Therapy of psoriasis in childhood and adolescence ‐ a German expert consensus

Psoriasis of childhood shows an annual prevalence of 0.71 % and accordingly has to be regarded as a frequent chronic inflammatory skin disorder of this age. The impact on the quality of life as well as development of the afflicted children and their parents is evident. On the other side, therapy is demanding with regard to the specific juvenile metabolism, physical development and skin penetration of topical drugs. Long‐term treatment at an early age has to be critically judged regarding the chronicity of the disease. Topical corticosteroids, alternatively dithranol may be used first‐line, followed by vitamin D derivatives. A combination with UV‐light, preferably UV‐B, has to be decided on an individual basis. Systemic treatment may be initiated in recalcitrant disease with methotrexate and cyclosporine where long‐term experience is available from juvenile rheumatology and transplantation medicine. Alternatively fumaric acid esters or retinoids are available. Rehabilitation procedures will help the children and their parents to cope with the disease and its treatment. The different treatment options are presented here as a German expert consensus, as clinical studies are hardly available and only a few therapeutics are licensed for this age. In any case the therapy has to be individually planned and decided together with the patients and their parents to gain maximal safety, comfort and success.     

S1‐Leitlinie zur UV‐Phototherapie und Photochemotherapie

Die heilsame Wirkung des Sonnenlichts war teilweise schon im Altertum bekannt und fand in der zweiten Hälfte des 19. Jahrhunderts wieder zunehmend Beachtung. Den Beginn der modernen Phototherapien markiert die Entwicklung einer Apparatur zur ultravioletten Bestrahlung der Hauttuberkulose durch Finnsen zu Beginn des zwanzigsten Jahrhunderts. Zur Therapie von Hauterkrankungen finden beinahe ausschließlich die spektralen Bereiche unterhalb des sichtbaren Lichtes (ultraviolett) Anwendung. Seit den 1970er Jahren stehen zunehmend leistungsfähige künstliche Strahlenquellen bereit für die Therapie mit UVB, UVA und die Kombination von UVA mit Photosensibilisatoren (Photochemotherapie). Hohe strukturelle und prozedurale Qualitätsstandards sind unabdingbare Voraussetzung für die Durchführung einer gleichermaßen wirkungsvollen wie auch sicheren Phototherapie. Die Leitlinie formuliert den aktuellen Konsens führender Experten auf dem Gebiet der Phototherapie in Bezug auf die Indikationen für die jeweiligen Therapieverfahren, deren Gegenanzeigen und Nebenwirkungen und insbesondere für die Wahl der korrekten Dosis zu Beginn und im Verlauf einer Therapie sowie das Management von Nebenwirkungen.     

DRGs in der Dermatologie: Ergebnisse des DRG‐Evaluationsprojektes der Deutschen Dermatologischen Gesellschaft

Background: The implementation of a DRG system in Germany – voluntarily since January 1^st, 2003, and obligatory after January 1^st, 2004 – has led to uncertainty, particularly in the hospitals. There are fears that current well‐accepted German diagnostic and therapeutic services may not be properly financed by the new system. In response, the German Dermatologic Society (DDG) in cooperation with the DRG Research Group of the University Hospital Muenster and the German Medical Association carried out a DRG evaluation project in order to investigate the medical and economic homogeneity of the case groups. Patients and methods: 19,403 dermatological cases from 19 hospitals – ten university hospitals and nine non‐university hospitals – were collected over a period of four months and then evaluated with regard to their performance, length of stay and cost homogeneity. Results: The data provided the background needed to indicate suspected potential deficiencies for mapping dermatology cases within the German DRG system. Based on the data 10 modifications were formulated and submitted to the InEK by the deadline of March 31^st, 2003. Conclusions: The results of the DRG Evaluation Project show that the G‐DRG‐Variant Version 1.0 does not offer the necessary possibilities of differentiation to map the broad spectrum of various dermatology services in Germany.     

A sensitive gas chromatography-mass spectrometry assay reveals increased levels of monohydroxyeicosatetraenoic acid isomers in human plasma after extracorporeal photoimmunotherapy and under in vitro ultraviolet A exposure

Extracorporeal photoimmunotherapy (photopheresis) is a highly effective therapy in the treatment of various disorders. Although extracorporeal photoimmunotherapy has been successfully used for more than 10 y, its mechanism of action is still unclear. The formation of reactive oxygen species have been implicated in extracorporeal photoimmunotherapy, but malonyl dialdehyde as a marker of systemic lipid peroxidation did not increase significantly during treatment. To investigate further the involvement of reactive oxygen species in extracorporeal photoimmunotherapy, we have introduced a highly sensitive negative ion gas chromatography-mass spectrometry based method for quantitating oxygenated arachidonic acid isomers (hydroxyeicosatetraenoic acids) in plasma samples of patients treated with extracorporeal photoimmunotherapy. In the plasma of healthy volunteers pmole amounts of 2-, 3-, 5-, 8-12-, and 15-hydroxyeicosatetraenoic acid were detected and we observed a dose-dependent augmentation in these metabolites when the blood was irradiated with increasing doses of ultraviolet A in the presence of the photosensitizer 8-methoxypsoralen. Analysis of plasma samples obtained from patients before and after extracorporeal photoimmunotherapy revealed a characteristic increase in total hydroxyeicosatetraenoic acid levels, particularly of 5-hydroxyeicosatetraenoic acid which contributed 80% to the sum of all hydroxyeicosatetraenoic acid isomers. Chiral phase high-performance liquid chromatography indicated almost equal amounts of 5S- and 5R-hydroxyeicosatetraenoic acid suggesting that the majority of lipid peroxidation products are formed via nonenzymatic oxidation reactions.     

Systemic drugs with antipruritic potency

Despite the predominance of itch as a leading and distressing symptom in most of the dermatological and several systemic diseases, there is relatively little progress in understanding its pathophysiology. This is most likely the main reason for the limited number of satisfactory anti-itch treatments and the fact that even today various therapies have empirical but not evidence-based character. There are no specific antipruritic drugs on the market, but there are a high number of case reports and experimental investigations describing medications with antipruritic potency. It is therefore the aim of this article to briefly review the major systemic antipruritic drugs and give a short overview on the different types of pruritus and their possible systemic therapy.     

Borrelia burgdorferi-induced pseudolymphoma with pathogen cultivation in an HIV-1 positive patient

Cutaneous symptoms and skin diseases are common findings in almost all HIV-1-positive patients. In many cases the clinical presentation and course of the skin diseases are atypical, and occasionally the development of the appropriate circulating antibodies is lacking or impaired. In this report we present a patient seen in our multidisciplinary outpatient clinic for HIV patients. This patient had a Borrelia burgdorferi infection with an unusual course. The acute inflammatory phase of the arthropod reaction was maintained over a period of 9 months with development into pseudolymphoma showing unusual cytological characteristics. Immunohistological evaluation revealed an almost complete lack of T-helper and Langerhans cells, but an increased number of activated cytotoxic cells with class II antigen expression. A marked serological response was observed on IgG-ELISA and in the IgG-immunofluorescence test. Borrelia burgdorferi was cultured in vitro from a skin biopsy of the involved area. To our knowledge this is the first reported case of skin borreliosis in an HIV-1-positive patient.     

Investigation of annexin V binding to lymphocytes after extracorporeal photoimmunotherapy as an early marker of apoptosis

BACKGROUND: Induction of programmed cell death is assumed to be a possible effect of extracorporeal photoimmunotherapy (ECPI). OBJECTIVE: In the present study lymphocytes of patients with cutaneous T cell lymphoma undergoing ECPI were investigated for early apoptotic events. METHODS: Annexin V, known for its selective affinity to phospholipids, was used to detect early phases of apoptosis. Simultaneous staining with propidium iodide binding to DNA allowed detection of late apoptotic/necrotic cells. RESULTS: At 1 h after ECPI, an increase in early apoptotic cells was found indicating a direct effect of ECPI. At 20 h after each ECPI session, a delayed increase in the number of apoptotic lymphocytes was observed in early apoptotic annexin-stained cells and in late apoptotic cells, whereas in nonirradiated cells no remarkable changes were found. Apoptosis was confirmed by altered light scattering properties and DNA fragmentation. CONCLUSION: The apoptotic cell death of reinfused lymphocytes is supposed to be a therapeutic effect of ECPI.