Diabetes mellitus may be associated with dermatological lesions affecting the skin and mucous membranes. In some cases they may even provide the physician with a first indication that the patient may be suffering from diabetes. Typical examples include necrobiosis lipoidica, granuloma annulare, acanthosis nigricans and vitiligo.

[Diagnosis of major sexually transmitted infections in the doctor's office: bacterial infections]

Bacterial infections that can be transmitted by sexual contact are usually caused by the following organisms: Neisseria gonorrhoeae, Chlamydia trachomatis, Treponema pallidum and Klebsiella granulomatis. These pathogens can be detected with the aid of specific nutrient media, stained microscopic sections and serological and molecular biological methods.

[Diagnosis of major sexually transmitted infections in the doctor's office: viral diseases]

Sexually transmitted infections caused by viruses include infections by the Herpes simplex virus (HSV), the human papillomavirus (HPV), and the human immunodeficiency virus (HIV). The diagnosis is established on the basis of clinical presentation and the direct demonstration of the antigen or antibodies.

[Diagnosis of major sexually transmitted infections in the doctor's office: ectoparasites and yeasts]

Ectoparasites, such as lice and itch mites (scabies) as well as yeasts, may be transmitted not only by sexual contact, but also by less intimate skin contact. The nits of the louse are visible to the naked eye, while Candida albicans is detected under the microscope or by culture.

[Tinea capitis et corporis due to Microsporum canis in an immunocompromised female adults patient]

Tinea capitis as well as tinea corporis in adults may occur under conditions of immunosuppression. If suspected clinically, direct microscopy and examination by culture is indispensable. Therapeutic intervention should start without delay. A proven fungal infection of scalp hairs warrants immediate initiation of systemic treatment. Hereby prevention of disfiguring hair loss, permanent formation of scar tissue, spread of fungal organisms to other cutaneous regions as well as infection of other persons is possible.

[Alarming skin manifestations: eczema, urticaria or cancer? How to discriminate between benign and dangerous skin changes]

Numerous dermatological lesions can be provisionally diagnosed by the family doctor on the basis of such parameters as location, duration, degree of pruritus, involvement of the epidermis, and the age of the patient. Whenever a lesion is difficult to interpret or suspicious for malignancy, the patient should be referred to a specialist without delay. This is also mandatory in all such cases in which accepted therapeutic measures initiated on the basis of an apparently certain diagnosis on the part of the family doctor fail to cure the problem within a reasonable period of time.

[Tinea capitis. Therapeutic options in the post-griseofulvin era]

Tinea capitis is the most common dermatophyte infection during childhood. In Germany, only griseofulvin is approved for therapy by regulatory agencies. In recent years, several newer antifungal agents such as itraconazole, fluconazole and terbinafine have broadened the therapeutic armamentarium and are used for the treatment of childhood tinea capitis. Itraconazole and terbinafine seem to be equally or more effective in treatment of tinea capitis within a shorter period of time than griseofulvin. Fluconazole is probably also effective for this indication, although supporting data is limited. Encountered side effects as well as interactions with other drugs appear to be well within acceptable limits for all three drugs. In conclusion, systemic therapy of scalp ringworm with itraconazole and terbinafine, as well as perhaps fluconazole, seems to be an equivalent or a superior therapeutic approach as compared to the use of griseofulvin. For the future, regulatory approval for the use of these newer antifungal agents in tinea capitis of childhood is recommended.

[Confluent and reticulate papillomatosis. Successful therapy with azithromycin]

Confluent and reticulated papillomatosis is a fairly rare dermatosis of still unknown origin affecting mostly female young adults. The lesions are mainly localized in the midline of the trunk. Systemic treatment is the treatment of choice because the disease is resistant to topical therapy and recurrences are often seen. In recent publications retinoids and minocycline have been reported as the favourite therapeutic approaches. We successfully treated a 19-year-old-girl with azithromycin resulting in a complete healing of all skin lesions. The patient has been free of disease for five months. Based on our own case and data in literature, azithromycin is an effective, reasonable and safe therapeutic alternative.

Onychogryphosis in elderly persons: an indicator of long-standing poor nursing care? Report of one case and review of the literature

A 92-year-old immobilized white woman under the daily nursing care of a private ambulatory nursing service displayed acquired deformities of the toenails resembling a ram's horn. In light of a rapidly growing elderly population, this case report illustrates the need for close monitoring of the quality of care that nursing services provide to older persons. In addition, it reviews the clinical aspects of onychogryphosis, as well as its pathomechanisms and treatment options.

[What's new in diagnosis and therapy of dermatomycoses in childhood]

Mycotic infections in childhood are caused in the majority of cases by dermatophytes. If an oral treatment is indicated, itraconazole and terbinafine are superior to griseofulvin and are nowadays drugs of first choice although an official registration for treatment of children is missing in Germany. Yeasts in infections of childhood are the causative organisms in Pityrosporum-folliculitis and act as an important co-factor in diaper dermatitis.

[Symptomatic therapy of exanthema. Finding the proper externum]

In the treatment of exanthems, the first step is the elimination of the causal agent. Of great importance also is the symptomatic treatment of the cutaneous changes and such associated symptoms as itching and pain. The choice of the appropriate external medication and its vehicle will depend on the clinical findings, skin type, and the location of the skin lesions. The most important therapeutic principles are discussed taking drug-induced exanthema, acute urticaria and (herpes) zoster as examples.