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ZusammenfassungDie Behandlung von Patienten mit chronischen Wunden ist weiterhin eine interdisziplinär und interprofessionell relevante Herausforderung. Die Grundlage einer erfolgreichen Therapie der Betroffenen basiert auf der Behandlung der zugrunde liegenden, pathophysiologisch relevanten Erkrankungen. Zusätzlich sollte aber auch immer eine lokale Wundtherapie erfolgen, um die Wundheilung zu unterstützen und Komplikationen zu vermeiden. Um die Vielzahl von Wundprodukten besser strukturieren zu können, wurde durch eine multidisziplinäre Expertengruppe von WundDACH, dem Dachverband deutschsprachiger Fachgesellschaften, das M.O.I.S.T.-Konzept entwickelt. Hier beschreibt M das Exsudatmanagement (Moisture balance), O die Sauerstoffzufuhr (Oxygenation), I die Infektionskontrolle (Infection control), S die Unterstützung des Heilungsprozesses (Support) und T das Gewebemanagement (Tissue management).Das M.O.I.S.T.-Konzept soll Therapeuten eine Hilfestellung bei der systematischen Planung und auch für die Edukation im Hinblick auf die Lokaltherapie von Patienten mit chronischen Wunden bieten. Hier wird nun das Update 2022 dieses Konzeptes erstmalig vorgestellt.

Die vorliegende aktualisierte und auf S2k-Niveau angehobene Leitlinie befasst sich mit der Diagnostik und der Therapie der Rosazea, bei welcher es sich um eine häufige, chronisch-entzündliche Hauterkrankung handelt, die meist das Gesicht betrifft. Der Verlauf der Rosazea ist initial durch rezidivierende Erytheme, Teleangiektasien sowie Flushing gekennzeichnet. Später überwiegt die entzündliche Komponente, wobei es zu persistierenden Erythemen mit follikulären Papeln, Papulopusteln und Pusteln kommt. Die Bildung von Phymen, die meist an den Akren auftreten, stellt dabei die schwerste Ausprägung der Erkrankung dar. Zur Behandlung empfiehlt die interdisziplinäre Leitlinienkommission, die aus Vertretern der Deutschen Dermatologischen Gesellschaft (DDG), des Berufsverbandes der Deutschen Dermatologen (BVDD), der Deutschen Ophthalmologischen Gesellschaft (DOG), der Gesellschaft für Dermopharmazie (GD), der Schweizerischen Gesellschaft für Dermatologie und Venerologie (SGDV) und der Deutschen Rosazea Hilfe e. V. besteht, neben der Meidung von Triggerfaktoren, die topische Anwendung der Wirkstoffe Metronidazol, Azelainsäure oder Ivermectin. Zur symptomatischen Behandlung persistierender zentrofazialer Erytheme können zudem die Vasokonstriktoren Brimonidin oder Oxymetazolin topisch angewandt werden. Bei therapieresistenten sowie bei schweren Formen der Rosacea papulopustulosa wird eine systemische Therapie empfohlen. Hierfür ist niedrigdosiertes Doxycyclin das Präparat der 1. Wahl. Alternativ kann niedrigdosiertes Isotretinoin empfohlen werden. Für die okulären Rosazea kann neben einer Lidrandhygiene die topische Behandlung mit Ciclosporin-haltigen Augentropfen, Azithromycin, Ivermectin oder Metronidazol empfohlen werden.

Wund-D.A.CH., as the umbrella organization of German-speaking wound treatment societies, has currently developed a best practice recommendation for skin damage caused by body fluids, which is known as moisture-associated skin damage (MASD) in English-speaking countries. In this expert consensus, the diseases incontinence-associated dermatitis (IAD), intertriginous dermatitis, including intertrigo, gram-negative bacterial toe web infection and toxic contact dermatitis, including periwound and peristomal dermatitis are presented in a differentiated manner. A common feature of these clinical diseases is a deterioration of skin integrity due to prolonged exposure to body fluids such as urine, stool, sweat or wound exudate with associated physical-irritative and/or chemical irritation. In addition, other comorbidities and cofactors play an important role. The diagnosis of these interdisciplinary and interprofessionally relevant MASD is difficult in everyday clinical practice because there are currently no uniform definitions and many relevant differential diagnoses. Effective strategies for the prevention and therapy of these skin diseases are, for example, continence management, use of efficient, absorbent aids with good retention as well as consistent skin protection and adequate skin care. Another important aspect is the education of patients and relatives about the origin, treatment and prevention of MASD.

This updated and upgraded S2k guideline deals with the diagnosis and treatment of rosacea, which is a common, chronic inflammatory skin disease mostly affecting the face. Initially, rosacea is characterized by recurrent erythema, telangiectasia and flushing. Later, the inflammatory component predominates, with persistent erythema with follicular papules, papulopustules and pustules. The development of phyma, which usually occurs on the acral localizations, is the most severe manifestation. For the treatment of rosacea, the interdisciplinary guideline committee, with representatives of the German Dermatological Society (DDG), the Professional Association of German Dermatologists (BVDD), the German Opthalmological Society (DOG), the Society for Dermopharmacy (GD), the Swiss Society for Dermatology and Venereology (SGDV) and the German Rosacea Aid e. V., recommends the avoidance of trigger factors and topical applications of metronidazole, azelaic acid or ivermectin. For symptomatic treatment of persistent centrofacial erythema, the topical vasoconstrictors brimonidine or oxymetazoline can also be used. Systemic therapy is recommended for therapy-resistant and severe forms of rosacea papulopustulosa. The drug of choice is low-dose doxycycline. Alternatively, low-dose isotretinoin can be recommended. Ocular rosacea should be treated with lid margin hygiene. For topical treatment, ciclosporin eye drops, azithromycin, ivermectin or metronidazole are suggested.

Hidradenitis suppurativa (HS) ist eine schmerzhafte, belastende entzündliche Hauterkrankung mit chronisch-intermittierendem Verlauf. Das zentrale pathogenetische Ereignis scheint die Okklusion von Haarfollikeln zu sein. Die 1-Jahres-Prävalenz der HS beträgt rund 1%. Die Erkrankung tritt typischerweise nach der Pubertät auf und ist durch schmerzende, tief sitzende, entzündete Läsionen in Körperregionen mit apokrinen Drüsen gekennzeichnet, vor allem in der Achsel-, Inguinal- und Anogenitalregion. HS geht mit erheblicher Beeinträchtigung der Lebensqualität der Patienten schon bei geringer Krankheitslast einher und die Diagnosestellung erfolgt oft erst mit erheblicher Verzögerung. Die vorliegende Kurzfassung für die Praxis enthält diagnostische und therapeutische Empfehlungen auf der Grundlage einer systematischen Literaturanalyse sowie eines informellen Expertenkonsenses von Schweizer Dermatologen und dermatologischen Chirurgen.

BACKGROUND: Changes in mental and sexual health among men having sex with men (MSM) due to the SARS-CoV-2 pandemic remain unclear. METHODS: Design: Longitudinal analysis of an ongoing, multicentre, pre-exposure prophylaxis (PrEP) cohort (NCT03893188) in Switzerland. Participants: HIV-negative MSM aged ≥18 who completed at least one questionnaire before and one after the start of the SARS-CoV-2 pandemic. Outcomes: Primary: mental health, defined as anxiety and depression scores assessed by the Patient Health Questionnaire-4. Secondary: sexual behaviour, well-being, PrEP use and disruption of care. Outcomes were assessed over seven periods corresponding to different SARS-CoV-2 prevention measures in Switzerland. We performed pairwise comparisons between periods (Wilcoxon signed rank test). RESULTS: Data from 1,043 participants were included. Whilst anxiety scores remained stable over time, depression scores worsened in the second wave and the second lockdown period compared to pre-pandemic scores. This was confirmed by pairwise comparisons (pre-SARS-CoV-2/second wave and pre-SARS-CoV-2/second lockdown: p

Background: Oxygen is mandatory for almost all wound healing processes, in particular the processes of cell regeneration and angiogenesis. As it is lacking in chronic and even acute wounds, oxygen substitution seems to be an obvious adjuvant tool. In vitro and in vivo tests showed improvement of microenvironment essential for the onset of appropriate healing processes.

Zusammenfassung. Vier Pathologien bilden zusammen die makrovaskulären Ursachen des Ulcus cruris: Venöse Ulzera (50 %), gemischte venös-arterielle Ulzera (20 %), arterielle Ulzera (5 %) und das Ulcus hypertonicum Martorell (5 %). Die übrigen 20 % verteilen sich auf sehr viele weitere Ursachen. Jedes Ulcus cruris erfordert eine vaskuläre (arterielle und venöse) Abklärung, gegebenenfalls ergänzt durch Biopsie, Mikrobiologie, und eine vertiefte internistische Diagnostik. Venöse Ulzera werden zunächst durch Kompression therapiert. Insuffiziente Stammvenen und deren Seitenäste werden saniert, sofern das tiefe Venensystem durchgängig ist. Okkludierte Beckenvenen werden nach Möglichkeit rekanalisiert und gestentet. Refraktäre venöse Ulzera werden je nach Fläche mit Spalthaut oder Punch Grafts gedeckt. Je nach Ausdehnung der Dermatolipofasziosklerose kann zuvor die Fibrose mit der «Shave-Therapie» oder Fasziektomie abgetragen werden. Mit der Unterdruck-Wundtherapie können tiefere oder kritisch kolonisierte Wunden konditioniert werden. Hautersatzverfahren sind eine Alternative zur Behandlung oberflächlicher venöser Ulzera ohne Epithelisierungstendenz. Für alle weiteren Indikationen muss ihr Stellenwert noch näher untersucht werden. In der chirurgischen Behandlung komplexer chronischer Wunden führt der Aufbau einer Neo-Dermis vor einer Hautverpflanzung zu einer stabileren Narbe. Gemischte venös-arterielle Ulzera (Ulcus cruris mixtum) heilen langsamer und rezidivieren häufiger. Die Kompressionstherapie muss reduziert werden. Bei ausbleibendem Therapieerfolg wird eine arterielle Revaskularisation angestrebt, womit das gemischte in ein venöses Ulcus cruris umgewandelt wird. Arterielle Ulzera (Ulcus cruris arteriosum) benötigen in aller Regel eine arterielle Revaskularisation und danach eine Spalthautverpflanzung. Das Ulcus hypertonicum Martorell ist noch vielerorts unbekannt und wird oft mit dem Pyoderma gangraenosum verwechselt, was die Therapie in eine falsche Richtung lenkt. Wundchirurgie in kleinerer oder grösserer Form, Antibiotika-Therapie bei klinisch relevanter Superinfektion, und Hautverpflanzungen, oft mehrfach wiederholt, führen in aller Regel zur Abheilung dieser äusserst schmerzhaften und bei falscher Behandlung potenziell lebensgefährlichen Wunden.

Die Herausforderungen der modernen Wundversorgung wie die Behandlung chronischer Wunden oder eine phasengerechte Versorgung sind anspruchsvoll und erfordern optimal angepasste Therapiemasnahmen. Die Prinzipien der feuchten Wundbehandlung sowie ein adaquates Debridement stehen dabei im Vordergrund. Um diese erforderlichen Masnahmen zu unterstutzen, stehen mehrere Optionen zu Verfugung, u. a. eine neue Produktklasse mit phasenubergreifender Wirkung. Es erfolgt die Vorstellung eines Expertenkonsenses zu einer neuen Behandlungsoption in der modernen Wundversorgung. Auf Basis klinischer Erfahrungen und den Grundlagen publizierter Evidenz wurden aktuelle und neue Prinzipien der Wundbehandlung in einer Expertenrunde diskutiert und als Konsens formuliert. Enzym-Alginogele bestehen aus einer Wirkstoffkombination mit autolytischen, absorbierenden sowie antimikrobiellen Eigenschaften, die 3 Wundmanagementkomponenten des TIME-Konzepts abdecken. Dadurch unterscheiden sie sich von anderen Praparaten und konnen gemas Expertenkonsens als eigene Produktklasse klassifiziert werden. Evidenz fur die Wirksamkeit der Enzym-Alginogele belegen klinische Studien sowie Erfahrungen aus der klinischen Praxis. Das Potenzial der Enzym-Alginogele, angewendet unter Berucksichtigung der Prinzipien der feuchten Wundbehandlung, liegt gemas Expertenmeinung v. a. in der dreifachen Wirkung (kontinuierliches und deutlich vereinfachtes Debridement, Aufrechterhaltung eines feuchten Wundmilieus, antimikrobielle Wirkung ohne Zytotoxizitat) sowie der einfachen und flexiblen Anwendung. Zudem birgt die Flexibilitat dieser Produktklasse hinsichtlich Anwendungshaufigkeit, Behandlungsdauer und der Kombination mit Sekundarverbandstoffen medizinokonomisches Potenzial.

Background: To evaluate efficacy and cost-effectiveness of a plant-derived wound dressing (ONE), a mixture of hypericum oil (Hypericum perforatum L.) and neem oil (Azadirachta indica A. Juss.), in scalp wounds with exposed bone. Patients and Methods: All patients with scalp wounds with exposed bone, following the excision of skin tumors, and treated with ONE in 2011 were included. Time of healing, wound size, area of exposed bone, ease of handling, pain, and complications were evaluated. Costs of dressings and nursing time were compared with those cited in literature for other treatment modalities. Results: Fifteen consecutive patients with a mean age of 76.87 ± 10.3 years (59-90 years) were analyzed. The mean wound size was 10.9 ± 6.84 cm2 (0.4-22.6 cm2) with 4.8 ± 5.9 cm2 (0.3-20.7 cm2) of exposed bone. The time of complete healing by secondary intention was 8.1 (4-20) weeks. Rapid formation of granulation tissue was observed which after 4 weeks covered the entire exposed bone surface in 11 of 15 cases (73%). Dressing change was simple with no pain reported; no infections or other complications occurred. Using ONE for a mean healing time of 56.7 days resulted in mean costs of EUR 423.73, which is substantially lower than those published for fascia lata, negative pressure therapy, or collagen matrix followed by skin grafting (EUR 1,612.82, EUR 4,411.80 and EUR 1,503.72, respectively). Conclusion: This retrospective, non-controlled analysis supports ONE as a simple-to-use and safe treatment option for scalp wounds with exposed bone. Treatment costs compare favorably to those published for other treatment modalities.

Introduction Martorell hypertensive ischemic leg ulcer (HYTILU) and pyoderma gangrenosum share a violaceous, rapidly progressive necrotic wound border and excruciating pain as essential clinical features. Clinicians unaware of Martorell HYTILU readily misdiagnose pyoderma gangrenosum or necrotic vasculitis. This can be detrimental since disease management is totally different. Material and methods This review includes two patient series with Martorell hypertensive ischemic leg ulcer (HYTILU), 31 patients from the University Hospital of Zurich and 64 patients from a randomized controlled trial in France. The analysis of confounding Martorell HYTILU and histological study is based on the Zurich data and the analysis of therapeutic issues is based on the French and Zurich data. Results Fifty-two percent (16/31 patients) were referred with an erroneous diagnosis of pyoderma gangrenosum, and another 19% (6/31 patients) with an erroneous diagnosis of necrotizing vasculitis. The hallmark of Martorell HYTILU are the location at the laterodorsal leg or Achilles tendon (in the present series 100%) in a patient with usually long-standing and controlled hypertension (95–100%), often accompanied by diabetes (40–60%). Histology of a several centimeter long, 4–6 mm narrow, and deep (to fascia) performed spindle-shape skin and ulcer biopsy shows a skin infarction with sclerotic subcutaneous arterioles. Arteriolosclerosis is defined by thick vessel walls at the cost of a narrow lumen, and in approximately 70% of histologic sections part of the arterioles show a striking medial calcification. The narrow lumen may be occluded by acute or organized thrombosis. In the French multicenter serie, at 8 weeks only 10% (3/31 patients) healed by conservative means, and this could not be improved with the use of topical application of platelet-derived growth factor-BB (becaplermin) (18% healing, 5/28 patients, no significant difference). In the Zurich series, 84% of patients (26/31) had wound surgery (necrosectomy, split skin graft) to heal the ulcer and 10% (3/31) died from wound infection and sepsis, amongst two under immunosuppression received for misdiagnosed pyoderma gangrenosum. Conclusions Martorell HYTILU can easily be confounded with pyoderma gangrenosum or necrotizing vasculitis. Physicians involved in wound treatment should be sensitized to the typical clinical setting: a progressive and extremely painful skin infarction at the laterodorsal leg in a hypertensive and often diabetic subject. Diagnosis is confirmed histologically on a long-enough, narrow, but deep spindle-shape skin and ulcer biopsy, showing a highly characteristic form of stenotic and occlusive subcutaneous arteriolosclerosis. Management is essentially based on wound surgery. Conservative means are almost uneffective. Immunosuppression must be avoided, and antibiotic treatment introduced as required.

L’hidrosadenite suppuree est une dermatose dramatique qui a un lourd impact sur la qualite de vie des personnes touchees en raison de la formation de kystes, d’abces et de fistules dans les grands plis cutanes. Malgre sa prevalence elevee pouvant atteindre 1%, cette maladie est souvent interpretee comme une furonculose recidivante et aucun traitement efficace n’est mis en place. Cet article resume les aspects principaux de cette pathologie facile a reconnaitre et propose quelques diagnostics differentiels a envisager en cas d’abces dans les grands plis cutanes.

Wund-D.A.CH. ist der Dachverband deutschsprachiger Fachgesellschaften, die sich mit den Thematiken der Wundbehandlung beschaftigen. Experten verschiedener Fachgesellschaften aus Deutschland, Osterreich und der Schweiz haben nun einen aktuellen Konsens der Kompressionstherapie fur Patienten mit Ulcus cruris venosum erstellt. In Europa ist das Ulcus cruris venosum eine der haufigsten Ursachen fur chronische Wunden. Neben der konservativen und interventionellen Wund- und Venentherapie, ist die Kompressionstherapie die Basis der Behandlungsstrategien. Die Kompressionstherapie kann heute mit sehr unterschiedlichen Materialien und Systemen durchgefuhrt werden. Wahrend in der Entstauungsphase insbesondere Verbande mit Kurzzugbinden oder Mehrkomponentensysteme zur Anwendung kommen, sind es anschliesend uberwiegend Ulkus-Strumpfsysteme. Eine weitere, bislang wenig verbreitete Alternative sind adaptive Kompressionsbandagen. Insbesondere fur die Rezidivprophylaxe werden medizinische Kompressionsstrumpfe empfohlen. Durch die Vielzahl der heute zur Verfugung stehenden Behandlungsoptionen, kann fur nahezu alle Patienten ein Konzept entwickelt werden, dass sich an den individuellen Bedurfnissen und Fahigkeiten orientiert und daher auch akzeptiert und durchgefuhrt wird. Die Kompressionstherapie ist fur die Behandlung von Patienten mit Ulcus cruris venosum essentiell. In den letzten Jahren sind viele verschiedene Therapieoptionen verfugbar, die in den deutschsprachigen Landern unterschiedlich angewendet oder durchgefuhrt werden. Daher soll dieser Expertenkonsens dazu beitragen, konkrete Empfehlungen fur die praktische Durchfuhrung der Kompressionstherapie von Patienten mit Ulcus cruris venosum darzustellen.

Polyhexanidhaltige Wundbehandlungs-Produkte werden häufig für die Behandlung von akuten und chronischen Wunden eingesetzt. Obwohl ausreichende Informationen zur Verwendung von Polyhexanid in der Literatur zu finden sind, ist die angemessene Anwendung dieser Produkte in der klinischen Praxis nicht immer klar. Das Ziel dieser Konsensus-Empfehlung ist es, Ärztinnen/Ärzten und Pflegefachleuten, die Patienten mit akuten und chronischen Wunden behandeln, klinisch relevante Empfehlungen zur Verfügung zu stellen. Dieser Bericht beschreibt die klinisch relevanten Eigenschaften von Polyhexanid und gibt Empfehlungen für die Prophylaxe und Behandlung von Wundinfektionen.

Rund ein Viertel der Patienten mit einem Ulcus cruris haben ein "nicht-vaskuläres" Ulkus, d. h. kein venöses, kein gemischt venös-arterielles, und kein arterielles Ulkus. Die Differenzialdiagose umfasst etwa 70 Entitäten. Im Alltag relevant sind das hypertensiv-ischämische Ulkus (Ulcus hypertonicum Martorell) und seine beiden "Imitatoren", das Pyoderma gangraenosum und die nekrotisierenden Vaskulitiden der Haut, Hautnekrosen in Folge von Infekten (Ecthymata u. a.), durch physikalische Traumen verursachte chronische Hautwunden (z. B. Kontusionen [tiefes dissezierendes Hämatom]), oder nach Radiotherapie oder Kryotherapie wegen Hautkrebs am Unterschenkel), im Rahmen kongenitaler Krankheiten auftretende Ulzera (beispielsweise bei Klinefelter-Syndrom oder Sichelzellanämie), Hautnekrosen als Folge von Medikamenten-Toxizität (z. B. unter Hydroxyurea, Anagrelid oder Methotrexat) und last not least die ulzerierten Hauttumore (primär und sekundär bei maligner Entartung auf chronischer Entzündung). Die klinische Präsentation sowie ein pragmatischer Algorhythmus zur Abklärung und Therapie dieser Krankheiten werden vorgestellt.

SummaryRestless legs syndrome (RLS) is characterised by an uncontrollable urge to move, in particular the lower limbs, often accompanied by discomfort or a painful sensation that occurs typically at night. It is categorized under the ICD-Classification of extrapyramidal and movement disorders. As patients often suffer from insomnia due to the involuntary nocturnal leg movements and irritable sensations in the legs, RLS is also classified as a sleep-related movement disorder. The incidence of a mild form of RLS is frequent, although it often remains undiagnosed.After the exclusion of other diseases by differential diagnosis, RLS is diagnosed on the basis of a clinical test administering a single dose of levodopa. There are two forms of RLS: idiopathic and secondary. The secondary form is encountered in an astonishing number of diseases, including renal insufficiency, diabetes, chronic obstructive pulmonary disease (COPD) and iron deficiency. The treatment of RLS is complex and the benefits and risks of pharmacotherapy should be considered carefully. Non-ergoline dopamine agonists (e.g. ropinirole, pramipexole) are the first-line treatment in severe cases of RLS. Transdermal rotigotine is also a promising treatment option. Opioids in combination with naloxone are recommended for patients suffering from severe pain. In mild cases of RLS, patients benefit from a balanced lifestyle with gentle physical activity and avoiding the excessive consumption of caffeine or alcohol.

Venous disorders have a high prevalence and require approximately 1% of health budgets of industrialized countries. The postthrombotic syndrome (PTS) is defined by subjective symptoms and morphologic trophical skin changes following deep venous thrombosis. Prevention of venous thromboembolism in risk situations, easy availability of diagnostic tools (D-dimers, colour-coded duplex sonography) and early detection of deep venous thrombosis, as well as immediate therapeutic anticoagulation along with leg compression during the acute phase and over a two year period of time significantly reduce the incidence of PTS. Chronic venous insufficiency (CVI) includes trophical skin and soft tissue pathologies of the lower leg due to venous hypertension in the distal venous system of the lower extremity. Roughly, two main causes can be distinguished. (A) Deep venous insufficiency (A1 in postthrombotic syndrome; A2 in primary deep venous insufficiency) and (B) superficial venous reflux, usually varicose veins. Compression therapy, surgical ablation of superficial venous reflux, and tangential ablation with split skin graft (shave treatment) of refractory venous ulcers are the mainstays in the treatment of CVI.

Squamous cell carcinoma (SCC) is the most frequent cancer in organ transplant recipients (OTRs). The immune system plays a major role in the fight against SCC, however, little is known about the local inflammatory response in SCC at all. We analyzed quantity and quality of the perineoplastic inflammatory SCC microenvironment in immunocompetent patients and immmunosuppressed OTRs. RNA expression profile of SCC patients was analyzed for 8 different sets of genes relating to Th1 versus Th2 response using Gene Set Enrichment Analysis. SCC from immunocompetent patients and OTRs were analyzed by real-time polymerase chain reactions for CD4, CD8, TBET, GATA-3, FOXP3, RORC, IFN-gamma, IL-4, TGF-beta, IL-10, and IL-17A mRNA expression. Immunohistochemistry was carried out in SCC for CD3, CD4, CD8, and FOXP3 expression. Considerable inflammation was seen in both patient groups. SCC in immunocompetent patients and OTRs was associated with a mixed Th1 and Th2 gene expression signature. CD4(+) mRNA was diminished in immunosuppression. Skin adjacent to SCC in OTRs showed Th2 expression pattern as compared with immunocompetent patients. T-BET and IFN-gamma mRNA expression were decreased in the OTR group. Although Th17-weighted inflammation was unchanged, IL-17A mRNA level was markedly decreased with immunosuppression. Regulatory T cells, characterized by FOX-P3 and TGF-beta mRNA level, were decreased in OTRs. Our findings support the hypothesis that nontumor-bearing skin adjacent to SCC in OTRs is not necessarily normal and that the local microenvironment may contribute to a field effect contributing to higher recurrence rates and more aggressive behavior observed in these patients.

Venenkrankheiten sind in der Bevolkerung weit verbreitet und chronische Wunden verursachen hohe Morbiditat und Kosten. Die Pravalenz der schweren Formen der chronischen venosen Insuffizienz ist rucklaufig, einerseits dank der verbesserten Thrombosediagnostik und -therapie und andererseits dank der verbesserten Chirurgie der Varikosis und deren Folgen. Das Spektrum der chronischen Wunden hat sich vom venosen Ulkus in Richtung komplexer Pathologien verschoben, aber gleichzeitig haben auch die Behandlungsmoglichkeiten zugenommen. Die moderne Phlebologie kann die Varikose wirksam behandeln, die Spatschaden von Varikosis und tiefer Venenthrombose verhindern und der grosen Mehrzahl von Patienten mit chronischen Wunden weiterhelfen. gefunden. Im hoheren Alter uber 80 Jahren erleiden auch heute noch noch rund 4 % aller betagten Personen ein Ulcus cruris, und die Morbiditat und Kosten fur Wundbehandlung ist in dieser betagten Personengruppe besonders hoch. Insgesamt geht man davon aus, dass die Gesundheitssysteme der westlichen Industrienationen ungefahr 1 % ihres Budgets fur die Behandlung von Venenkrankheiten und fur das Ulcus cruris ausgeben.

Die Dermatochirurgie ist der operative Pfeiler des medizinisch-chirurgischen Fachs Dermatologie. Insbesondere der starke Anstieg der Hautkrebserkrankungen hatte in den westlichen Ländern eine erhebliche Bedarfssteigerung an kompetent ausgeführter Dermatochirurgie zur Folge. Das Beispiel „Hautkrebs“ veranschaulicht plausibel, dass der Dermatologie in der Abklärung, der differenzierten Indikationsstellung und der Durchführung konservativer, semi-invasiver und chirurgischer Behandlungsoptionen und in der Zusammenarbeit mit den plastisch-rekonstruktiven Fächern eine zentrale Rolle zusteht. Die chirurgische Dermatologie hat in den letzten zwei Jahrzehnten wertvolle Impulse bei der mikrographischen Chirurgie von Hautkrebs, der Verfeinerungen der Lokalanästhesietechniken, der Nagelchirurgie, der Wund- und Narbenbehandlung, der Laserchirurgie der Haut und der Sentinellymphknotenbiopsie beim malignen Melanom geleistet.

Towards the end of the last century some sexually transmitted infections (STI), which had been held to be almost extinct, have seen an unexpected resurgence. They mainly present as urethritis, genital ulcers or genital warts and must always be diagnosed and treated so as to prevent further transmission. The main causes of urethritis are gonorrhea and chlamydia, the latter can also cause only minor symptoms. The pathogen should always be diagnosed with direct microscopy of a urethral smear as well as culture or PCR. Antibiotic treatment is usually straightforward. Genital ulcer disease can be caused by a wide spectrum of bacteria and viruses as well as non-infectious causes. It is significant as it can facilitate the transmission of HIV. The most frequent cause is herpes simplex virus which usually presents itself with painful ulcers and a recurrent course. Syphilis occurs in different clinical stages. The first stage is usually a painless ulcer, it can be difficult to diagnose and is often missed. In the second stage, characterised by a rash and a variety of classical symptoms such as condylomata lata, the diagnosis can be made with various serologic tests. Long-acting penicillin remains the treatment of choice. Genital warts are a consequence of HPV infection and can usually easily be diagnosed based on the clinical picture. Some high-risk HPV types can lead to malignant transformation, especially in immunocompromised patients. Besides different destructive therapeutic modalities, some effective treatments can be applied locally by patients themselves.

Die chronisch venöse Insuffizienz (CVI) der Beine ist eine der häufigsten Krankheiten der Erwachsenen in der westlichen Bevölkerung mit beträchtlicher sozioökonomischer Bedeutung. Aufgrund der jetzigen Datenlage darf davon ausgegangen werden, dass die Entstehung variköser Beinvenenveränderungen multifaktorieller Genese ist und dass neben Umweltfaktoren vor allem dem Lebensstil eine wichtigere Rolle in ihrer Entstehung zukommt als bisher angenommen. Dies zeigt auch die im Sommer 2008 in 40 verschiedenen Schweizer Apotheken durchgeführte Umfrage mit 1099 Teilnehmern.

Background: The excimer laser is a new therapeutic option in the treatment of psoriasis vulgaris. Objective: The purpose of this study was to determine the response of psoriasis lesions to the 308-nm excimer laser compared to 311-nm UVB phototherapy. Methods: In this prospective right/left comparative, open, single-blinded trial, selected psoriasis plaques of 16 patients were treated with the excimer laser whereas the rest of the body was treated with UVB narrow-band phototherapy. A modified PASI score was used to evaluate the results. Results: After 12 treatments, 15 patients were evaluated. In 2 patients no difference between the two body sides was observed. In 9 patients the laser-treated lesions showed better results, whereas in 4 patients the side treated with 311-nm UVB showed more clearing. The mean reduction in PASI score was 5.6 and 4.9, respectively (difference not significant). Conclusion: The use of the 308-nm xenon chloride excimer laser is an additional effective therapeutic option for the treatment of psoriasis vulgaris.

Zusammenfassung Ziel: Wir beurteilten die Ätiologie von Ulcera crurum bei Patienten mit Kollagenosen und evaluierten den Heilungsverlauf nach gezielter, kausaler Behandlung. Methoden: Retrospektive klinische Studie mit 20 konsekutiven Patienten: rheumatoide Arthritis (n = 12), progressive systemische Sklerose (n = 7), systemischer Lupus erythematodes (n = 1). Ergebnisse: Folgende relevanten Pathologien wurden vorgefunden: Makrozirkulation (insgesamt 17; arteriell 10, venös 10, kombiniert 3), kutane leukozytoklastische Vaskulitis (5), Steroid-induzierte Hautatrophie (8), arthrogenes Stauungssyndrom (9), dystrophe Kalzinose (3). Folgende Interventionen wurden durchgeführt: Arterielle Revaskularisation (9), Krossektomie und Stripping von insuffizienten Stammvenen (7), Spalthauttransplantation (17), wovon fünfmal unter Immunsuppression bei Vaskulitis. Bei Studienabschluss waren 13 abgeheilt, 4 gebessert (90% geheilt) und 3 unverändert; ferner 1 Unterschenkelamputation der Gegenseite, ein Patient verstarb. Schlussfolgerung: Ulcera crurum bei Patienten mit Kollagenosen haben meistens eine multifaktorielle Ätiologie. Die Verbesserung der arteriellen und venösen Makrozirkulation ist der wichtigste Schritt in der Therapieplanung. Selbst dann benötigen noch drei Viertel aller Patienten eine Spalthauttransplantation, um die chronische Wunde unter verbesserten Voraussetzungen zur Abheilung oder Besserung zu bringen.

Background: A large proportion of chronically immunosuppressed patients suffer from recalcitrant viral warts. Furthermore, the incidence of nonmelanoma skin cancer is clearly elevated in this patient group and human papillomavirus is most likely to play a causal role in these neoplasms. Objective: To analyze the effectiveness of treatment of viral warts with the CO2 laser in immunosuppressed patients. Methods: Multiple viral warts of 13 patients with immunosuppression, a majority of them renal allograft recipients, were treated with CO2 laser in local or regional anesthesia. In case of recurrences, the lesions were treated again after 3 months. Results: 12 of 13 patients experienced dramatic improvement after 1–3 treatment sessions, 6 of these patients showed full remission. Side effects such as postoperative pain or scarring were minimal. Conclusion: CO2 laser treatment of recalcitrant warts in immunosuppressed patients shows promising results which are comparable to those in immunocompetent hosts. This offers a welcome enlargement of the array of therapies in this otherwise difficult-to-treat group of patients and may contribute to the reduction of risk factors for nonmelanoma skin cancer.

Leg ulcers are not a diagnosis but a symptom of many different diseases. In this chapter we will describe leg ulcers caused by arterial disease. However, many other causes should be considered in refractory ulceration on the lower extremity such as venous disease, neuropathy, and miscellaneous causes like vasculitis, malignancy, and autoimmune disease and even rare causes like pyoderma gangrenosum [1], thromboangiitis obliterans, or arterial-venous malformation. Martorell hypertensive ischemic leg ulcers [2] as part of the arterial causes are not discussed here as they are described in another chapter. Very often the ulcers of the lower leg result from a combination of factors [3]. Therefore, it is important to rule out arterial insufficiency even when other causes or clinical signs are present. For example, about 15 % of all leg ulcers are of a mixed arterial-venous origin [4, 5]. We postulate that every patient with ulceration on the lower leg should receive an arterial workup, not only because a concomitant arterial disease may delay healing but also because of the underlying systemic process (arteriosclerosis) for which the patient might profit by an appropriate systemic therapy [6, 7].

BACKGROUND Axillary hyperhidrosis is a common and distressing problem interfering with the life of affected individuals. Currently, local surgery is the treatment of choice once conservative treatment has failed. OBJECTIVES To evaluate the clinical efficacy and safety of tumescent suction curettage (TSC) in treating axillary hyperhidrosis and to correlate it with histological markers. METHODS Thirty patients (17 females and 13 males, average age 29.9 years) underwent TSC. After tumescent anaesthesia, a suction cannula was inserted in the axilla on each side through two tiny incisions and subcutaneous tissue was removed by suction. We evaluated the clinical efficacy and complications, and in a subset of patients performed biopsies before surgery, as well as 1 month and 1 year after the operation. RESULTS In comparison with preoperative values, the sweat rate was diminished by 85% after 1 month, 71% after 6 months, 77% after 12 months and 61% after 24 months. The reduced efficacy with time was histologically correlated with an increase in the innervation, whereas the number of sweat glands continued to diminish. The majority of patients were satisfied with the operation but the satisfaction diminished with time. Patients with the highest preoperative sweat rates were the most satisfied after the intervention. CONCLUSION TSC is an effective and safe treatment for axillary hyperhidrosis. The long-term recurrence may be due to reinnervation.

e report the case of a 57-year-old white manwithout personal or family history or otherrisk factors for melanoma. On clinical examination,we found an isolated pigmented lesion on the soleof his right foot that did not resemble any otherlesion on his body (ugly duckling lesion). Accordingto the patient, the lesion had been present for a ‘‘longtime’’ but had recently increased in size.Clinical examination showed an irregularly pig-mented brown macule on the right sole measuring 12by 10mm (Figure 1, left part).

Background: To study the dose-dependent effects of histamine on capillary permeability in human skin, using the microinjection technique. Patients and methods: Eight healthy volunteers (2 w, 6 m; mean age 33 years) were included in the study. On two separate occasions, glass microcannulas with a tip diameter of 7 to 9 mum were inserted into the subepidermal layer of the skin at the distal medial tibia surface of each lower limb with a micromanipulator. In each subject, 0.5 mul of 3 different concentrations of histamine solution (0.1™, 0.01™ and 0.001™) were injected and compared to the solvent (0.9% NaCl). Transcapillary diffusion of intraveneously administered Na-fluorescein was assessed simultaneously using two fluorescence videomicroscopy systems. Off-line video densitometry was performed in an area of 0.56 mm2 around the injection sites and fluorescence light intensities were measured in arbitrary units (AU) at 10, 30, 60, 120 and 600 s after dye appearance. Results: Compared to the solvent histamine microinjections resulted in a dose-dependent increase of mean fluorescence light intensities (FLI). Whereas mean FLI for the 0.001™ histamine injection was only significantly elevated 10 min after dye appearence (p < 0.05) an increase of mean FLI was already observed 10 s after dye appearence following the 0.1™ histamine injection (p < 0.05), which was more pronounced at later time points (p < 0.001). Mean FLI’s for the 0.01™ histamine solution were in between and resulted in significantly elevated values 1 min to 10 min after dye appearence (p < 0.05). Conclusions: We conclude that the microinjection technique together with fluorescence videomicroscopy described previously [6] is able to document a dose-dependent effect of histamine microinjections on skin capillary permeability. The technique may facilitate to determine appropriate dosages not only of histamine in order to test the effect of antagonists on human skin capillary permeability.

OBJECTIVES:: To compare postoperative healing of split-thickness skin graft (STSG) donor sites using traditional dressings (paraffin gauze) or modern wound dressings (alginate dressing and polyurethane film) in a randomized controlled trial. METHOD:: Thirty patients were randomly assigned to treatment of an STSG donor site with an alginate dressing and a polyurethane film or nonadherent paraffin gauze. Outcome variables were pain (measured with a visual analog scale), amount of dressing changes, healing time, cosmetic outcome, treatment costs, and overall satisfaction with the procedure. RESULTS:: There was no significant difference in pain (postoperative day 1: 2.1 vs 1.2, P = .26; postoperative days 5-7: 1.0 vs 0.9, P = .47; final removal: 1.9 vs 1.0, P = .19) and time to healing (18.1 vs 15.4 days, P = .29) between alginate/polyurethane film dressing and nonadherent paraffin gauze. The semiocclusive dressings with polyurethane film required multiple dressing changes, whereas the nonadherent paraffin gauze could be left in place until complete epithelialization. Treatment costs were substantially lower for paraffin gauze. CONCLUSIONS:: Semiocclusive dressings with alginate dressings and polyurethane film showed no advantages over treatment with paraffin gauze. With lower costs and better patient acceptance, paraffin gauze dressings were the preferred treatment for STSG donor sites.

Acne vulgaris is one of the most common dermatological diseases, and caused by a combination of pathogenetic factors including follicular hyperkeratosis, seborrhea, colonization with Propionibacteriumacnes and inflammatory phenomena. Various medical treatments address these causative factors, but they are not always well tolerated. In the last decades, there has been increased interest in laser and light-based treatments. These optical devices mainly target Propionibacteriumacnes by activating porphyrins produced by the bacterium, whereas some treatments directly lead to the destruction of sebaceous glands. Photodynamic therapy can enhance these effects through the prior application of a photosensitizing agent. Many laser and light-based treatments have shown excellent clinical results in the reduction of inflammatory acne lesions and improved acne severity. Although relapses are frequent, results can be improved by combination therapy with conventional medical treatments. Data of randomized controlled studies or studies with a split-face design are contradictory and difficult to compare. Furthermore, the cost of the treatments is often a limiting factor. In summary, some optical devices are an important additional tool in the treatment of patients with mainly inflammatory acne where conventional treatments are not well tolerated.

A clinical model to examine the hypothesis that venous hypertension of the lower leg per se can cause lower leg stasis dermatitis is described. To prove this concept, we retrospectively studied a consecutive series of 38 patients with lower leg dermatitis who underwent phlebological examination at our consultation over a period of four years. Among those patients who had an insufficiency of the superficial veins only, without insufficiency of the deep veins, 22 had undergone patch testing to common allergens in phlebology. We found 10 patients with a stasis dermatitis of the lower leg and an incompetent great saphenous vein, six of whom had no detectable contact sensitization at all and another four exclusively to phlebologically irrelevant substances, e.g. nickel, cobalt, chromate or epoxid resin. All these 10 patients showed long saphenous vein incompetence from the groin to the medial aspect of the leg. All were operated by classical flush ligation and saphenectomy. Lower leg dermatitis healed in all 10 patients within 8–12 weeks and no recurrence was observed (1 year follow-up). These results support clinical experience that venous hypertension alone indeed can cause lower leg dermatitis.

Objectives To better define the diagnosis and treatment of Martorell hypertensive ischemic leg ulcer (HYTILU) and to compare Martorell HYTILU with calciphylaxis (calcific uremic arteriolopathy) and nonuremic forms of calciphylaxis. Design Retrospective study from 1999 through 2007. Setting Department of Dermatology, University Hospital of Zurich, Zurich, Switzerland. Participants Of 330 patients with leg ulcers, 31 had a clinical diagnosis of Martorell HYTILU confirmed by dermatopathologic examination. Main Outcome Measures Clinical features, suspected diagnosis at initial presentation, cardiovascular risk factors, findings from vascular examination and histologic analysis, specific medical and surgical management, and outcome. Results Of the 31 patients, all presented with 1 or multiple painful necrotic skin ulcers on the laterodorsal part of the leg, with bilateral involvement in 16 of 31 cases (52%), and 16 were referred with suspected pyoderma gangrenosum. All patients had arterial hypertension, and 18 (58%) had diabetes. All patients had subcutaneous stenotic arteriolosclerosis on histologic analysis, with medial calcification in 22 of 31 of cases (71%). Martorell HYTILU, calciphylaxis, and nonuremic forms of calciphylaxis shared identical histologic features. Of the 31 patients, 29 (94%) were successfully treated with surgical debridement and split-thickness skin grafting. Three patients (9%) died of sepsis, 2 of whom were undergoing immunosuppressive treatment for wrongly diagnosed pyoderma gangrenosum. Conclusions Ischemic subcutaneous arteriolosclerosis is the hallmark of Martorell HYTILU, calciphylaxis, and the nonuremic forms of calciphylaxis. All patients are hypertensive and approximately 60% are diabetic. Martorell HYTILU can easily be confused with pyoderma gangrenosum, which can be detrimental, since the 2 diseases require a completely different treatment strategy.