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Notes: Background  Recent studies have shown that collagen-degrading matrix metalloproteinase (MMP)-1 and MMP-3 are produced by fibroblasts in response to photodynamic therapy (PDT) with 5-aminolaevulinic acid (ALA) and are considered to be involved in the antisclerotic effects of ALA-PDT observed in the treatment of localized scleroderma.Objectives  As the primary target of topical PDT is epidermal keratinocytes, we studied the indirect participation of keratinocytes in the production of MMPs and collagen by dermal fibroblasts.Methods  Keratinocytes were treated with sublethal doses of ALA (100 µmol L−1) and red light. The conditioned media were collected 24 h after PDT and primary human fibroblasts were exposed to these media for 6–48 h. Further, a coculture model, keratinocytes seeded on to collagen type IV-coated transwells in the upper chamber and fibroblasts in the lower chamber, was used to study paracrine effects of keratinocytes after PDT.Results  Keratinocyte supernatants after PDT showed a significant, up to 10-fold increase of interleukin (IL)-1α and a 2·5-fold increase of tumour necrosis factor-α as determined by enzyme-linked immunosorbent assay, while IL-6, MMP-1 and MMP-3 were not altered significantly. Fibroblasts treated with keratinocyte-conditioned media after PDT showed an induction of MMP-1 and MMP-3 protein levels up to threefold in both models used, suggesting that ALA-PDT modulates MMP-1 and MMP-3 production via indirect mechanisms. Collagen type I mRNA expression by fibroblasts was not altered significantly in either model. The addition of an IL-1 receptor antagonist to the keratinocyte-conditioned media completely inhibited the induction of MMP-1 and MMP-3 in stimulated fibroblasts, suggesting that IL-1 is mainly responsible for the observed paracrine effects.Conclusions  We present evidence that PDT can trigger MMP production in dermal fibroblasts not only directly as has been already shown, but also by an indirect paracrine loop mediated by soluble factors released by epidermal keratinocytes.

Notes: Summary Background The current laboratory methods for diagnosing fungal infections of the nails are the potassium hydroxide (KOH) scraping technique and fungal culture. However, due to the long incubation period required for fungal culture and the reported rate of approximately 30% false negative results observed when using these methods, a quick and highly specific screening test for diagnosing onychomycosis is urgently needed. Objectives In a prospective study, to compare the traditional mycological diagnostics using culture medium and KOH preparation with the histopathological diagnosis of onychomycosis by periodic acid–Schiff (PAS)-stained nail clippings. Methods Material from 387 nails of 350 patients suspected of having onychomycosis was obtained and a KOH stain as well as two fungal cultures (Kimmig agar with and without cycloheximide) were prepared. In addition, the same specimen was histopathologically examined (PAS stain). Results Culture medium and KOH preparation respectively revealed 100 and 156 cases of onychomycosis, as compared with 182 cases by histological examination. Histological examination gave a significantly higher rate of positive results (P 〈 0·05). Considering the total number of positive results given by at least one of the three methods (total = 438), histological evaluation was found to give the highest rate of successful recognition of mycotic infection (41·6%). Conclusions The histopathological evaluation of PAS-stained nail clippings is very quick and easy to perform, and will increase the frequency of diagnosing onychomycotic disease above that achieved by culture and KOH preparation alone. However, because information concerning the vitality of the fungi and accurate identification of the specific pathogen is not available through this investigation alone, mycological culture continues to remain the indisputable ‘gold standard’ of mycological diagnostics.

Notes: Background Pharmacoeconomic outcome research is based on three criteria: (i) evaluation of objective therapeutic effects; (ii) quality of life; and (iii) treatment costs. Evaluation of therapeutic effect is mainly based on the results of clinical trials using objective clinical measures, e.g.: Psoriasis Area and Severity Index (PASI) (score for psoriasis vulgaris) and the Severity Scoring of Atopic Dermatitis (SCORAD) (score for atopic dermatitis). In most studies, only results for a treatment-optimized subpopulation (patients treated according to the protocol) are presented in publications. The relevance of such data for daily routine therapy is doubtful. Objectives Our purpose was to investigate the expected loss of effectiveness of switching from a clinical trial to daily routine therapy for the synchronous application of narrow-band ultraviolet (UV) B phototherapy (311 nm) and bathing in 10% Dead Sea salt solution (synchronous balneophototherapy) for patients with psoriasis vulgaris and atopic dermatitis. Methods We conducted a multicentre, uncontrolled observational study of outpatients. To achieve data for ‘clinical trial’ and ‘daily routine’ situations, two populations were compared: (i) all patients strictly treated according to the protocol (ATP) with no protocol deviations (data published in clinical trials), and (ii) all patients participating in the study who received active treatment at least once, despite treatment irregularities, non-compliance, early withdrawal or other protocol violations [intention-to-treat-population (ITT), model for ‘daily routine’]. Results A total of 2526 patients were included in the ITT analysis for psoriasis vulgaris (n = 487 for atopic dermatitis), of which 818 patients could be analysed according to protocol (n = 104 for atopic dermatitis). Striking differences in the therapeutic effect between both groups (ITT and ATP) were found using relative PASI and SCORAD score improvement: 11% (57% ‘daily routine’ vs. 68% in ‘clinical trial’) for psoriasis vulgaris and 16% (39% ‘daily routine’ vs. 55% ‘clinical trial’) for atopic dermatitis. The main reasons for excluding patients from the ‘clinical trial’ group were early study withdrawal in 29% (atopic dermatitis, 47%) of patients and fewer treatments per week than planned in the protocol in 24% (atopic dermatitis, 52%). Conclusions Our data clearly indicate that for the prediction of the therapeutic effect for daily routine therapy the ITT data appear to be more relevant than the ATP results (i.e. those presented in clinical trials). Although these data are only a first step for evaluating the ‘real’ therapeutic effect of a treatment modality in daily routine, they seem to support the requirements for ITT analyses in efficacy studies and demonstrate the necessity of ITT data for pharmacoeconomic evaluation.

Notes: Objectives To assess the importance of the patient’s age at the start of treatment of a port-wine stain (PWS) with the flashlamp-pumped pulsed dye laser (FPDL). Background FDPL treatment is safe and effective for PWSs, with a low risk of scarring and pigmentary changes. The degree of clearing of the lesion is, however, unpredictable, and the ideal time to start treatment has not yet been agreed. Patients/methods By means of a questionnaire, we investigated the frequency of recurrence in PWS in 147 patients after completion of treatment with the FPDL. Results In 24 patients (16·3%), partial redarkening of their PWS was observed. The patients who had a recurrence were not different from the group who did not regarding the colour of the PWS , the response to previous treatment or the frequency of side-effects. Children under 10 years of age did not show any PWS recurrence, at least in our group of patients. Conclusions The age at the beginning of treatment may have an influence on the recurrence rate.

Notes: Folliculitis decalvans is a chronic purulent folliculitis resulting in permanent hair loss and follicular atrophy. We report 32-year-old identical female twins presenting with relapsing pruritic outbreaks on the scalp resulting in areas of permanent baldness. Staphylococcus aureus was detected in the lesions of both women. Histopathology confirmed the diagnosis of folliculitis decalvans. Immunological testing showed no alteration of the immune system. To our knowledge, this is the first report on folliculitis decalvans occurring in identical twins, suggesting a possible genetic component in this disease.

Notes: Background At present, laser therapy of port-wine stains (PWS) using the flashlamp-pumped dye laser (FPDL) at 450 µs is accepted as the optimal approach. A few years ago, a new long-pulsed tunable dye laser (LPTDL, 1·5 ms) was introduced for the treatment of leg veins. Objectives To investigate the efficacy and side-effects of FPDL vs. LPTDL therapy of PWS. Methods Sixty-two patients with untreated PWS underwent test treatments with the FPDL (585 nm; 7-mm spot size; 5·75–7·0 J cm−2 fluence) and LPTDL (585, 590, 595, 600 nm; 5-mm spot size; 11–20 J cm−2 fluence). With the LPTDL, the epidermis was additionally cooled (Spray cooling device). The fading was evaluated clinically 6 weeks after the test treatments. Results Optimal fading was achieved by the LPTDL (≥ 585 nm) in 30 patients and by the FPDL in 12 patients. No difference was found in 20 patients. At 585 nm, the lasers worked equally well in 12 (FPDL) and 13 (LPTDL) patients, respectively. Results were independent of the localization of the PWS and of the patient's age. In spite of the longer pulse duration, the LPTDL treatment did not result in more side-effects as long as sufficient cooling was provided. Conclusions The results provide evidence that wavelengths longer than 585 nm can increase the efficacy of treatment in some PWS. Owing to the reduced light absorption by haemoglobin at longer wavelengths and consequently increased depth of the vascular injury, larger vessels can be damaged more adequately using an increased fluence. The LPTDL at 585 nm seemed to be slightly superior to the FPDL, while accepting that due to technical reasons the laser parameters were not directly comparable. Availability of both lasers increases the therapeutic possibilities in PWS.

Notes: Summary Background Digital dermoscopy for the follow-up of melanocytic naevi (MN) is becoming more common in dermatological private practice. Objectives To evaluate the clinical outcome, including the patient's compliance, in a long-term follow-up of single MN. Methods Criteria for the selection of MN for follow-up: clinically suspicious without dermoscopically atypical features, or typical for the patient. Clinical outcome measures: number of detected malignant melanomas (MM) and/or atypical MN; quantity, quality, and differences in morphological changes between ‘low-risk’ patients (no MM in history and 〈 50 MN) and ‘high-risk’ patients (MM in history and/or 〉 50 MN). Compliance: the number of patients who joined a recommended follow-up scheme. Results No MM was found in 145 consecutive patients (mean age 28 years, 54% female) during a 4-year period (median follow-up per patient: 24 months; ranging 4–45; at least three visits). In five patients (3%), seven histologically proven atypical MN were shown on whole body examination at sites other than those documented. A total of 1968 images in 177 ‘low-risk’ and 95 ‘high-risk’ MN were analysed: 37% (n = 65) of ‘low-risk’ and 32% (n = 30) of ‘high-risk’ MN showed dermoscopic changes (difference not statistically significant), none were suspicious for MM. Compliance, evaluated within a separate database of 303 consecutive patients (mean age 32 years, 52% female) over a 6-month period, was only 46%, although recall letters were used. Conclusions (i) In our setting of daily routines in dermatological private practices long-term follow-up of a single MN seems not to be helpful for the detection of MM. (ii) A whole body examination must be done at each visit. (iii) The clinician's experience of the type and number of possible morphological changes in MN is crucial in order to avoid unnecessary excisions. (iv) The patient's compliance might be an important problem. (v) Cost-effectiveness has yet to be analysed.

Notes: The synchronous application of narrowband UVB phototherapy with 311 nm lamps (Philips TL-01) and bathing in Dead Sea salt solution was evaluated in a multicentre trial (n = 60) in outpatients suffering from psoriasis vulgaris. The study design consisted of an initial therapy phase of up to 35 treatments (three to five times a week) followed by maintenance therapy with up to 35 further applications (once or twice a week). Evaluation was performed separately for patients in according-to-protocol (ATP) (n = 280) and intention-to-treat (ITT) (n = 692) groups. An overall significant improvement of the Psoriasis Area and Severity Index (PASI) score (P 〈 0·05) could be shown for both groups during initial therapy with 71·4% improvement for ATP and 61% for ITT patients. The mean PASI for ATP (values for ITT in parentheses) was 17·7 (18·6) at baseline, 9·5 (10·7) after 20 applications and 5·2 (7·4) at the end of initial therapy. On average, ATP patients received 3·9 (3·5) applications per week with a cumulative irradiation dose of 19·5 J cm−2 (16·2 J cm−2). The most frequent side-effect was erythema, observed in 8·7% of the patients. Subjective evaluation of the therapy by the patients (n = 168) was excellent. Seventy-nine per cent of patients preferred the new treatment strategy in comparison with other previous therapies and 88% regarded this therapy as pleasant and comfortable. In conclusion, we could demonstrate a significant effect of therapy in both the ATP and the ITT groups for this new treatment system which imitates, as far as possible, the Dead Sea climatic conditions, with no severe side-effects and a high acceptance by the patients.