[Current aspects of pain management during and after dermatologic surgery]. / Aktuelle Aspekte zum Schmerzmanagement während und nach dermatologischen Operationen.

The project "Pain-free Hospital" was the first attempt to improve the level of postoperative care by standardizing pain therapy standards (concepts) in the individual surgical disciplines. Dermatosurgery is no exception. In addition to drug therapy, it is also important to consider biopsychosocial aspects of the symptom pain, as this is the only way to prevent chronification of acute pain in the further course of a disease. Drug therapy should not only be adapted to the classic WHO system (only considering pain intensity), but should also address aspects of pain quality. In this article, we discuss these aspects in more detail and present our treatment concept for dermatosurgery.

Retrospective 8-year analysis of negative pressure wound therapy in dermatosurgery: a single-centre experience.

BACKGROUND: Negative pressure wound therapy (NPWT) is an established treatment modality in dermatologic surgery, but proof of evidence for efficacy is inconclusive. PURPOSE: To evaluate patient characteristics, treatment modalities and outcomes in a single dermatosurgery centre with NPWT applied over chronic and acute surgical wounds. METHODS: Of all surgical patients between 2008 and 2015, we selected those who were treated and hospitalized due to NPWT for treatment of acute and chronic wounds. The medical records of 188 patients were retrospectively evaluated and statistically calculated. RESULTS: Method of surgical defect closure depends significantly on localization of the surgical defect, cardiovascular comorbidity and age. Hence, outcome depends significantly on the surgical situation that indexes NPWT, the underlying diagnosis and the vacuum system used, but is not associated with distinct treatment modalities or gender of the patients. Hospitalization significantly depends on the vacuum system used, surgical situation that indexes NPWT and underlying diagnoses. CONCLUSION: NPWT has a fixed role in distinct, well-defined clinical indications in dermatosurgery as the treatment of acute surgical wounds, fixation of skin grafts and treatment of skin substitutes, as well as an important treatment option for refractory, superinfected chronic wounds in dermatologic patients.

[Practice-oriented pain therapy in dermatology : Concept with special emphasis on pain quality]. / Praxisorientierte Schmerztherapie in der Dermatologie : Konzept mit besonderer Berücksichtigung der Schmerzqualität.

In order to avoid chronification of pain, appropriate treatment has to be started as early as possible. Inpatient dermatology patients not only suffer from old age and associated multimorbidities but also from characteristic pain due to distinct dermatological diseases. In many cases clinicians have little experience with specific pain treatment but instead have many concerns about how to deal with analgesics. So far chronic pain has been treated according to the pain ladder of the World Health Organization (WHO), which prioritizes the intensity of pain. This article presents an easily implementable concept of pain therapy with special emphasis on the quality of pain. This provides information on whether it is neuropathic or nociceptive pain, which can ultimately be differentially treated. The primary aim is to provide treating dermatologists with a concept to assist in the initiation of an efficient and correct pain therapy. This brief introduction of an individualized pain treatment can reduce the risk of chronification of pain, which can severely impair the quality of life particularly in dermatology patients and also the frequent stigmatization due to the dermatosis.

[A different kind of wrestler's ear]. / Das Ringerohr der etwas anderen Art.

We report the case of a 19-year-old patient who presented with recurrent circular and scaly skin changes. The patient reported wrestling as his main leisure activity. After an unsuccessful attempt at local antibiotic treatment, detailed dermatological work-up revealed the skin changes to be tinea corporis gladiatorum. According to dermatological guidelines for dermatophytosis, systemic treatment with fluconazole and local ointments containing ciclopirox olamine and ketoconazole were administered, which rapidly led to significant improvement.

[Contact allergic gastritis : Rare manifestation of a metal allergy]. / Kontaktallergische Gastritis : Seltene Manifestation einer Metallallergie.

Only a few cases of contact allergic gastritis in patients with nickel allergy have been reported in the literature. We report a case of probable contact-allergic gastritis in a 46-year-old woman. Clinical examination revealed lichenoid mucosal lesions of the gums adjacent to a bridge and crowns that had been implanted several weeks previously. Since implantation, the patient suffered from gastrointestinal complaints including stomach pain. Gastroscopy and histological investigation of stomach biopsies showed eosinophilic gastritis. Patch testing done under the diagnosis of contact allergic stomatitis showed positive reactions to gold sodium thiosulphate, manganese (II) chloride, nickel (II) sulphate, palladium chloride, vanadium (III) chloride, zirconium (IV) chloride, and fragrances. The crowns and the bridge contained gold, palladium, and zirconium, hence they were replaced by titan-based dentition. Shortly after replacing the artificial dentition, all gastrointestinal symptoms resolved spontaneously without further treatment. Delayed-type allergy to components in the artificial dentition seem to have caused the gastritis.

[Malignant head and neck melanoma : Part 1: Diagnosis and histological particularities]. / Maligne Melanome im Kopf-Hals-Bereich : Teil 1: Diagnostik und histologische Besonderheiten.

About 15% of all cutaneous melanomas develop in the head and neck region. Mucosal melanomas are rare and represent only 1% of all melanomas, however, most frequently, these are located in the nose, the paranasal sinuses and the oral cavity. Visual diagnosis and reflected-light microscopy are relevant for the evaluation of melanoma-suspect lesions. Histological investigation of resected tumors need special skills of the histopathologist and includes in case of high-risk tumors investigations of mutations in the tumor tissue concerning NRAS, BRAF and KIT. The risk of lymphatic or hematogeneous spread rises with increasing tumor thickness and the presence of further prognostic risk factors such as ulceration of the primary tumor or the presence of mitoses within the tumor.

[Malignant head and neck melanoma: Part 2: Therapy]. / Maligne Melanome im Kopf-Hals-Bereich: Teil 2: Therapie.

Resection margins of melanomas in the head and neck region often have to be adapted according anatomical circumstances. In the case of thicker primary tumors or after complete resection of locoregional lymph node metastases, adjuvant therapy with interferon-α can be performed; in some cases, adjuvant radiotherapy may also be indicated. In the case of inoperable lymph node or distant metastases, systemic treatment is required. Beside well-established mono- or polychemotherapy regimens, newer targeted therapies with BRAF inhibitors (vemurafenib, dabrafenib), mitogenic-activated protein kinase (MEK) inhibitors (trametinib, binimetinib, and cobimetinib), and kinase inhibitors (imatinib, sunitinib, nilotinib, dasatinib) are also available.

[Monosystemic, oligolesional Langerhans cell histiocytosis. A rare congenital dermatosis]. / Monosystemische, oligoläsionale Langerhans-Zell-Histiozytose der Haut. Eine seltene kongenitale Dermatose.

A five-day-old female infant presented with congenital red-livid papules and nodules on the head, chest, back and left arm. The nodule on the chest was ulcerated at birth. The pregnancy and delivery were uneventful. There was no history of birth trauma to account for the ulcerated lesion. The parents and the three older siblings were healthy without similar skin lesions. The skin biopsy showed in the deep layer of the dermis a multinodular, granulomatous histiocytic infiltrate. The histiocytic cells expressed S-100 and CD1a. There were additionally many eosinophils. The suspected diagnosis Langerhans cell histiocytosis was confirmed by the histologic results. The patient was referred to pediatric hematology-oncology where evaluation showed no evidence of systemic involvement. The clinical, radiological, sonographic and histological results led to the diagnosis of a congenital, monosystemic, oligolesional Langerhans cell histiocytosis of the skin. In addition to the case presentation, we review the current stand of knowledge of the pathogenesis, the clinical classification and the therapy of the Langerhans cell histiocytosis.

Expression of the T-cell regulatory marker FOXP3 in primary cutaneous large B-cell lymphoma tumour cells.

BACKGROUND: Primary cutaneous B-cell lymphomas (PCBCL) are subdivided into the aggressive form, primary cutaneous diffuse large B-cell lymphoma, leg type (PCLBCL, LT) and two subtypes of indolent behaviour (primary cutaneous follicle centre lymphoma and primary cutaneous marginal zone B-cell lymphoma). The difference in clinical behaviour can be explained by the tumour cell itself, or the lymphoma microenvironment including the antitumour immune response. OBJECTIVES: To investigate the presence of regulatory T cells (Treg), CD4+CD25+FOXP3+, in the microenvironment of PCBCL in correlation with clinical outcome. METHODS: Tumour specimens of 55 consecutive cases of PCBCL were blinded and analysed for FOXP3, CD4 and CD25 expression by immunohistochemistry. Confocal images were taken with a Leica SP5. Statistical analyses were performed to determine significance. The test was considered significant when P<0.05. RESULTS: The CD4 and FOXP3 expression as well as the CD4/FOXP3 ratio were significantly increased in PCBCL of indolent behaviour in contrast to PCLBCL, LT (P=0.0002 for CD4, P<0.0001 for FOXP3 and P=0.0345 for FOXP3/CD4 ratio). CD25 expression did not differ in the three groups (P=0.9414). Within the group of patients with PCLBCL, LT we identified a subgroup with FOXP3+ tumour cells as demonstrated by CD20/FOXP3 double stainings. Patients with FOXP3+ PCLBCL, LT tumour cells showed a better prognosis on Kaplan-Meier analysis. CONCLUSION: High numbers of Treg in the lymphoma microenvironment correlate with a better prognosis in PCBCL. In PCLBCL, LT the presence of FOXP3+ tumour cells is beneficial for prognosis suggesting that FOXP3 expression of PCLBCL, LT tumour cells might serve as a tumour suppressor.

[Disseminated infiltrated cutaneous pruritis]. / Disseminierte infiltrierte juckende Läsionen am Körper.

The diagnosis of scabies is clinically not always simple without the detection of mites. Histology can be difficult, particularly without clinico-pathologic correlation. [corrected] Even after adequate antiscabies treatment the dermatological symptoms and complaints can persist and necessitate an [corrected] intensive follow-up treatment. The case example described here underlines that in consideration of the multifaceted clinical appearance and the sometimes difficult detection of mites, scabies should always be considered as a differential diagnosis in cases of persistent pruritis.

[Frontal fibrosing alopecia with androgenetic pattern. A diagnostic challenge - a therapeutic problem]. / Frontale fibrosierende Alopezie mit androgenetischem Muster. Eine diagnostische Herausforderung - eine therapeutische Crux.

Diagnosis of scarring alopecia is a particular diagnostic and therapeutic challenge. Frontal fibrosing alopecia was first described by Kossard as a scarring alopecia characterized by progressive recession of the frontal-temporal hair margins leading to permanent alopecia. Primarily affected are postmenopausal women. A 56 year-old woman presented with fibrosing alopecia in a male-pattern distribution. Evaluation of medical history, clinical, dermoscopic and histopathological findings led us to the diagnosis of frontal fibrosing alopecia with additional androgenetic pattern. Other forms of scarring alopecia have to be considered as differential diagnoses. This case emphasizes that dermoscopy of the scalp should become an integral part of the diagnosis of scalp diseases.

[Reticulated teleangiectatic erythema after implantation of medical devices. An increasingly occurring phenomenon?]. / Retikuläre teleangiektatische Erytheme nach Implantation von elektrischen medizinischen Geräten. Ein an Häufigkeit zunehmendes Phänomen?

Reticulated telangiectatic erythema (RTE) is a rare skin reaction to extraneous materials. We present three cases in which asymptomatic persistent erythemas developed in the area of implantation after medical devices were inserted. Topical and systemic treatment did not improve the skin changes. Patch testing including applied materials showed negative results in all cases. Histological investigation of punch biopsy specimens showed moderate dilatated vessels and a slight lymphocytic infiltrate. Due to our findings and in synopsis with the clinical impression we diagnosed RTE. As RTE is asymptomatic in most cases, the devices need not be removed.

Lichen striatus and blaschkitis: reappraisal of the concept of blaschkolinear dermatoses.

BACKGROUND: Blaschkitis (BL) and lichen striatus (LS) are rare dermatoses occurring along the Blaschko lines of the skin with preferential occurrence in distinct age categories. Controversy exists regarding the pathogenesis and classification of BL and LS within the spectrum of blaschkolinear dermatoses. OBJECTIVES: To describe the clinicopathological characteristics of six cases of BL/LS with special emphasis on immunophenotyping the inflammatory infiltrate. Additionally, we review and critically discuss current concepts of the blaschkolinear dermatoses. METHODS: Skin biopsies from six patients with BL and LS were analysed retrospectively. The immunophenotypes of the inflammatory cells were determined and related to clinical features. RESULTS: The clinical characteristics of the diseases occurred equally in both genders and all ages. BL and LS had similar histopathological findings with respect to epidermal changes and composition of the inflammatory infiltrates. Characteristically, a lichenoid lymphocytic infiltrate with exocytosis of inflammatory cells and obvious alterations of the interface zone was observed. CONCLUSIONS: We characterize the two main blaschkolinear dermatoses BL and LS sensu stricto morphologically and open new insights into the pathogenesis of these diseases. We propose the concept of a wide spectrum of blaschkolinear dermatoses with BL and LS located somewhere within the spectrum. We do not think that it is helpful for clinicians to enlarge the spectrum of blaschkolinear diseases and to create numerous 'new' entities. Rather, our aim was to unify diseases with similar clinical and histopathological features and common genetic pathomechanisms underlying phenotypic variations.

Expression of CD30 antigen in superficial mycotic infections of the skin: a possible non-specific finding without clinical relevance.

Expression of CD30 is a distinct marker of lymphocytic activation, originally described in Reed-Sternberg cells of Hodgkin's disease. Recently, the first two cases in which CD30 was expressed in tissue samples derived from superficial cutaneous fungal infections have been reported. The objective of this study was to investigate the expression of CD30 in tinea corporis and to discuss the clinical relevance of CD30. Twenty-three skin biopsies from 23 patients with mycotic infections of the skin were analysed retrospectively. The immunophenotypic expression of CD30 was investigated. In the series investigated, some large CD30-positive cells located in the upper dermal infiltrate were noted in two of 23 biopsy specimens (8.7%). The existence of CD30-positive cells was independent of the density and composition of the accompanying inflammatory infiltrate. We showed that the expression of CD30 in dermatophytoses is not a consistent finding. Instead, as a sign of lymphocytic activation, CD30 expression is observed coincidentally in cutaneous fungal infections. Our data confirm the observation that CD30 antigen is expressed in a variety of benign and malignant skin disorders, including cutaneous fungal infections, probably as an epiphenomenon without clinical relevance.

Plaque-Like Sclerodermiform Localized Mucinosis Rapidly Responsive to Topical Tacrolimus.

We report the successful treatment of plaque-like sclerodermiform mucinosis using tacrolimus ointment topically. We present a 70-year-old male with a large chronic erythema and hardening of the nuchal skin and shoulder area. Subjective symptoms were a moderate pruritus and a rather disabling stiffness. A biopsy specimen revealed typical features of lichen myxedematosus. In a subsequent clinical examination, no associated illnesses such as hypothyroidism or gammopathy were found. Since no established therapy exists for this condition, and as there was a lack of response to potent topical glucocorticosteroids, tacrolimus 0.03% ointment was used off-label twice daily. Surprisingly, this resulted in a rapid, almost complete clearance of the skin within three weeks of treatment.

[Sudden growth of previously indolent scalp nodule]. / Plötzliches Grössenwachstum vorher indolenter Knoten am Capillitium.

Cylindromas are benign adnexal tumors with eccrine and apocrine differentiation. They may appear in combination with spiradenomas and trichoepitheliomas in patients with the Brooke-Spiegler syndrome. Malignant changes are rare; possible clues are ulceration, bleeding or sudden growth of the lesions. Cylindromas are often removed for cosmetic reasons. We present a case of scalp cylindromatosis in which a primary cutaneous adenoid-cystic carcinoma developed. The patient was treated with local surgical excision. As our case shows, histological evaluation is mandatory, even when the clinical diagnosis seems obvious.

[Gastric signet ring cell carcinoma presenting. An erysipelas-like cutaneous metastasis of the abdominal skin]. / Erysipelas carcinomatosum der Abdominalhaut. "Erstmanifestation" eines Siegelringzellkarzinoms des Magens.

A 71-year-old patient presented with diffuse and poorly circumscribed erythematous plaques of the abdominal skin, present for 5 months. Histology revealed a diffuse infiltration of the entire dermis with cytokeratin-positive signet-ring-cells. Subsequently, an extensive search for a primary adenocarcinoma uncovered a locally advanced signet-ring-cell gastric carcinoma. There were no metastases to other organs. This case shows the unusual clinical-diagnostic sequence of a patient with a signet-ring-cell-carcinoma of the stomach presenting with an erysipelas-like cutaneous metastasis of the abdominal skin.