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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: We describe a 65-year-old woman who had had wart-like lesions on the hands, lower arms and forehead for about 45 years. She had already had several basal cell carcinomas excised. Histological study, electron microscopy and in situ hybridization [human papilloma virus (HPV)-types 5/8/12/14/19–23/25/36] of skin biopsies confirmed a diagnosis of epidermodysplasia verruciformis (EV). Photodynamic therapy (PDT) was performed using a 20% 5-aminolaevulinic acid ointment applied for 6 h to the lesions and irradiating using an incoherent light source (λ = 580–740 nm, 160 mW/cm2, 160 J/cm2). Following PDT, blistering and crusting of the lesions occurred, but these healed completely within 2–3 weeks without scarring, and the cosmetic result was excellent. Six months after PDT a skin biopsy was taken. In situ hybridization was positive for HPV type 8 in skin which was clinically and histologically normal. Twelve months after PDT a few lesions had recurred on the hands. Although permanent cure of EV cannot be achieved by any therapy at present and single lesions continue to appear in this patient, topical PDT might result in better control of HPV-induced lesions.

Notes: Wells’ syndrome, or eosinophilic cellulitis, is characterized by recurrent cutaneous swellings which resemble acute bacterial cellulitis, and by distinctive histopathological changes. Skin lesions show dermal eosinophilic infiltration and the characteristic‘flame figures, which are composed of eosinophil major protein deposited on collagen bundles. The idiopathic hypereosinophilic syndrome is a multisystem disease with a high mortality rate. It is characterized by peripheral blood eosinophilia and eosinophilic infiltration of many organs, including the skin. The most common skin lesions are pruritic maculopapules and nodules over the trunk and limbs, with urticaria and angio-oedema. In contrast to Wells’ syndrome, the pathology of these skin lesions is non-specific with variable eosinophil infiltration. We report overlapping clinical and histopathological findings characteristic of both syndromes in one patient. Our data favour the hypothesis that both syndromes represent an abnormal eosinophilic response to a variety of underlying diseases or causative agents and thus are different expressions of one disease entity linked to theimmunobiology of eosinophils.

Notes: We report a child with scalp aplasia cutis congenita, whose mother was treated with methimazole during pregnancy. The relationship between antithyroid drug administration during pregnancy and the occurrence of scalp defects is discussed, and the pertinent literature is reviewed.

Notes: Summary We report three patients with severe, localized scleroderma, and with elevated titres of antinuclear antibodies, who were treated by plasmapheresis in combination with systemic steroid therapy. The therapeutic effectiveness of plasmapheresis was assessed on the basis of improvement in cutaneous and joint lesions. In all cases, significant improvement occurred after 2 months of therapy. Thus, in addition to treating systemic sclerosis, plasmapheresis can also be recommended for treatment of severe cases of localized scleroderma with elevated titres of antinuclear antibodies and antibodies to ss-DNA.