Medical, psychological and socio-economic implications of chronic hand eczema: a cross-sectional study.

BACKGROUND: Hand eczema (HE) is a common skin disease with major medical psychological and socio-economic implications. Onset and prognosis of HE are determined by individual as well as environmental factors. So far, most epidemiological data on HE have been reported from Scandinavian and recently German studies. OBJECTIVE: To investigate the characteristics and medical care of patients with chronic HE (CHE) in Switzerland, and identify risk factors. METHODS: In this cross-sectional study, data from patients with chronic HE were obtained by means of medical history, dermatological examination and patient questionnaires. Multiple logistic regression analysis was applied to identify risk factors for high severity and dermatology life quality index (DLQI). RESULTS: In seven dermatology departments, 199 patients (mean age 40.4 years, 50.8% female) with CHE (mean duration 6.6 years) were enrolled. Moderate to severe HE was reported by 70.9% of patients, and was associated with age <30 or >50 years, localization of lesions and pruritus. Because of the CHE, 37.3% of patients were on sick leave over the past 12 months, 14.8% had changed or lost their job. Practically all patients applied topical therapy, 21% were treated with alitretinoin, and 21% with psoralen plus UVA light (PUVA). The effects on the health-related quality of life was moderate to large in 33.7% and 39.4% of CHE patients, respectively. Factors associated with a high impact on DLQI (mean 9.7 ± 5.8) were female sex, lesions on back of the hands and pruritus as well as mechanical skin irritation and wearing gloves. CONCLUSION: In agreement with recent studies, the Swiss data demonstrate the high impact of CHE on medical well-being, patient quality of life and work ability. As it is associated with an intense use of health care services, high rate of sick leave, job loss and change, CHE may cause a high socio-economic burden.

Extensive annular verrucous late secondary syphilis.

We report an illustrative case of an apparently healthy 38-year-old man with a past history of alopecia universalis who developed extensive, slightly pruritic, infiltrated annular verrucous lesions of the scalp, perioral, lumbar, perianal and genital areas over a 6-month period. The combination of an unusual clinical presentation, positive syphilis serology and rapid response to penicillin therapy was consistent with a diagnosis of extensive annular and verrucous late secondary syphilis. We present this case to illustrate a rare and potentially misleading clinical feature of late secondary syphilis, a disease considered to be of the past but still present in today's practice.

Topical colchicine therapy for actinic keratoses.

BACKGROUND: The beneficial effect of topical colchicine therapy for actinic keratoses has already been described in 1968. OBJECTIVE: To confirm that the application of a 1% colchicine gel is a safe and effective treatment for actinic keratoses. METHODS: Twenty patients were included in a double-blinded protocol. They all had actinic keratoses on the scalp, most of which had been previously treated with 5-fluorouracil or cryotherapy. Ten patients applied twice daily on the forehead a hydrophilic gel (placebo group), while the other 10 where treated with the same gel containing 1% of colchicine (colchicine group). Erythema and efficacy were evaluated at each control on days 7, 30 and 60, with repetitive blood tests to exclude a possible systemic absorption. RESULTS: A complete healing of the solar keratoses was observed in 7 out of the 10 patients treated with 1% colchicine gel; these showed no recurrence after 2 months of follow-up. Burning and itching occurred only in the colchicine group after 2 or 3 days of application, with an inflammatory reaction on the areas where the gel was applied, while pustules and crusts were located specifically on the actinic keratoses. Repeated blood controls showed that there was no systemic absorption. CONCLUSIONS: This double-blind placebo-controlled study confirms the activity of colchicine for the treatment of actinic keratosis. A comparison with other topical treatments in terms of efficacy and practicability is needed.

Frey syndrome treatment with botulinum toxin.

The goal of this work is to present our results of the intradermic infiltration with botulinum toxin in patients with Frey syndrome. Sixteen hemifaces in 15 patients were studied. Gustatory stimulation was evoked by sucking on a slice of lemon while measurements were done on both hemifaces, with the normal side being used as a control. Skin temperature and color (erythema) were measured with a digital surface thermometer and a skin chromameter, respectively. Sweat quantity and surface were measured by using the previously described blotting paper and iodine-sublimated paper histogram methods, respectively. Testing was repeated 2 weeks after skin infiltration with botulinum toxin (dilution of 50 U/mL). The interinjection distances were 1 cm, and 0.1 mL (5 U) was infiltrated at each injection site. Frey syndrome complaints disappeared in all patients. Small residual amounts of sweat were measurable. The difference in sweat quantity before and after botulinum toxin infiltration was significant in every patient (P < 0.001). Skin temperature and color measurement gave inconclusive results. In conclusion, Frey syndrome treatment with botulinum toxin is an efficient and well-tolerated technique. Further work should address the optimal injection parameters.

Takayasu arteritis and cutaneous necrotizing vasculitis.

Takayasu arteritis (TA) is an inflammatory arteriopathy involving predominantly the aorta and its main branches. The disease evolves in two phases: a first, nonspecific inflammatory stage and a late 'pulseless' stage, in which complications related to arterial stenosis and aneurysm formation predominate. In both phases, skin manifestations, such as inflammatory nodules, erythema-nodosum- and pyoderma-gangrenosum-like ulcers, have been described. We report 2 patients with TA, who had cutaneous necrotizing vasculitis as presenting manifestation of the disease. A review of the literature revealed 8 similar cases. TA does not only involve large arteries, but also small blood vessels. The observation that in TA the inflammatory process of the large arteries affects regions of the walls supplied by the vasa vasorum, the anatomy of which bears resemblance to the cutaneous vessel system, suggests that primary involvement of small vessels contributes to the development of the clinicopathological features of TA. Knowledge of the skin manifestations associated with TA remains important for its diagnosis and prompt instauration of life-saving treatment.

Incidence of transient acantholytic dermatosis (Grover's disease) in a hospital setting.

BACKGROUND: Grovers's disease may be triggered by bed rest. METHODS: We have prospectively analyzed, over a 30-month period, all cases of transient acantholytic dermatosis (TAD) diagnosed in the context of a dermatological consultation for inpatients of a community hospital. RESULTS: A total of 28 cases of TAD were diagnosed within a total of 3,750 patients examined (0.8%). The mean age of patients with TAD was 66.7 years, and the male-to-female ratio was 1.8. In 83% of cases the length of hospitalization preceding TAD was 66.7 years, and the male-to-female ratio was 1.8. In 83% of cases the length of hospitalization preceding TAD exceeded 2 weeks, and in all cases there was an association with strict bed rest. No association with malignant disease or other specific pathologies was observed. CONCLUSION: Our results suggest that TAD, which is frequent in elderly patients within a hospital setting, is not paraneoplastic and favor the hypothesis of a sweat-related pathogenesis.

New objective and quantitative tests for gustatory sweating.

Two newly developed tests for gustatory sweating, providing both quantitative and topographic information, are presented. In both tests a paper stencil shaped to fit the complex anatomy of the parotid region is used. The blotting paper technique uses the difference in weight before and after gustatory stimulation to measure the amount of sweating. The iodine-sublimated paper histogram (ISPH) uses iodine sublimated office paper that changes colour when wet. The paper stencil is than digitized and a histogram algorithm applied to measure the area of sweating. A calibration of these tests with known and appropriate quantities of saline is presented.

Prevention of Frey syndrome during parotidectomy.

OBJECTIVE: To evaluate the incidence of Frey syndrome (auriculotemporal nerve syndrome) after parotidectomy with and without placement of a subcutaneous implant and to examine the relationship between different implants and postoperative wound complications (hematoma, seroma, salivary fistula). DESIGN: A prospective nonrandomized controlled trial. SETTING: A primary care and referral university hospital center. PATIENTS: All patients scheduled for parotidectomy from April 1994 through August 1998 were eligible. Seventy patients were enrolled (2 refused). All 70 patients were evaluated for wound complications. Sixty patients with a follow-up of more than 1 year were evaluated for Frey syndrome. INTERVENTION: The choice of implant was left to the individual surgeon: 24 patients had no implant; 7, lyophilized dura implant; 7, polyglactin 910-polydioxanone (Ethisorb) implant; and 32, expanded polytetrafluoroethylene (e-PTFE) implant. OUTCOME MEASURES: The incidence of Frey syndrome was evaluated (1) subjectively by history (clinical Frey syndrome) and (2) objectively by using 2 newly developed tests. Both hemifaces were tested, with the normal side being used as a control. RESULTS: Clinical Frey syndrome was present in 12 patients: 11 without implants (11/24 [53%]) and 1 with an implant (1/46 [2%]) (P<.001). Objective tests were positive in 24 patients: 16 (76%) of 21 without implants and 8 (20%) of 39 with implants (P<.001). In the implanted patients, the objective tests were positive in 71% (5/7) of those with lyophilized dura, 14% (1/7) of those with Ethisorb, and 8% (2/29) of those with e-PTFE implants (P<.001). Wound complications included hematoma in 5 patients (7%), seroma in 4 patients (6%), and salivary fistula in 15 (21%). Salivary fistula occurred more frequently with Ethisorb (57%) and e-PTFE (25%) implants (P = .04). CONCLUSIONS: In patients without an implant, the incidence of Frey syndrome is 50% for subjective and 80% for objective evaluation. In patients with an implant, these incidences are 3% and 10%, respectively. Some implants are associated with a higher incidence of salivary fistula.

Adverse skin reactions to low molecular weight heparins: frequency, management and prevention.

Adverse skin reactions to low molecular weight heparins (LMWH) are rare even though their true incidence is probably underestimated because of under-reporting. These reactions may occur as an urticarial rash, presumably due to local histamine release or have the features of a classic type I immediate hypersensitivity reaction. They can also present as skin necrosis often due to vasculitis (type III Arthus reaction) or heparin-induced thrombocytopenia. Erythematous, well circumscribed lesions without necrosis are usually secondary to a delayed type IV hypersensitivity reaction. Although most LMWH-induced skin lesions are benign, treatment should be discontinued. In type I reactions or in the presence of skin necrosis with or without heparin-induced thrombocytopenia, the LMWH should be replaced by an alternative medication such as danaparoid sodium or hirudin. Platelet counts should be monitored to diagnose heparin-induced thrombocytopenia. In a type IV delayed hypersensitivity reaction, in the absence of severe, extensive, life-threatening mucocutaneous manifestations, a first-line pragmatic approach consists, in our view, of replacing the particular LMWH with another one. If the skin symptoms do not improve, cutaneous tests may help detect the presence of a cross-reactivity between the available preparations of LMWHs and danaparoid sodium. In the presence of a negative subcutaneous provocation test, the compound can be used with little risk. If all types of LMWH and danaparoid sodium are positive in skin testing, mechanical prevention or oral anticoagulants should be used, and intravenous injections of any kind of heparin should be avoided because of the potential risk of anaphylactic shock. Alternatively, hirudin might be administered but experience with this compound is still very limited. Prevention is only possible in type IV hypersensitivity skin reactions, by avoiding long term LMWH therapy, particularly in middle-aged, obese women and during pregnancy. In these patients, oral anticoagulation should be preferred, whenever possible. In conclusion, though rare, skin reactions to LMWH may have important consequences which can be reduced by rapid diagnosis and appropriate management.

Influence of metoclopramide on the pharmacokinetics of 8-methoxypsoralen.

BACKGROUND: Previous studies have shown important inter- and intraindividual variations in bioavailability of 8-methoxypsoralen (8-MOP) under the influence of factors that are not yet known with certainty. However, they seem to be independent of age, sex and concomitant retinoid administration for RePUVA whereas the influence of diet remains controversial. OBJECTIVE: The purpose of this study was to investigate a possible effect of metoclopramide on the bioavailability of 8-MOP since these drugs are frequently combined to prevent nausea, a common side effect of systemic 8-MOP. METHODS: After a standard breakfast and the ingestion of 8-MOP plasma kinetics of 8-MOP were assessed in 6 healthy volunteers at 0, 1, 1.30, 1.45, 2, 2.15, 2.30, 3 and 4 h after drug ingestion. This procedure was repeated 3 weeks later by associating metoclopramide with 8-MOP. Plasma determinations of 8-MOP were performed using high-pressure liquid chromatography. RESULTS: Time and peak value of maximum plasma 8-MOP concentrations (Tmax, Cmax) ranged from 1 to 3 h and from 124 to 540 ng/ml, respectively. Individual values of the area under the curve of time-related 8-MOP concentration were between 284 and 1,158 ng-h/ml. Concomitant intake of 8-MOP with metoclopramide did not significantly influence these 3 pharmacokinetic values. CONCLUSIONS: Our results confirm the important interindividual variability of the pharmacokinetics of 8-MOP. Associating 8-MOP with metoclopramide does not alter the pharmacokinetic values of 8-MOP and should not require any change in PUVA treatment.

Circulating skin-homing T cells in atopic dermatitis. Selective up-regulation of HLA-DR, interleukin-2R, and CD30 and decrease after combined UV-A and UV-B phototherapy.

BACKGROUND: As the cutaneous lymphocyte-associated antigen appears to detect circulating T cells that migrate to the skin in atopic dermatitis but not T cells that migrate to mucosal sites in allergic asthma and rhinitis, we investigated T-cell activation markers and CD30 on the cutaneous lymphocyte-associated antigen-positive circulating T-cell subset in atopic dermatitis to see whether these markers are different from those in normal controls and related to disease activity. DESIGN: Open study. SETTING: University referral center. PATIENTS: Twelve patients with atopic dermatitis and 12 healthy controls. INTERVENTION: Combined UV-A and UV-B treatment for 2 months. MAIN OUTCOMES MEASURES: Percentage of circulating cutaneous lymphocyte-associated antigen-positive T cells that express HLA-DR, interleukin-2 receptor, CD69, CD71, and CD30 (triple-color flow cytometric analysis). Clinical score, Dermatology Life Quality Index, pruritus score, and consumption of topical corticosteroids were determined. RESULTS: Increased relative numbers of cutaneous lymphocyte-associated antigen-positive T cells expressing HLA-DR, interleukin-2 receptor, and CD30 were found in patients with atopic dermatitis before treatment. Treatment with UV-A and UV-B was associated with clinical improvement and a decrease of levels of HLA-DR, interleukin-2 receptor, and CD30 in cutaneous lymphocyte-associated antigen-positive T cells. HLA-DR on cutaneous lymphocyte-associated antigen-positive T cells correlated significantly with the clinical score. CONCLUSION: Expression of HLA-DR and interleukin-2 receptor is a sensitive marker of disease activity in atopic dermatitis. Apart from giving information on disease activity in atopic dermatitis, the availability of skin-seeking T cells in the blood offers the opportunity to obtain further information on T cells that may have effector function in the skin.