Pruritus – Pathophysiologie,Klinik und Therapie – Eine Übersicht

Pruritus is an unpleasant sensory perception of the skin associated with the desire to scratch. As a physiological nociception, pruritus leads to the removal of harmful agents such as parasites and plants from the skin surface. More often, pruritus occurs as a severe and therapy‐refractory symptom of various underlying dermatological and systemic diseases. Comparable to chronic pain, chronic pruritus worsens the general condition and may lead to physical and psychological exhaustion. Until the 1990s, pruritus had been regarded as an incomplete pain sensation. Only recently, itch was defined as a separate, pain‐independent sensation with its own mediators, spinal neurons and cortical areas. These observations led to the development of new therapeutic modalities. This paper gives an overview of itch pathophysiology, clinical types and therapies.     

Malignes Melanom – Eine Betrachtung von Studenten der Humanmedizin

Malignant melanoma is a primarily cutaneous melanocytic tumour with increasing incidence responsible for 90 % of skin cancer mortality. Genetic predisposition has been identified as the most important risk factor, while UV is second in importance and can be avoided. New diagnostic methods include sentinel lymph node biopsy and the detection of tumour markers in blood. Furthermore, malignant melanoma shows an extraordinary resistance to therapy; at present the only cure lies in early excision of the primary tumour. Thus early recognition is of utmost importance. Experimental approaches, such as dendritic cell vaccination, have shown some effectiveness which must be confirmed in multicenter, randomised trials.     

Papillomatosis confluens et reticularis Gougerot Carteaud: erfolgreiche Therapie mit Minocyclin. Falldarstellung und Literaturübersicht

Summary: Confluent and reticulate papillomatosis is a diss‐eminated skin disease.
The lesions consist of flat papules which by confluence form a reticular pattern. The etiology is still unknown. This entity has been regarded both as a genetically determined defect of keratinization and as an abnormal response to colonization with microorganisms (Malassezia furfur and follicular bacteria). Most cases are sporadic. There is a gynaecotropy.
Treatment with topical and systemic imidazoles as well as with antibiotics was shown to be successful. However, the success was very variable. We report two cases which after 4 to 6 weeks of systemic treatment with minocycline (100 mg per day) show resolution. The literature on the treatment of papillomatosis confluens et reticularis is reviewed.     

Versorgung der Akne vulgaris in Deutschland – Patientenbefragung in einem bundesweiten Apothekennetzwerk

Background: No empirical “real world” data on the health care of patients with acne vulgaris in Germany currently exist. The objective of this study was to get an informative basis of health care of patients with acne vulgaris in Germany, taking into account both doctor‐prescribed medication and self‐medication. Patients and Methods: Surveying both medically and self‐treated patients, n = 504 patients with acne vulgaris were interviewed in 48 pharmacies nationwide. In addition to socio‐demographic data, the duration of illness, localization and therapy as well as patient‐relevant outcomes such as patient benefit, psychological strain and markers of compliance were evaluated. The participation and significance of individual treatment providers were also evaluated. Results: A large percentage of the patients found acne vulgaris to be burdensome. Despite the longstanding necessity of treatment and the chronic course of the illness, the treatment of acne vulgaris was deemed a rather satisfactory experience by most of those affected. Dermatologists were most frequently consulted for treatment. A great number of medicinal products were further acquired through self‐medication or after consulting with a pharmacist. The medically regulated therapies predominantly complied with the latest guidelines. Conclusions: Acne vulgaris is a burdensome, socio‐economically relevant illness, and dermatologists treat most cases in Germany. Surveying across a network of pharmacies offers a unique access to relevant treatment data. Selection effects, particularly by choice of doctors and self‐medication, were minimized.     

Therapie des Erysipels in Deutschland und Österreich – Ergebnisse einer Umfrage an deutschen und österreichischen Hautkliniken

Background: Erysipelas is a severe soft tissue infection usually caused by streptococci. The infection is restricted to the dermis and subcutaneous tissues. Treatment with antibiotics is essential. Many different therapeutic regimens are recommended, based mainly on empirical data and only partly proven by clinical studies. Material and methods: Our aim was to evaluate the treatment of erysipelas in Germany and Austria by means of a questionnaire and to derive treatment recommendations from this data. Results and conclusion: The majority of clinics treat patients with erysipelas as inpatients with intravenous antibiotics. The usual first line treatment is group G penicillin (80 %). Other choices include amino‐penicillins (11 %), cephalosporins (16.5 %) and anti‐staphylococcal penicillins (6.9 %) are used. As second line antibiotics macrolides (63.5 %), clindamycin (52.5 %), penicillins (18.5 %), cephalosporins (40 %) and fluoroquinolones (20.5 %) are mentioned. Carbapenems, tetracyclines, nitroimidazoles, glycopeptides, aminoglycosides, cotrimoxazole, fusidic acid and fosfomycin are used rarely. The median treatment duration is 10 days. Adjuvant measures are anticoagulation, non‐steroidal anti‐inflammatory agents, dressings, immobilization and treatment of local predisposing factors such as interdigital tinea.     

15 % Azelainsäuregel in der Behandlung der Akne. Zwei doppelblinde klinische Vergleichsstudien

Background: Topical measures are still the mainstay in the therapy of mild‐to‐moderate acne vulgaris. Azelaic acid 20 % in a cream formulation has been established as an efficacious and safe topical drug for 15 years. A new non‐alcoholic hydrogel formulation containing 15 % azelaic acid was clinically tested against two standard drugs – 5 % benzoyl peroxide (BPO) and 1 % clindamycin. Patients and Methods: In two independent, randomized, blinded comparative trials 15 % azelaic acid gel was clinically tested against 5 % benzoyl peroxide (BPO) gel in 351 patients and against 1 % clindamycin gel in 229 patients. The drugs were applied b. i. d. for 4 months. Results: Azelaic acid 15 % gel proved to be as effective as BPO and clindamycin with median % reduction of the inflamed lesion (papules and pustules) of 70 %, and 71 % respectively. The azelaic acid gel was well‐tolerated, the side effects (local burning and irritation) were distinctly less than with BPO but more pronounced than with clindamycin. Despite these side effects, the treatment was well‐accepted by the majority of patients. Conclusions: Azelaic acid gel is an effective topical monotherapy for mild‐to‐moderate acne vulgaris; its new gel form is an enrichment of acne therapy.     

TNF‐alpha‐Antagonisten in der Therapie der Psoriasis – Nutzen und Risiken

Summary: Anti‐TNF‐α agents including etanercept, a fusion protein of the p75 TNF receptor and IgG1 and infliximab, a chimeric human‐mowie monoclonal antibody. They have been approved for the treatment of rheumatoid arthritis and/or Crohn's disease. New understanding of the importance of the inlammatory cytokine TNF‐α in the pathophysiology of psoriasis led to the use in open‐label and randomized studies in patients with psoriasis and psoriatic arthritis. Although larger randomized trials are needed to confirm early results, both anti‐TNF‐α agents, have demonstrated activity in improving the signs and symptoms of psoriatic arthritis and psoriasis. Further investigations will fully elucidate the role of infliximab in these and other dermatological diseases.     

Drei Jahre Deutsche S3‐Leitlinie zur Therapie der Psoriasis vulgaris – Hat der Aufwand sich gelohnt?

The S3 (evidence‐based) psoriasis guidelines were an important milestone in German dermatology. Three years after their publication, a review and evaluation of their success is important. Since the publication of the guidelines, the quality of care of psoriasis patients has improved. The proportion of patients with a PASI above 20 in the general patient population has decreased, there are less days of work lost due to psoriasis, uncertainties in administering systemic therapies have been decreased and the proportion of patients with severe psoriasis receiving a systemic treatment has increased. The guidelines’ website as well as the original publication in the JDDG has been accessed more than 50,000 times. The guidelines’ discussion was continued even after its publication and in further publications from within the group a therapeutic algorithm, treatment goals and indicators for the quality of care have been developed.     

Wirksamkeit und Nutzen eines 5‐FU‐/Salicylsäure‐haltigen Präparates in der Therapie vulgärer und plantarer Warzen – systematische Literaturübersicht und Metaanalyse

Background: 1) Salicylic acid (SA) and 5‐Fluorouracil (5‐FU) are effective drugs in wart therapy. 2) In Germany, increasing data on the benefit and the economic efficiency of drugs at Level I of evidence‐based medicine are needed. Methods: Evaluation of the effectiveness and benefits of a drug combination containing 0.5 % 5‐FU and 10 % SA in the therapy of a) common and b) plantar warts in form of a two‐step procedure – 1. Systematic literature analysis, 2. Meta‐analysis of the randomised‐controlled studies (RCTs). Results: 1. The efficacy of 5‐FU/SA therapy was tested in a total of 625 patients (n = 8 RCTs) with common warts and 101 patients (n = 4 RCTs) with plantar warts. The therapeutic effect across all studies in common warts was 63.4 % response (complete healing) for 5‐FU/SA vs. 23.1 % for the 5‐FU‐free controls, respectively. In plantar warts, the response was 63.0 % vs. 11.0 %. 2. A meta‐analysis of n = 7 RCTs on common warts (n = 325 patients) showed a mean risk difference of 0.42 (CI 0.34 – 0.50, p < 0.05), thus a significant superiority of 5‐FU/SA over SA. A comparable result was also found for plantar warts. Conclusion: The combination of 5‐FU and SA is an effective and beneficial therapy for common and plantar warts.     

Erfolgreiche Therapie der fokalen epithelialen Hyperplasie (M. Heck) mit 5 % Imiquimod

Summary: Imiquimod belongs to the newly identified class of topical immunomodulators called imidazoquinolins. Their mechanism of action involves the stimulation of the innate and adaptive immunity via the induction of INF‐α, TNF‐α, and IL‐12 at the site of application. The resulting Th₁‐immune profile serves to treat viral infections as well as several forms of skin cancer. Besides the licensed indication of condyloma acuminata, common warts, mollusca, basal cell cancer, actinic keratoses and initial squamous cell cancer have been successfully treated in both immunocompetent and immunodeficient patients. We present the case of an 81‐year old lady who suffered from Heck's disease (focal epithelial hyperplasia) that was successfully treated after 3 applications of 5 % imiquimod under her upper gum prothesis.     

Sensibilisierung auf Teebaumöl in Deutschland und Österreich – Eine multizentrische Studie der Deutschen Kontaktallergiegruppe

Background and aim: Tea tree oil, a distillation product of the Australian tea tree (Melalence alternitolia) is increasingly used as an alternative remedy for various dermatological diseases. Tea tree oil contains several allergenic monoterpenes and sesquiterpenes. In this multicenter study it was evaluated, whether the increasing use of tea tree oil has lead to an increased frequency of sensitization in Germany and Austria which would justify its inclusion into the standard series. Patients and method: For patch testing a standardized tea tree oil was used, dissolved 5 % in diethylphtalate (DEP). Consecutive patients of 11 dermatological departments in Germany and Austria were tested. Readings were taken on day 2 and 3 according to the guidelines of the German Contact Dermatitis Research Group (DKG). Results: 5 % tea tree oil was positive in 36/3375 patients (1.1 %). Sensitization frequencies showed great regional variations and ranged from 2.3 % (Dortmund), 1.7 % (Buxtehude), 1.1 % (Essen), 0.7 % (Graz), to 0 % (Berlin, Vienna). 14/36 patients (38.9 %) also showed a positive patch test reaction to oil of turpentine. Conclusion: Our results show that tea tree oil is an important contact allergen for some centers. It should be tested, if medical history suggests its previous use. Considering the great regional differences in frequencies of sensitization its inclusion into the standard series is not recommended yet.     

Deutliche Einschränkung der Lebensqualität bei Patienten mit Pemphigus vulgaris: Ergebnisse der deutschen Bullous Skin Disease (BSD)‐Studiengruppe

Background: Pemphigus vulgaris is a potentially life‐threatening autoimmune disorder of the skin and mucous membranes characterized by antibodies against epidermal adhesion molecules. Clinically characteristic are painful chronic blisters or erosions of mucous membranes and skin. There are no published studies on the impact o this disease on quality of life. Patients and methods: This registration was performed within the scope of the German BSD (Bullous Skin Disease) study group, from November 1997 until January 2002. A total of 36 patients with the first diagnosis of pemphigus vulgaris were registered at the university hospitals of Dresden, Erlangen, Kiel, Mannheim, München and Würzburg. Thirty of the 36 (83 %) patients participated in the quality of life questionnaire utilizing the German version of ‘Dermatology Life Quality Index’ (DLQI) provided by A. Y. Finlay. The DLQI varies from 0 to 30 with an increased DLQI score indicating a decrease in quality of quality. Results: The overall DLQI total score of 10 ± 6,7 in the investigated pemphigus patients was significantly increased in comparison to other skin diseases. Conclusions: These results suggest that the DLQI can be a very useful additional outcome criteria for clinical studies with pemphigus vulgaris and in the treatment of these patients.     

Computer‐based Training in der Dermatoonkologie – erste Ergebnisse zum Vergleich elektronischer Lernprogramme mit Präsenzlehre

Background: Electronic media are increasingly used in medical education. The question arises whether tutorial programs are as effective as innovative face‐to‐face didactic formats. Methods: 26 students underwent a special dermatooncology course in an integrated undergraduate medical curriculum. One part of the content was acquired face‐to‐face with emphasis on team learning and mini‐lectures; the other part was presented as web‐based electronic computer‐based training objects. The performance of the students in a subsequent multiple choice test was evaluated. Results: In total, questions referring to computer‐based training contents were answered correctly in 90.4 ± 12.5 %, which was significantly superior to the questions referring to team learning in the face‐to‐face teaching format (80.6 ± 13.1 %; p < 0.001). There was, however, a significant correlation between both results for each individual student (r = 0.52; p < 0.01), but there was no correlation between the results obtained for computer‐based training or team learning on the one hand, and the overall performance of the individual student on the other. Conclusions: Though different contents were concerned, our study provides evidence that computer‐based training may be more efficient than face‐to‐face teaching using team learning to communicate dermatooncology contents in an undergraduate medical curriculum.