The three moments of skin cream application: an evidence-based proposal for use of skin creams in the prevention of irritant contact dermatitis in the workplace.

Contact dermatitis is one of the most common occupational diseases, with serious impact on quality of life, lost days at work and a condition that may be chronically relapsing. Regular prophylactic skin cream application is widely acknowledged to be an effective prevention strategy against occupational contact dermatitis; however, compliance rates remain low. To present a simple programme for skin cream application in the workplace with focus on implementation to drive down the rate of occupational irritant contact dermatitis, an expert panel of eight international dermatologists combined personal experience with extensive literature review. The recommendations are based on clinical experience as supported by evidence-based data from interventional studies. The authors identified three moments for skin cream application in the work place: (i) before starting a work period; (ii) after washing hands; and (iii) after work. Affecting behaviour change requires systematic communications, monitoring and reporting, which is proposed through Kotter's principles of organizational change management. Measurement tools are provided in the appendix. Interventional data based on application of this proposal is required to demonstrate its effectiveness.

[Skin involvement in zoster]. / Hautbeteiligung bei Zoster.

Zoster is a localised, generally painful cutaneous eruption that occurs most frequently among older adults and immunocompromised persons. It is caused by reactivation of latent varicella zoster virus (VZV). A common complication of zoster is postzosteric neuralgia (PZN), a chronic, often debilitating pain condition that can last months or even years. The risk for PZN in patients with zoster is 10 % - 20 %. Another complication of zoster is eye involvement, which occurs in 10- 25 % of zoster episodes and can result in prolonged or permanent pain, severe itch, facial scarring, and loss of vision etc. Prompt treatment with the oral antiviral agents acyclovir, valacyclovir, brivudine or famciclovir decreases the severity and duration of zoster-associated pain (ZAP). Additional pain control can be achieved by supplementing antiviral agents with analgesics, tricyclic antidepressants, and other agents, e. g., gabapentin. Efficacy of the therapy depends on its early initiation. Because zoster starts with unspecific symptoms, specific treatment starts late, as a rule 3 - 7 days after the beginning of virus replication, responsible for complications. A licensed zoster vaccine is a preparation of a live, attenuated strain of VZV, the same strain used in the varicella vaccines. However, its minimum potency is at least 14-times higher than the potency of single-antigen varicella vaccine. In a large clinical trial, zoster vaccine was more than 50 % efficacious for preventing zoster. It is also efficacious in reducing the severity and duration of pain and preventing PHN. Therefore zoster vaccination is recommended for elderly persons.

Multiple colon ulcerations, perforation and death during treatment of malignant melanoma with sorafenib.

BACKGROUND: Sorafenib (Nexavar) is an oral multi-kinase inhibitor with anti-angiogenic and antiproliferative effects. It has shown in-vitro and clinical activity against several kinds of tumors, such as malignant melanoma. HISTORY, DIAGNOSIS, TREATMENT AND COURSE: A 66-year-old man with malignant melanoma was treated with sorafenib, 2 yen 400 mg per day. Because of severe diarrhea and abdominal pain, sorafenib was eventually discontinued and the patient was hospitalized for further treatment. Diagnostic work-up by upper gastrointestinal endoscopy and colonoscopy revealed multiple deep ulcerations within the whole colon. One week after admission the patient developed symptoms of acute abdomen with signs of bowel perforation requiring an emergency operation. Colectomy of the right colon with ileostomy revealed multiple (20-30) acute and subacute colonic perforations. Despite intensive care treatment the patient died of septic complications 13 days after surgery. CONCLUSION: Treatment with anti-angiogenic multi-kinase inhibitors may be associated with gastrointestinal perforations. This has been reported for sorafenib in up to 2.3 % of cases.

[Varicella-zoster virus infections]. / Varizella-zoster-Virusinfektion.

The primary infection with varicella-zoster virus (VZV) is manifest clinically as varicella. It is a common very contagious disease, normally appearing in childhood. VZV is a ubiquitous virus with a high prevalence. Clinically it is characterized by pleomorphic skin lesions. Normally antiviral therapy is necessary only in severe cases, in adults or in immunosuppressed patients. Herpes zoster, also caused by (VZV), is a neurodermal disease representing the endogenous relapse of the primary varicella infection. Herpes zoster is characterized by lesions concentrated in the innervation region of a cranial or spinal nerve. One of the most feared manifestations of herpes zoster is pain. Several antiviral drugs are approved and many studies have shown that antiviral therapy, started early in the course of disease, can significantly reduce risk and duration of postherpetic neuralgia in elderly patients. Therefore, antiviral therapy in combination with an adequate pain management should be given to all elderly patients as soon as herpes zoster is diagnosed.

Herpes zoster guideline of the German Dermatology Society (DDG).

Varicella zoster virus (VZV) causes varicella (chickenpox), remains dormant in dorsal root and cranial nerve ganglia and can be reactivated as a consequence of declining VZV-specific cellular immunity leading to herpes zoster (shingles). Patients older than 50 years of age affected by herpes zoster may suffer a significant decrease of quality of life. These patients and immunocompromised individuals are at increased risks for severe complications, involving the eye, the peripheral and the central nervous system (prolonged pain, postherpetic neuralgia). Such complications occur with and without cutaneous symptoms. The German Dermatology Society (DDG) has released guidelines in order to guarantee updated management to anyone affected by herpes zoster. Diagnosis is primarily clinical. The gold standard of laboratory diagnosis comprises PCR and direct identification of VZV in cell cultures. Detection of IgM- and IgA-anti VZV antibodies may be helpful in immunocompromised patients. Therapy has become very effective in the last years. Systemic antiviral therapy is able to shorten the healing process of acute herpes zoster, to prevent or to alleviate pain and other acute and chronic complications, particularly, when given within 48 h to a maximum of 72 h after onset of the rash. Systemic antiviral therapy is urgently indicated in patients beyond the age of 50 years and in patients at any age with herpes zoster in the head and neck area, especially in patients with zoster ophthalmicus. Further urgent indications are severe herpes zoster on the trunk and on the extremities, herpes zoster in immunosuppressed patients and in patients with severe atopic dermatitis and severe ekzema. Only relative indications for antiviral therapy exist in patients younger than 50 years with zoster on the trunk and on the extremities. In Germany acyclovir, valacyclovir, famciclovir and brivudin are approved for the systemic antiviral treatment of herpes zoster. These compounds are all well tolerated by the patients and do not differ with regard to efficacy and safety. Brivudin has a markedly higher anti-VZV potency than oral acyclovir, valacyclovir and famciclovir and thus offers a simpler dosing regimen. It must be given only once daily during 7 days in comparison to three and five times dosing per day of valacyclovir, famciclovir and acyclovir, respectively. Brivudin is an antiviral agent with no nephrotoxic properties, which is an advantage when compared to acyclovir. The most important aim of therapy of herpes zoster is to achieve painlessness. Appropriately dosed analgesics in combination with a neuroactive agent (i.e. amitriptylin) are very helpful when given together with antiviral therapy. The additive therapy with corticosteroids may shorten the degree and duration of acute zoster pain, but has no essential effect on the development of postherpetic neuralgia, which is a very difficult condition to treat. Thus early presentation to a pain therapist is recommended in specific cases.

Early diagnosis of herpes zoster by polymerase chain reaction.

BACKGROUND: Herpes zoster is a common disease caused by the varicella-zoster virus. The use of virostatic agents as early as possible is necessary in shortening zoster-associated pain. OBJECTIVES: Rapid diagnosis is necessary for the optimal efficacy of antiviral therapy. The diagnosis in the early stage of infection is often difficult. METHODS: In the present study skin biopsies of patients with herpes zoster and unclear skin changes were analysed by detecting viral DNA using the polymerase chain reaction (PCR) in order to amplify open reading frames (ORF) 14, 29 and 63. RESULTS: Varicella-zoster virus DNA could be detected with PCR of all three ORF not only from blisters but also from erythematous skin. CONCLUSIONS: PCR is the method of choice for the viral diagnosis in herpes zoster before blister eruption.

New developments in the epidemiology, natural history and management of genital herpes.

The prevalence of genital herpes is increasing in several populations worldwide. Factors that may be contributing to this increase include greater numbers of sexual partners, the high frequency of asymptomatic infections, poor use of safe sexual practices, and possibly the decreased incidence of childhood oral herpes simplex virus infection. Transmission occurs via skin-to-skin or mucous membrane contact during periods of viral shedding when lesions are present but may also occur when the patient is unaware of the lesions or when lesions are not clinically apparent. This has important implications for strategies to prevent transmission of the disease. The introduction of the antiherpes agent, acyclovir, and more recently famciclovir and valacyclovir, facilitates the management of genital herpes. Treatment of first-episode genital herpes reduces the severity and duration of symptoms, time to lesion healing, and cessation of viral shedding. Episodic treatment of recurrences as they occur may be of benefit to some patients. Daily suppressive therapy significantly reduces the frequency of recurrences and asymptomatic viral shedding. Accordingly, patients who experience frequent or severe recurrences, those particularly troubled by their disease, and those who wish to reduce the frequency of asymptomatic infection generally prefer suppressive therapy. The possibility that suppressive therapy may have an impact on transmission of the disease is currently under investigation. Antiviral treatments have important implications for public health and may help reduce the psychological and psychosocial impact of genital herpes on individual patients.

[History of the Krefeld Dermatology Clinic]. / Die Geschichte der Dermatologischen Klinik Krefeld.

The dermatology clinic in Krefeld has treated a wide range of patients since its founding in 1845. Nowadays the spectrum consists of allergology, occupational dermatology, phototherapy, dermatosurgery, phlebology and proctology as well as special clinics for andrology, sexually transmitted diseases and patients with HIV-infection.

Assessment of pain in herpes zoster: lessons learned from antiviral trials.

Pain typically accompanies acute herpes zoster and, in a proportion of patients, it persists well beyond rash healing. Pain must therefore be analyzed in trials of antiviral agents in herpes zoster, but different methods have been used to analyze pain in recent published trials. These reports are reviewed and their methodological strengths and weaknesses examined. Based on this review, recommendations for the design and analysis of future trials of antiviral agents in herpes zoster are proposed. The principal recommendation is that antiviral efficacy should be evaluated both by distinguishing post-herpetic neuralgia from acute pain and by considering pain as a continuum. The primary endpoint should address both the prevalence and duration of post-herpetic neuralgia and should be examined in those patients who have post-herpetic neuralgia. Adopting the proposed recommendations in design and analysis of future trials should facilitate comparison across trials of the efficacy of antiviral agents in the treatment of herpes zoster.

Antipsoriatic effect of fumaric acid derivatives. Results of a multicenter double-blind study in 100 patients.

BACKGROUND: Psoriasis vulgaris may benefit from treatment with fumaric acid and/or its derivatives; however, because different preparations have been used, results have been contradictory and difficult to interpret. OBJECTIVE: The purpose of this clinical trial was to evaluate the therapeutic value of fumaric acid derivatives. METHODS: A randomized double-blind study was carried out in patients with psoriasis, comparing a well-characterized formulation of fumaric acid derivatives with placebo. RESULTS: The results indicated statistically significant superiority of the fumaric acid derivatives over placebo. Adverse events (flush, gastrointestinal disturbances) were initially relatively frequent, but decreased thereafter. CONCLUSION: Fumaric acid derivatives were found to be effective and safe in the treatment of psoriasis.

[Sexually transmitted diseases by herpes simplex, wart, hepatitis B, and human immunodeficiency virus]. / Sexuell übertragbare Erkrankungen durch Herpes-simplex-, Warzen-, Hepatitis-B-und das humane Immundefizienzvirus.

Sexually transmissible diseases (STD), caused by viruses are by far the most important ones, even though German legislation has ignored them up to now as STD. Anogenital herpes is easily diagnosed by means of monoclonal antibodies. This makes therapy available with acyclovir without delay in atypical cases or for example in persons with immunodeficiency. The therapy regimen usually is 5 x 200-400 mg/day. Recurrent herpes in high frequency and with severe pain may be successfully suppressed by 2-5 x 200 mg/day of acyclovir orally without serious side effects. This will not eliminate herpes viruses. Anogenital warts may look very different and occasionally cannot be detected before local application of 3% acetic acid. Histology is diagnostic. There are different strains causing diseases in men. Therapy of choice is destroying infected cells by CO2-laser coagulation. The incidence of hepatitis B in developed countries is decreasing slowly within the past years, this may partly be due to vaccines, that are available since the early eighties, producing immunity in about 95%. Treatment of chronic hepatitis with interferons seems to be beneficial. Infections with the human immunodeficiency virus (HIV) and their end stage disease AIDS are a growing problem all over the world. Interventions are possible with different nucleoside analogs, e. g. zidovudine (AZT), dideoxycytidine (DDC), dideoxyinosine (DDI). Up to now there is no agreement on when to start with one of the drugs and if or when to switch to combination therapy. Hopefully this may stabilize immunologic parameters and hold disease progression to some time.