Dermatologische Radiotherapie

Dermatologic radiotherapy is based on the standard physical and radiobiological parameters. The radiation quality most often used in dermatology lies between 10 and 50 kV. Another important parameter is the half-value depth which should correspond to the depth of the tumor below the skin surface. In this way the skin is not over-exposed to radiation treatment. Indications for radiotherapy of malignant skin tumors include basal cell carcinoma, squamous cell carcinoma, severe actinic keratoses, lentigo maligna, lentigo maligna melanoma, Merkel cell carcinoma, and Kaposi sarcoma, as well as T- and B-cell lymphomas. Most patients with malignant skin tumors require life-long monitoring after radiotherapy. The most common benign lesions where radiotherapy may be indicated are eczemas, psoriasis, and keloids, but its use should be carefully weighed in these settings.

Pseudoxanthoma elasticum: evaluation of diagnostic criteria based on molecular data

BACKGROUND

Pseudoxanthoma elasticum (PXE) is a genetic disorder due to mutations in the gene encoding the transmembrane transporter protein adenosine triphosphate binding cassette (ABC)-C6, resulting in calcification of elastic fibres in the skin, eyes and cardiovascular system.

OBJECTIVES

To evaluate the diagnostic criteria for PXE based on molecular data.

METHODS

Of 10 families with a positive history of PXE 142 subjects were investigated for clinical symptoms, histological findings and genetic haplotype analysis.

RESULTS

Of these, 25 subjects were haplotypic homozygous for PXE and 23 had typical clinical and histopathological manifestations. Two of the 25 patients showed such marked solar elastosis and macular degeneration that PXE could not be confirmed clinically. Sixty-seven subjects were haplotypic heterozygous carriers and 50 were haplotypic homozygous unaffected. Of these 117 subjects, 116 showed no cutaneous or ophthalmological signs of PXE. In one of the 50 haplotypic homozygous unaffected patients important solar elastosis and scarring of the retina mimicked PXE lesions. Only four of the 67 haplotypic heterozygous carriers had biopsies of nonlesional skin; all were histopathologically normal.

CONCLUSIONS

In our patients, PXE presents as an autosomal recessive genodermatosis. Correlation of haplotype and phenotype confirmed actual major diagnostic criteria. In patients with marked solar elastosis and/or severe macular degeneration clinical diagnosis can be impossible and molecular testing is needed to confirm the presence of PXE. To the best of our knowledge our large study compares for the first time clinical findings with molecular data.

Multiple nodules of the scrotum: histopathological findings and surgical procedure. A study of five cases

BACKGROUND

Multiple nodules of the scrotum are uncommonly reported. Their origin is controversial. Treatment is always surgical but the best procedure is still to be determined.

MATERIALS AND METHODS

Five new cases are reported with description of the histopathological findings and surgical procedure.

RESULTS

Nodules of the scrotum were more frequent in patients with dark skin suggesting an ethnic susceptibility. No other predisposing factors were noted. Screening for disturbances of phosphate or calcium balance was negative. The following histopathological findings were observed: non-calcified epidermoid cysts (3 patients), calcified epidermoid cysts (1 patient) and nodular calcifications without epithelial or glandular structures (1 patient). Subtotal excisions of the scrotum wall using tumescent anaesthesia were performed in all patients without any significant complications. Cosmetic results were excellent. No new lesions were observed during the 1-year follow-up period.

CONCLUSIONS

Most cases of multiple nodules of the scrotum are due to non-calcified epidermoid cysts. The term scrotal calcinosis is therefore probably abusively used by many authors. Some cases of nodular calcifications may be due to dystrophic calcification of epidermoid cysts, but calcifications may also occur without any visible epithelial or glandular structure. Subtotal excision of the scrotum wall is a safe and effective surgical procedure to treat multiple nodules of the scrotum. Cosmetic results are excellent and recurrences are rare.

[Melanoma prevention in Switzerland: where do we stand?]

Over the last 50 years, skin cancer rates (particularly melanoma) have markedly increased in Caucasian populations. Switzerland, with some 1,600 cases of, and 220 deaths from, malignant melanoma per year has among the highest rates in Europe. This public health issue, affecting relatively young people, has led to primary and secondary nationwide prevention campaigns being carried out for nearly 20 years. Observed changes in sun protection knowledge and attitudes have yet to impact on incidence trend. Early detection has resulted in a large increase in rates of thin melanoma with little change in rates of thick melanoma. Mortality has levelled off and a recent decrease, especially in women, cannot be ruled out. The efficiency of prevention campaigns should soon become more blatant if current efforts persist.

Sirolimus-Induced Acneiform Eruption

Sirolimus is a new immunosuppressive agent used to prevent rejection in renal allograft recipients in order to reduce the need of potentially nephrotoxic calcineurin inhibitors (cyclosporine, tacrolimus). The cutaneous side effects of sirolimus are not well known and they may have been underestimated. We report 2 cases of follicular acneiform eruptions induced by sirolimus in renal allograft recipients. This dermatologic complication was severe and difficult to treat, and resolved only after discontinuation of sirolimus.

Severe Pustular Eruption Associated with Imatinib and Voriconazole in a Patient with Chronic Myeloid Leukemia

Imatinib is a specific and potent inhibitor of the BCR-ABL tyrosine kinase. Several clinical trials have demonstrated the efficacy of imatinib in chronic myeloid leukemia. Adverse cutaneous reactions induced by imatinib are frequent and may be dose related. We report a case of an unusual pustular eruption in a patient with chronic myeloid leukemia, who received high doses imatinib for blast crisis and later voriconazole for invasive pulmonary aspergillosis. At the time of his skin eruption, elevated plasma levels of imatinib were recorded. Imatinib is primarily metabolized by the cytochrome CYP3A4. Voriconazole is a cytochrome CYP3A4 inhibitor and can lead to high plasma levels of imatinib. This case suggests that severe drug reactions to imatinib may be related not only to imatinib doses, but also to elevated plasma drug levels resulting from pharmacokinetic interactions. The monitoring of imatinib plasma levels may be of help for identifying patients at risk for severe toxicity.

[Diagnosis and treatment of onychomycosis]

Onychomycosis are the more prevalent nail infections. They may be caused by dermatophytes (Tricophyton rubrum and T. mentagrophytes) as well as by Candida species and a number of other moulds. Laboratory confirmation of a clinical diagnosis of onychomycosis should be obtained before the beginning of oral treatment, because of the long periods of treatment that are usually required, the high costs of such treatments, and the potential side effects of the drugs. However, terbinafine, itraconazole and fluconazole are effective against the dermatophytes in nail. Moulds infections of nails more seldom respond to antifungal therapy.

Use of duplex ultrasonography in the treatment of thromboangiitis obliterans with iloprost

We present a 34-year-old patient with digital necrosis due to thromboangiitis obliterans. He was successfully treated with iloprost, a prostaglandin analogue. Duplex ultrasonography was performed during the perfusion of iloprost to optimize the doses and the treatment duration. A complete revascularization was observed after 10 days. Iloprost perfusions were stopped, and a slow regression of the necroses was observed in the subsequent days. With the use of duplex ultrasonography, unnecessary high doses of iloprost and long periods of treatment can be avoided reducing side effects and treatment costs.

Giant fibrokeratoma of the heel

We describe a 77-year-old patient with a giant acquired fibrokeratoma on the heel. The size and the localization of the tumor was unusual. Simple shave excision was curative.

Quantitative assessment of cell viability and apoptosis in cultured epidermal autografts: application to burn therapy

Cultured epidermal autografts (CEA) have been used in the treatment of burns for almost two decades but the clinical results are still inconsistent. In a group of 37 patients with extensive burn wounds admitted to the University Hospital of Lausanne, CEA take ranged between 10 and 100% with a mean of 65%. To investigate CEA efficacy in burns, twelve CEA preparations were tested for their biological properties with particular emphasis on the balance between cell viability and apoptosis. Apoptosis was evaluated by in situ end-labeling (TUNEL), detection of DNA fragments in CEA extracts and analysis of caspase-3 activity. All CEA samples displayed a high cell viability (> 90%) and a low apoptosis rate (< 6%). However, several biological parameters including the activity of transglutaminase showed wide interindividual variability suggesting that CEA therapeutic efficacy could be partly determined by intrinsic biological factors.

Prevention campaign against skin cancer

BACKGROUND

The melanoma incidence has increased over recent decades. Educational campaigns aim to encourage protection from the sun and early detection of melanoma.

METHODS

During a campaign in Switzerland, information on risk factors, sun protection and melanoma prevention was distributed. 10987 people completed a questionnaire regarding risk factors, and 2746 people were examined by a dermatologist.

RESULTS

Men had a higher risk as assessed by skin type, ultraviolet exposure, family history, number of moles and sunburns during childhood. Changes in moles were reported significantly more often by people with: (1). a positive family history (p < 0.0001); (2). multiple moles (p < 0.0001), and (3). sunburns during childhood (p < 0.0001). A precancerous or cancerous condition was suspected in 16% of individuals examined.

CONCLUSION

Early detection of melanoma can be achieved by this type of campaign. Primary prevention is a long-term approach and educational efforts targeting risk groups must be continued.

Radiotherapy of skin tumors

The incidence of cancers of the skin is increasing, as is life expectancy among most of the population. Besides surgery, all skin cancers can be treated with radiotherapy, with excellent results. Unfortunately, both less training and less equipment are available than earlier, which means that dermatologists also have less experience in this field. We would like to propose radiotherapy for medium-sized or larger lesions, especially on the face in elderly people. Good indications are keratoacanthomas, extensive actinic keratoses, Bowen's disease including erythroplasia of Queyrat, basal cell and squamous cell carcinomas, but also lentigo maligna and lentigo maligna melanomas. These tumors can be treated in a curative way. Excellent results of palliative X-ray therapy are achieved in Kaposi's sarcoma and in lymphomas, and also in Merkel cell tumors. After 100 years of treatment of skin cancers by radiotherapy, dermatologists should not forget that if appropriate principles are followed and precautions are taken, X-ray treatment is still a safe and effective method.

Wegener's granulomatosis: description of a case where cutaneous involvement was correlated with elevation of the c-ANCA titer

Wegener's granulomatosis is a systemic disease characterized by necrotizing granulomas and vasculitis involving the upper and lower respiratory tract as well as the kidneys. Cutaneous manifestations consist mainly of papules or papulonecrotic lesions. c-ANCA are known to be a valuable adjunct for the diagnosis and follow-up of Wegener's granulomatosis with systemic involvement. We report the case of a 49-year-old man with Wegener's granulomatosis who developed two relapses of the disease with cutaneous manifestation and who presented with concomitant elevation of the c-ANCA and more precisely the subset PR3-ANCA during the acute phase of the disease.

Cutaneous plasmacytosis: an unusual presentation sharing features with POEMS syndrome?

Cutaneous plasmacytosis is a recently described skin disorder consisting of brown to red papules and nodules containing polyclonal plasmacytes. In this particular case, leg ulcers developed but also a diffuse patchy hyperpigmentation coexisting with a primary hypothyroidisim. The last two signs have only been described to date in POEMS syndrome, which is linked to monoclonal plasmacytic proliferation, and might suggest an overlap between these two entities.

Pharmacokinetic behaviour of sublingually administered 8-methoxypsoralen for PUVA therapy

BACKGROUND

Conventional oral PUVA therapy is hampered by large inter- and intraindividual variations in the bioavailability of 8-methoxypsoralen (8-MOP), caused by its low solubility in the gastrointestinal juices and large interindividual differences in hepatic metabolism rate (hepatic first pass).

AIMS

New galenic formulations of 8-MOP based on solid dispersions, suspensions, and saturated solutions containing penetration enhancers were developed for sublingual administration, a drug delivery route which avoids the hepatic first pass metabolism.

METHODS

Solubility properties of 8-MOP were tested in 22 potential penetration enhancers and solubilizers. Following preliminary in vivo tests of 13 sublingual 8-MOP formulations, five were administered to groups of volunteers at a nominal dose of 0.6 mg/kg body weight: two solid dispersions based on PEG 1540 (with and without Xylitol); a solution in Labrasol (glyceryl and PEG-8 caprylate/caprate), PEG 400, Transcutol (ethoxydiglycol) (1:1:1); a micronized suspension in sorbitol, water, ethanol, propylene glycol (ca. 3:1:1:5 w/v); and Oxsoralen capsules. Pharmacokinetic behaviour of 8-MOP was examined in serum; samples were analysed by HPLC. Photosensitivity was measured in seven subjects.

RESULTS

The peak of maximum 8-MOP concentration in blood was sharp, rapid and reproducible: tmax of 8-MOP in blood averaged 23+/-3 min, independent of the particular formulation. Cmax was higher when 8-MOP was presented in dissolved form (solution and capsule formulations, 85+/-29 and 85+/-35 ng/ml, respectively) and lowest with the suspension (42+/-15 ng/ml). Photosensitivity peaked reproducibly at 45 min. post dosing.

CONCLUSIONS

Sublingual PUVA therapy is suitable for patients with skin types I and II, in particular patients who are less suitable candidates for standard PUVA therapy (due to hepatic, renal, or cardiac insufficiency) or who have experienced side effects with standard PUVA.

Expression of Melan-A/MART-1 antigen as a prognostic factor in primary cutaneous melanoma

In this study we assessed the expression of the Melan-A/MART-1 antigen by immunohistochemistry using monoclonal antibody A103 in 73 primary cutaneous melanomas and its correlation with tumor staging and patient survival. Melan-A/MART-1 was expressed in 90% of primary tumors, with loss of expression increasing with Breslow thickness. Kaplan-Meier analysis demonstrated a significantly reduced disease-free interval and overall survival rate for patients not expressing this antigen. The poor prognosis of such patients was even worse for those presenting with a primary melanoma and a Breslow thickness of > or = 1 mm. Thus, Melan-A/MART-1 is not only a useful and specific additional marker for the diagnosis of primary cutaneous melanoma, but it may also help refine the prognosis of patients with malignant melanoma.

Abnormal balance between proliferation and apoptotic cell death in fibroblasts derived from keloid lesions

A new culture model was developed to study the role of proliferation and apoptosis in the etiology of keloids. Fibroblasts were isolated from the superficial, central, and basal regions of six different keloid lesions by using Dulbecco's Modified Eagle Medium containing 10% fetal calf serum as a culture medium. The growth behavior of each fibroblast fraction was examined in short-term and long-term cultures, and the percentage of apoptotic cells was assessed by in situ end labeling of fragmented DNA. The fibroblasts obtained from the superficial and basal regions of keloid tissue showed population doubling times and saturation densities that were similar to those of age-matched normal fibroblasts. In contrast, the fibroblasts from the center of the keloid lesions showed significantly reduced doubling times (25.9 +/- 6.3 hours versus 43.5 +/- 6.3 hours for normal fibroblasts) and reached higher cell densities. In long-term culture, central keloid fibroblasts formed a stratified three-dimensional structure, contracted the self-produced extracellular matrix, and gave rise to nodular cell aggregates, mimicking the formation of keloid tissue. Apoptotic cells were detected in both normal and keloid-derived fibroblasts, but their numbers were twofold higher in normal cells compared with all keloid fibroblasts. To examine whether apoptosis mediates the therapeutic effect of ionizing radiation on keloids, the cells were exposed to gamma rays at a dose of 8 Gy. Under these conditions, a twofold increase in the population of apoptotic cells was detected. These results indicate that the balance between proliferation and apoptosis is impaired in keloid fibroblasts, which could be responsible for the formation of keloid tumors. The results also suggest that keloids contain at least two different fibroblast fractions that vary in growth behavior and extracellular matrix metabolism.

Pemphigus vulgaris occurring simultaneously on a recent and an old surgical scar due to a Koebner's phenomenon

Pemphigus vulgaris is an autoimmune bullous disorder involving the skin and sometimes the mucosa. Koebner's phenomenon is encountered when the typical features of a dermatosis are observed on a part of the skin previously subject to friction or trauma. A few cases of pemphigus vulgaris developing after damage to the skin and especially scars have been described. To the best of our knowledge, we report the first case where typical lesions of pemphigus vulgaris appeared simultaneously on a recent and an old scar as the sign of the reactivation of the disease.

[Muckle-Wells syndrome: 4 cases in three generations]

BACKGROUND

Muckle-Wells syndrome is a hereditary condition with variable penetrance. The main manifestations are urticarial rash, malaise in the evening, joint pain, perception deafness and renal amylosis.

CASE REPORT

We describe a family with 4 affected members in 3 successive generations. Clinical expression was variable.

DISCUSSION

Despite the absence of renal amylosis in our patients, this family presented the syndrome described by Muckle and Wells in 1962. As for other cases reported in the literature, the clinical course was favorable with low-dose corticosteroid therapy.

Thromboangiitis obliterans: a rare cause of a reversible Raynaud's phenomenon

A 25-year-old woman with progressive Raynaud's phenomenon and digital necrosis is presented. Systemic sclerosis and other connective tissue disorders as well as atherosclerosis and arterial emboli were excluded with appropriate laboratory examinations. Arteriography revealed multiple palmar and digital occlusions with corkscrew-shaped vessels. Based on these characteristic arteriographic and clinical findings, the diagnosis of thromboangiitis obliterans was finally retained. With intravenous perfusion of the prostacyclin analogue iloprost (2 ng/kg/min, 6 h daily during 21 days), a complete healing of Raynaud's phenomenon and of the digital necrosis was observed. There was no recurrence during the 1-year follow-up. This observation demonstrates that thromboangiitis obliterans is a potential reversible cause of severe Raynaud's phenomenon in young women even in the absence of lower limb involvement. Early recognition is important to avoid irreversible complications such as loss of digits.

Silicone granuloma

Since silicone has rapidly become one of the most commonly used prosthetic materials in the last 30 years in modern medicine, we have consequently been witnessing more silicone-related disease. Especially after silicone breast implantation, defects in the breast implant have led to serious complications, whereas complications of silicone prosthesis implantation in other body parts are less frequent. Here we present an unusual clinical presentation of a silicone granuloma in a patient with a 27-year history of a wide excision of a melanoma of the right lower extremity and subsequent soft-tissue reconstruction using a silicone device.

Bullosis diabeticorum in a newly discovered type 2 diabetes mellitus

Bullosis diabeticorum (BD), although a rare manifestation, is characteristic of diabetes mellitus. The exact origin of BD is unknown. We report another case of a 54-year-old man who developed a blistering lesion on his left leg. Histopathological examination revealed a microangiopathy with hyalinosis of the blood vessel walls.

Photodynamic therapy of superficial basal cell carcinomas using topical 5-aminolevulinic acid in a nanocolloid lotion

BACKGROUND

Photodynamic therapy (PDT) of superficial basal cell carcinomas using endogenous protoporphyrin IX generated by topically applied 5-aminolevulinic acid (5-ALA) is an innovative and clinically encouraging approach.

OBJECTIVE

This paper reports on the first results of an ongoing clinical study on photodynamic therapy of 55 basal cell carcinomas in 19 patients.

METHODS

Because of the chemical instability of 5-ALA, a novel nanocolloid lotion was developed. This formulation was applied to the lesions under occlusive dressing 6 h before irradiation with visible light from an unfiltered halogen lamp. Light-induced fluorescence was used to ascertain the superficial extension of the tumors. The response to the therapy was assessed by visual inspection and in 13 patients also by biopsies.

RESULTS

After a single treatment, 47 (85%) basal cell carcinomas showed a complete response at a follow-up time of at least 6 months. For the remaining 8 (15%) lesions, a partial response was observed, indicated by a marked reduction of the tumor size. The treatment modality without local anesthetics was well tolerated by all patients, with only slight discomfort during light irradiation.

CONCLUSION

Our results indicate that 5-ALA-PDT with our novel formulation, a nanocolloid lotion, is a highly effective and convenient therapy for the treatment of superficial basal cell carcinomas. Its use in the treatment of nodular tumors needs further investigations.

Comparison of 8-MOP aqueous bath and 8-MOP ethanolic lotion (Meladinine) in local PUVA therapy

BACKGROUND AND OBJECTIVE

Local PUVA (psoralen plus UVA light) is an effective outpatient treatment for patients with palmoplantar eczema or psoriasis. In this study, the efficacy, applicability and patient acceptance of two local forms of 8-methoxypsoralen (8-MOP) PUVA therapy were compared.

METHODS

The study design was a left-right comparison (n = 37): the left hand or foot was treated with (aqueous) 8-MOP bath PUVA whereas the right received (ethanolic) 8-MOP lotion PUVA. After 1 month, the more successful treatment was continued on both sides until lesions cleared.

RESULTS

Both therapies were effective and both useful for particular clinical applications: patients with erosive lesions and rhagades appreciated the gentleness of bath PUVA. Those with pustules or hyperkeratotic lesions appreciated the greater effectiveness of 8-MOP lotion PUVA. The total UVA dose and number of sessions to clearance were smaller with 8-MOP lotion. There was no difference in the length of the relapse-free period. Therapy nonresponders usually became apparent within the first 12 sessions.

CONCLUSIONS

The difference between bath PUVA and lotion PUVA can be described as 'gentle' versus 'strong' therapy. The better therapy depends on clinical indication.

Tinea capitis dermatophytes: susceptibility to antifungal drugs tested in vitro and in vivo

BACKGROUND

Tinea capitis is a worldwide-spread infection of the scalp caused by dermatophytes and is predominantly seen in children. The clinical manifestations range from mild scaling lesions to widespread alopecia or highly inflammatory suppurating lesions. Terbinafine and itraconazole seem to be promising therapies with shorter treatment durations than griseofulvin.

OBJECTIVE

The objective of the present study was to test the sensitivity of different species of dermatophytes towards terbinafine and itraconazole, and to compare the results with a retrospective study on 35 immunocompetent patients with tinea capitis who were treated with terbinafine (Lamisil(R)).

METHODS

Minimal inhibitory concentrations (MIC) were measured with an agar dilution method.

RESULTS

Each tested species of dermatophyte was sensitive to terbinafine and itraconazole at different concentration ranges. The MIC for terbinafine ranged from 0.005 to 0.5 microg/ml and for itraconazole from 40 to 80 microg/ml. Microsporum canis was the dermatophyte least sensitive to terbinafine. Our retrospective study showed that the cure rate was excellent for Trichophyton violaceum and T. soudanense, variable for T. mentagrophytes and poor for M. canis and M. langeronii.

CONCLUSIONS

(i) Regarding the results of susceptibility tests obtained with species involved in tinea capitis, clinical efficacy is not related to MIC measured in vitro; (ii) identification of the isolated dermatophyte from tinea capitis seems to be important for choosing the appropriate treatment.

Monosymptomatic Loa loa infection

We report the case of a 17-year-old student from Cameroon who presented an atypical, mono-symptomatic form of Loa loa infection, characterized only by rare subcutaneous movements of adult worms.

Norwegian scabies in a patient with acquired immunodeficiency syndrome

We report the case of a 42-year-old man with symptomatic HIV infection (C3 CDC stage) who presented widespread hyperkeratotic skin lesions diagnosed as Norwegian scabies. The CD4 count was 87 cells/mm3. The patient has been the source of a nosocomial outbreak (20 individuals affected). He was treated successfully with combined topical treatment (permethrin 5% cream plus keratolytic agents) and oral ivermectin.

Bullous and pruritic variant of disseminated superficial actinic porokeratosis: successful treatment with grenz rays

We describe a case of intensively pruritic and partially bullous disseminated superficial actinic prorokeratosis, with acute flare-ups. Histopathological examination showed the characteristic cornoid lamella and subepidermal blister formation in one biopsy. Grenz ray treatment resulted in a marked regression of the skin lesions and pruritus.

Photopatch testing: the 12-year experience of the German, Austrian, and Swiss photopatch test group

BACKGROUND

In 1984, the German, Austrian, and Swiss Photopatch Test Group was founded to standardize the photopatch test procedure and to investigate photoallergic reactions, as well as the epidemiology of photoallergy, in central Europe. Therefore in a first test period from 1985-1990, 32 test substances were applied on the backs of patients suspected to be photosensitive. After evaluation of these data, some substances were dismissed, and others were additionally integrated into the test tray. Thus a modified test tray comprising 26 test substances was used for the second test period (1991-1997).

OBJECTIVE

According to the standard photopatch test procedure defined in the first test period, the aim of this multicenter study was to apply compounds from the modified second test tray to a large group of photosensitive patients. After evaluation of the second test period (1991-1997), the outcome was compared with the results of the first period. On the basis of these results and influenced by concurrently published case reports, a third modified photopatch test tray has been established.

METHODS

After the application of a duplicate test tray for 24 hours, one test site was irradiated with 10 J/cm(2) UVA, and the other test site served as the control area. Readings were performed immediately and 24, 48, and 72 hours after irradiation. Test reactions were qualitatively graded according to a 4-point scale and classified by the investigators of the participating centers. In 49 participating clinics 1261 photopatch tests were performed. All data were subjected to computer-assisted analysis by using a specially developed software to classify all positive test reactions as plain contact or photoinduced reactions (nonspecific, toxic, or allergic photoreactions) and to define substance-specific reaction patterns.

RESULTS

In test period 1 data of 1129 patients were evaluated. From 2859 positive test reactions, 28.6% were excluded as plain contact reactions, 71.4% were found to be photoinduced reactions, and 3.8% were classified as photoallergic. In test period 2 data of 1261 patients were evaluated. One thousand four hundred fifteen positive test reactions were observed, and of these, 28.7% were excluded as plain contact reactions, 71.3% were classified as photoinduced reactions, and 8.1% were classified as photoallergic reactions. In both test periods nonsteroidal anti-inflammatory drugs, disinfectants, and phenothiazines represented the leading photoallergens in the evaluated central European region. By using computer-assisted reaction pattern analysis, substance-specific reaction patterns could be distinguished. These substance-specific reaction patterns comprised 4 main categories: the well-known decrescendo (phototoxic) and crescendo (photoallergic) reaction patterns, as well as a combined and a plateau pattern.

CONCLUSION

The test modification after the first test period led to a notably reduced number of positive (mainly nonphotoallergic and thus nonrelevant) test reactions per patient in the second test period (from 2.6 to 1.1). In contrast, the percentage of photoallergic reactions increased significantly from 3.8% to 8.1% of all positive test reactions. Test modifications after the first test period led to a remarkably improved specificity of the photopatch test. Furthermore, substance-specific reaction patterns observed in test period 1 were confirmed in test period 2.

Carcinogenic risk of bath PUVA in comparison to oral PUVA therapy

The potential carcinogenic risk of bath PUVA therapy was compared to that of systemic (oral) PUVA. An analysis of the epidemiological data on cancer risk following bath PUVA with trimethylpsoralen does not support the conclusion that bath PUVA per se is less carcinogenic than systemic PUVA with 8-methoxypsoralen (8-MOP). Pharmacokinetic studies indicate that both the concentration of 8-MOP in the target organ for PUVA carcinogenicity (skin) at the relevant time point (time point of UVA irradiation) and the extents of biological effects in the skin are comparable following bathwater or systemic 8-MOP administration. Furthermore, the therapeutic effects of PUVA arise from the same photochemical reaction mechanisms as do the carcinogenic effects. Theoretically, the ratio of (desired) cytotoxic versus (undesired) mutagenic effects could increase with increasing efficiency of the PUVA therapy itself. On the basis of the available evidence, it is concluded that all forms of PUVA therapy, independently of the route of 8-MOP administration, contribute to a small but dose-dependent increase in nonmelanoma skin cancer risk.

Co-regulation of melanin precursors and tyrosinase in human pigment cells: roles of cysteine and glutathione

Glutathione (GSH) and cysteine (CysH) have both been implicated in the biogenesis of the pheomelanin precursor 5-S-cysteinyldopa (5-S-CD). However, recent studies have shown that only CysH is transported across the membrane of isolated melanosomes, and that the positive regulation of CysH in pigment cells leads to an increased production of 5-S-CD. In the present study, the question was examined as to whether melanin precursors and tyrosinase could be coregulated by cellular thiols. To address this issue, the levels of CysH and GSH were varied in normal melanocytes and melanoma cells using buthionine sulfoximine (BSO), an inhibitor of GSH biosynthesis. Treatment with 50-100 microM BSO decreased GSH levels to less than 10% of control, and increased CysH levels between two- and five-fold in both cell types. Concomitant with this, an increase in the ratio of 5-S-CD to DOPA and a decrease in the pigment content of the cells were observed. The decrease in cell pigmentation was associated with strong decreases in tyrosine hydroxylase activity and 14C-melanin production. Only melanoma cells showed a modified tyrosinase isozyme pattern on Western immunoblots in response to BSO, while the mRNA expression of tyrosinase and TRP-1 were unchanged in both cell types. These results suggest that the balance between CysH and GSH, which is partly determined by the rate of utilization of CysH for GSH biosynthesis, regulates not only the levels of 5-S-CD and DOPA but also the melanogenic activity of pigment cells. Since DOPA functions as a cofactor in the monophenolase reaction of tyrosinase, it is proposed that the ratio of 5-S-CD to DOPA may be an important factor in the regulation of tyrosinase activity in situ.

Measurement of 5-methoxypsoralen and 8-methoxypsoralen in saliva of PUVA patients as a noninvasive, clinically relevant alternative to monitoring in blood

BACKGROUND

Monitoring of psoralen concentration and time-course in PUVA patients is vital for efficient PUVA therapy. Blood sampling is invasive and labour-intensive and thus unsuited for routine use and repeat measurements over the course of therapy.

OBJECTIVE

Psoralen pharmacokinetics in saliva were investigated and validated as a noninvasive, simple and biologically relevant alternative to measurements in blood.

METHODS

The time-course of psoralen concentration was measured in saliva and serum of volunteers and patients receiving PUVA or extracorporeal photopheresis therapy. The samples were analysed by high-performance liquid chromatography. Three commonly used oral psoralen preparations were tested: Psoraderm5 (5-methoxypsoralen; 5-MOP), Meladinine and Oxsoralen (both 8-methoxypsoralen; 8-MOP).

RESULTS

The pharmacokinetic parameter Cmax in saliva averaged 10% (range 6-20%) of the serum values for 8-MOP, and < or = 4% for 5-MOP. These concentrations correspond to the therapeutically relevant, non-albumin-bound fraction of psoralen in serum that is available to diffuse into the tissues. The parameter tmax in saliva and serum coincided, indicating that psoralens diffuse rapidly between the two compartments.

CONCLUSION

Monitoring of psoralens in saliva is a valuable, noninvasive alternative to measurements in serum, suitable for routine use. A series of five or six saliva samples is sufficient to determine tmax in a patient beginning photochemotherapy. To determine Cmax, three independent saliva measurements at t = tmax are recommended.

Pityriasis rosea is not associated with human herpesvirus 7

OBJECTIVE

To examine the proposed association between pityriasis rosea and human herpesvirus 7 (HHV-7).

DESIGN

A retrospective cross-sectional survey.

SETTING

University medical center in Switzerland.

PATIENTS

Thirteen patients with pityriasis rosea and 14 persons with normal skin (control subjects).

MAIN OUTCOME MEASURES

Detection of HHV-7-specific DNA sequences and antigen (85-kd phosphoprotein [pp85]) by nested polymerase chain reaction and immunohistochemical analysis, respectively.

RESULTS

Human herpesvirus 7 DNA sequences and expression of the HHV-7-specific immunodominant pp85 antigen were found in 1 (8%) of 13 lesional skin biopsy specimens of pityriasis rosea. The prevalence of HHV-7 DNA sequences and antigens is even slightly lower in lesional skin of patients with pityriasis rosea than in clinically and morphologically normal skin of 14 control persons, in 2 of whom (14%) HHV-7 DNA sequences and antigens could be detected.

CONCLUSION

The low detection rate of HHV-7 DNA sequences and antigens argues strongly against a causative role for HHV-7 in the pathogenesis of pityriasis rosea.

Drug-induced linear IgA bullous dermatosis probably induced by furosemide

Linear IgA bullous dermatosis (LABD) is an autoimmune disease, characterized by linear deposition of IgA along the basement membrane zone. Drug-induced LABD is rare but increasing in frequency. A new case of drug-induced LABD associated with the administration of furosemide is described.

[Clinical aspects and pathology of melanoma]

The annual incidence of melanoma is continually increasing. Melanomas can easily be diagnosed because they are readily visible on the skin. The prognosis is excellent for melanoma when it is diagnosed in an early stage. The clinical diagnosis of melanomas is made by the simple A-B-C-D-E-rule. Clinically, we distinguish the following melanoma types by the order of frequency: the melanoma of the superficial spreading type (SSM), the melanoma with nodular type (NM), the lentigo maligna melanoma (LMM) and the acro-lentiginous melanoma (ALM). Other clinical subtypes of melanoma are congenital giant nevus and melanoma of the mucous membranes. With help of histogenesis, we can distinguish similar forms for melanoma of the SSM-type, melanoma of the NM-type, the lentigo maligna melanoma (LMM) and the melanoma of the ALM-type. In this case, it is preferable to use the terminology acanthotic-lentiginous melanoma since acro-lentiginous is the clinical expression and not a histopathological one. Further subtypes can be distinguished histopathologically such as the desmoplasic melanoma which has been recently described as melanoma from a dysplasic nevus as well as melanoma of the lichen cleanness type. Furthermore, due to histopathology other particular forms can be distinguished such as the melanoma of the nevus Spitz type and melanoma originating from a blue nevus. Most important for the histopathological report is the thickness of the melanoma in millimeters related to the Breslow index as well as the invasion level in the skin by the Clark classification since the melanoma thickness is the most important risk factor for the melanoma patient.

'Tubular' epithelioid cell nevus: a new variant of Spitz's nevus

The term Spitz's nevus refers to a large spectrum of nevi composed of spindle and/or epithelioid cells. We report on a hitherto undescribed tubular variant of a dermal epithelioid nevus, characterized by aggregates composed exclusively of cuboidal cells with the prominent feature of tubular or microcystic structures. Immunohistochemically, the epithelioid cells expressed melanocytic markers (S-100, NKI/C3) lacking markers for cytokeratin or carcinoembryonic antigen. The three-dimensional analysis of the lesions by confocal laser scanning microscopy revealed the structural configuration of tubular or microcystic empty spaces bordered by cuboidal nevus cells. This rare variant of epithelioid nevus is another example for the remarkable diversity of Spitz's nevi.