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In the last few decades it has been reported that the intake of some drugs may lead to the onset of a leg ulcer. In the etiology particularly allergic and toxic mechanisms have been postulated to induce pathological reactions which potentially lead to vasculitis or vasculopathies. The causal association of the intake of drugs and the occurrence of a leg ulcer is not always clearly proven. Most of the presented drugs in this overview are substances for which only a few case reports has been described for an association with leg ulcers. Diagnoses are often made by exclusion of other causes and because of a temporal relationship. One exception is drugs which contain the active ingredient hydroxyurea. More than 100 published patients have developed leg ulcers while on hydroxyurea. Moreover, these ulcerations have a typical clinical morphology. Numerous systemic medicaments can lead directly or indirectly to the onset of a leg ulcer. Therefore it is important to recognize this potentially relevant factor and adjust the medications as part of the therapeutic plan.

The histological status of the sentinel lymph node (SLN) is one of the most relevant prognostic factors for the overall survival of patients with cutaneous malignancies, independent of tumour depth of the primary tumour.Our study seeks to evaluate the reliability and medical benefit of SLN excision (SLNE) performed with a portable γ-camera for intraoperative real time imaging of SLN.Therefore our study compares the visualization of SLN performed with preoperative lymphoscintigraphy and preoperative SPECT/CT with the intraoperative real time imaging of SLN performed with a new portable γ-camera (Sentinella) in 60 patients who were treated with a SLNE for early stage melanoma (n = 38), high risk cutaneous squamous cell carcinoma (n = 16), Merkel cell carcinoma (n = 4), sebaceous gland carcinoma (n = 1), and sweat glands carcinoma or porocarcinoma (n = 1).Sixty patients were enrolled in this study. The portable γ-camera visualized all 126 preoperatively identified SLN. 23 additional SLN (15.4%) in 15 patients were only identified using the portable γ-camera. Two of these additional SLN showed metastatic involvement.The portable γ-camera is an innovative imaging technique, reliable and providing additional information in the detection of SLN. Therefore SLNE with intraoperative γ-camera use is an attractive option to improve the detection of SLN in cutaneous malignancies and could help to reduce false negative SLN results.

The approach to patients with chronic leg ulcers should include not only an accurate diagnosis with appropriate therapy fort he underlying disease, but also the development of effective analgesia. To assess the analgesic effect of topical morphine, we developed a new morphine gel with polihexanide as a preservative for the local pain treatment.We have studied 30 patients with painful chronic leg ulcers with an average age of 66 years. The respective pain intensity was assessed 24 hours after application of the morphine hydrogel and objectified with a visual analogue scale (VAS) ranged from 0 to 10.All investigated patients had a pain intensity of at least 4 points before the topical application of the morphine gel; the average pain intensity was 7.8. After application of the morphine gel, a significant reduction of the average pain intensity was observed, with an average pain intensity of 4.5.These first clinical results with the new morphine gel suggest that at least fort he first 24 hours it combines the advantages of a moist wound healing and a local pain treatment. This new development is certainly a promising therapeutic alternative for pain treatment in patients with chronic leg ulcers.

Complete lymph node dissection (CLND) in melanoma patients with a positive sentinel lymph node (SLN) is currently being debated, as it is a cost-intensive surgical intervention with potentially high morbidity.This clinical study seeks to clarify the effectiveness, reliability and cost-effectiveness of CLND performed under tumescent local anaesthesia (TLA) compared with procedures under general anaesthesia (GA).We retrospectively analysed the data from 60 patients with primary malignant melanoma American Joint Committee on Cancer stage III who underwent CLND.Altogether 26 (43.3%) patients underwent CLND under TLA and 34 (56.7%) patients underwent CLND under GA. Fifteen of 43 (34.9%) patients had a complication, such as development of seromas and/or wound infections. The rate of complications was 25.0% (3/12) in the axilla subgroup and 28.6% (4/14) in the groin subgroup of the TLA group. In the GA group, the complication rate was 31.3% (5/16) in the axilla subgroup and 44.4% (8/18) in the groin subgroup. The costs for CLND were significantly less for the CLND in a procedure room performed under TLA (mean €67.26) compared with CLND in an operating room under GA (mean €676.20, P0.0001).In conclusion, this study confirms that TLA is an excellent, safe, effective and cost-efficient alternative to GA for CLND in melanoma patients.

There have been reports indicating seasonal differences in the onset of chronic leg ulcers. The reasons for such seasonal fluctuations are not well understood. Therefore we decided to examine the seasonal incidence of chronic leg ulcers in our patient population, caused by chronic venous insufficiency (CVI) or mixed arterial and venous disorders, for any correlation with climatic factors.We retrospectively analysed the data of 183 patients with chronic leg ulcers, evaluated the monthly and seasonal onset of the leg ulcers and investigated correlations between the incidence and climatic factors.The onset of chronic leg ulcers showed significant seasonal fluctuations with a decrease in summer and an increase in autumn-winter. The ulcer onset in the cold months, autumn and winter, was significantly higher (P = 0.026) compared with spring and summer. Furthermore, in the bivariate correlation analysis of the variables temperature and ulcer onset, there was a statistically significant negative correlation between temperature and new ulcer onset. The colder the temperature was, the higher was the new ulcer onset with a correlation coefficient of -0.613 (P = 0.034).The onset of chronic leg ulcers caused by CVI and mixed arterial and venous disorders in our patient population showed significant seasonal variations and demonstrated an inverse relationship to temperature. In summary, climatic factors appear to play an important role in the onset of chronic leg ulcers. Climatic factors may therefore need consideration in future clinical investigations and in the development of prophylactic therapeutic strategies.

There is some controversy around the value of sentinel lymph node excision (SLNE). Especially SLNE of cutaneous head and neck malignancies has been debated intensively, in part because of the complexity of the lymphatic drainage in this region associated with potential high morbidity. In order to improve preoperative three-dimensional mapping of sentinel lymph nodes (SLN), in the head and neck region, by means of hybrid single photon emission computed tomography/computed tomography (SPECT/CT) is gaining significance. Our study seeks to identify the potential medical and economic advantages of preoperative SPECT/CT in direct comparison to standard SLNE without SPECT/CT in patients with cutaneous head and neck malignancies.We retrospectively analysed the data of 48 clinically lymph node-negative patients with early stage melanoma, high risk cutaneous squamous cell carcinoma and porocarcinoma, who underwent SLNE with or without preoperative SPECT/CT within 4 years.The SLNE in the head and neck region with SPECT/CT-technique demonstrated better postoperative aesthetic results had lower morbidity and significantly reduced operating time. Moreover, SLNE with SPECT/CT-technique in the head and neck region was feasible using local anaesthesia (LA) and significantly reduced resulting costs (€32.65/SLNE with LA vs. €334.57/SLNE with general anaesthesia, P0.0001).SPECT/CT is an innovative imaging technique, reliably and readily providing additional anatomical/functional information to detect and to excise SLN in the head and neck region. Therefore, SLNE with SPECT/CT-technique is an attractive option to improve the detection of SLN in cutaneous head and neck malignancies.

Behandlungsdruck und Innovation fuhren zu immer neuen Entwicklungen auf dem Gebiet der Wundbehandlung. Durch den demographischen Wandel bekommt die Behandlung chronischer Wunden zudem auch eine zunehmende okonomische Bedeutung. Dabei verlangt der okonomische Einsatz auch eine Datenlage mit hoher Evidenz als Grundlage der Entscheidung fur oder gegen eine Therapiestrategie. Durch die stetig steigende Anzahl an Produkten fur die sog. moderne feuchte Wundbehandlung bleibt die wissenschaftliche Datenlage jedoch trotz vielfaltiger Bemuhungen um gute Studien meist luckenhaft. In diesem Ubersichtsbeitrag sollen Wundtherapien systematisiert dargestellt werden, wobei sich das aber nicht nur grundsatzlich auf die Einordnung der Wundauflagen bezieht, sondern auch auf die Besonderheiten der wichtigsten Wundentitaten.

Von zahlreichen Medikamenten wurde in den letzten Jahrzehnten berichtet, dass deren systemische Einnahme zur Entstehung eines Ulcus cruris fuhren kann. Atiologisch wurden insbesondere allergische und toxische Mechanismen diskutiert, die eine Reihe von relevanten pathologischen Reaktionen, insbesondere aber Vaskulitiden und Vaskulopathien induzieren konnen. Die kausale Assoziation des systemisch eingenommenen Medikamentes mit dem Auftreten eines Ulcus cruris ist jedoch nicht immer eindeutig zu klaren. Bei vielen der in diesem Ubersichtsbeitrag vorgestellten Medikamente handelt es sich um Wirkstoffe, bei denen lediglich in einigen wenigen Kasuistiken eine Assoziation mit dem Auftreten eines Ulcus cruris beschrieben wurde. Oft handelt sich somit um eine Ausschlussdiagnose, die aufgrund eines zeitlichen Zusammenhangs diskutiert werden kann. Eine Ausnahme stellen Medikamente dar, die den Wirkstoff Hydroxyurea enthalten. Zu diesem Wirkstoff existieren mehrere hundert publizierte Patienten, bei denen ein Ulcus cruris auftrat. Zudem weisen diese Ulzerationen oft eine typische Morphologie auf. Zahlreiche systemisch eingenommene Medikamente konnen direkt oder indirekt zur Entstehung eines Ulcus cruris fuhren. Somit ist es wichtig, dass Therapeuten diesen potenziell relevanten Faktor erkennen, um im Rahmen einer kausal ansetzenden Behandlung eine entsprechende Umsetzung der relevanten Medikamente zu veranlassen.

In the process of chronic wound care, adhesive wound dressings may cause pain and injury in the wound environment during dressing changes. At present, no standardized test procedures are available for the investigation of adhesion of wound dressings. Therefore, our study aimed to test the adhesion of different wound dressings on steel as well as on healthy skin.Within an open, comparative study, the adhesive areas of 56 wound dressings were investigated. The adhesives were categorized into acrylate (n = 23), silicone (n = 9), hydrocolloid (n = 17) and polyurethane groups (n = 7). Using an especially modified testing machine, the adhesion of the wound dressings was measured on steel as well as on the skin of healthy study participants, in compliance with the European EN 1939:2003 standard.The energy required to remove the wound dressings from human skin, was measured in Newton (N) and the following median values were obtained: hydrocolloid (2.25 N)acrylate (1.14 N)polyurethane (0.9 N)silicone (0.7 N). The subjective pain intensity during the removal of the wound dressings was recorded using the visual analogue scale (VAS) with values ranging from 0 to 10. For hydrocolloid, it was 6.8, for acrylate 4.9, for polyurethane 3.1 and for silicone 2.5 points VAS. In comparison with human skin, the adhesion of wound dressings was significantly higher on steel (P0.0001), but was different for the different groups of wound dressings. Moreover, there was a statistically significant correlation between the adhesion and pain intensity (correlation coefficient 0.806; P = 0.01).The knowledge about the widely differing adhesion properties of different wound dressings on the skin of patients should nowadays be considered during the individual selection of the applied products. Based on these data, different types of wound dressings could be developed, guaranteeing a good adhesion and a low traumatic risk when removed.

An increasing numbers of physical treatment options are available for chronic leg ulcer. In this review article, compression therapy, therapeutic ultrasound, negative pressure therapy, extracorporeal shock wave therapy, electrostimulation therapy, electromagnetic therapy, photodynamic therapy, water-filtered infrared-A-radiation and hydrotherapy are discussed in terms of their practical applications and the underlying evidence. With the exception of compression therapy for most of these treatments, good scientific data are not available. However this is a widespread problem in the treatment of chronic wounds. Nevertheless, several of the described methods such as negative pressure therapy represent one of the gold standards in practical treatment of patients with chronic leg ulcers. Although the use of physical treatment modalities may improve healing in patients with chronic leg ulcers, the diagnosis and treatment of the underlying causes are essential for long-lasting success.

The formation of post-operative lymphocele and lymphorrhea following lymph node surgery is a potentially serious complication. Until now there has been no consensus on the most effective treatment for these complications. Therefore, the aim of our clinical trial was to compare the use of polidocanol foam sclerotherapy with compression therapy to wound drainage, in the treatment of post-operative lymphoceles.Retrospectively we analysed the data of 33 consecutive surgical patients who had developed a post-operative lymphocele between 2004 and 2008. We offered all patients drainage with compression therapy or polidocanol foam sclerotherapy with 1-day compression to treat the post-operative lymphoceles.Altogether, 12 patients were treated with polidocanol foam sclerotherapy and 21 patients were treated with drainage alone. Secretion volumes declined from initial 50-350 ml/day to 0-20 ml/day at the end of the therapy. Lymphorrhea resolved much quicker (P0.0001) in patients treated with polidocanol foam sclerotherapy (median 4 days, mean value 6.4 days) than in those treated with drainage (median 31 days, mean value 30.2 days). None of the patients developed a major complication.Polidocanol foam sclerotherapy is an effective and well-tolerated new treatment for patients with post-operative lymphoceles.

A 73-year-old female patient presented with acute very painful perianal ulcerations. She reported using various ointments and later potassium permanganate baths because of maceration of the rima ani as a manifestation of her psoriasis vulgaris. Suddenly after starting the potassium permanganate baths, necrotic areas developed with then became ulcerated. After excluding the relevant differential diagnostic considerations, we diagnosed ulcerations caused by a caustic burn from potassium permanganate. After stooping potassium permanganate baths and employing modern moist wound therapy, we attained complete healing after 8 months of treatment.

The etiology of chronic leg ulcers is very heterogeneous. The primary aim of our investigation was to analyze the etiology of leg ulcers in patients treated in our wound care center over a period of 5 years. In this open retrospective study, data of 354 patients was analyzed. We found a venous leg ulcer in 203 (57%), and in 52 (15%) patients a combined arterio-venous induced leg ulcer. The third most common cause was leg ulcers due to different types of vasculitis in 47 (13%) patients. An exclusively arterial induced leg ulcer was diagnosed in 13 (3.7%) patients. Overall 16 different etiologies were identified. In contrast to the few comparable other investigations, we found a higher incidence of immunologic und infectious causes for leg ulcers in our patients. Even if our results do not allow a representative overview about the prevalence of leg ulcer in Germany, they demonstrate the wide spectrum of leg ulcer causes in a dermatologic wound care centre.

We report on a 60-year-old man with psoriasis vulgaris who had developed disseminated ulcerations of different sizes over the complete integument over a period of 3 months. The initial examination revealed approximately 150 clearly defined ulcerations, which were mostly reported to be painless. The histopathology report of a biopsy taken from the border area of an ulceration showed a nonspecific inflammation with a predominantly neutrophilic infiltrate. In the synopsis of all results, after excluding relevant differential diagnoses, we diagnosed a superficial multilocular pyoderma gangrenosum that had possibly developed in the areas of the preexisting psoriasis vulgaris. Reports of superficial multilocular pyoderma gangrenosum, a variation of pyoderma gangrenosum, are extremely rare. This condition is characterised by multiple superficial, chronically persistent ulcerations. These ulcerations are often described as indolent and usually develop from a pustule in the area of a preexisting condition or trauma. Up to now, psoriasis vulgaris has seldom been described as a trigger for pyoderma gangrenosum. The treatment is very difficult and is based on local and/or systemic immunosuppression. In this patient's case, considerable improvement was attained with a topical polyhexanide gel in combination with moist wound therapy, with no systemic immunosuppression. Our case report underscores that physicians should keep in mind the rare variation of superficial multilocular pyoderma gangrenosum in the differential diagnosis of multiple disseminated, painless ulcerations over the complete integument in patients with psoriasis vulgaris.

Major components in the conservative treatment of patients with chronic venous leg ulcers are compression therapy and modern wound dressings. Both therapies are used simultaneously. Consequently it is important to know the exudate capacity of modern wound dressings changes during compression therapy. In the first part of our study we analyzed the maximum exudate capacity of 15 modern wound dressings. In the second part we showed that under compression stockings of class 2, a reduction of 44.08% and under compression stockings of class 3, a reduction of 50.49% occurred. In the third part we pointed out that all the investigated wound dressings released absorbed fluid when under compression. Again the effect was higher when using compression class 3 with 40.78% compared to compression class 2 with 40.50%. Our results show for the first time the broad variability of exudate capacity of modern wound dressings. Our results show that compression therapy has a considerable effect on the ability of modern wound dressings to absorb and retain exudate and suggests that more frequent changes may be required.

Although the positive effects of negative pressure-therapy in wound-healing has been well known for several decades, the first paper on the now widely used vacuum systems was published ten years ago. Since then vacuum-therapy has been widely used in patients with"hard-to-heal" wounds, including dermatologic patients. Although there is still a lack of relevant comparative prospective controlled clinical trials, vacuum-therapy seems to accelerate the healing process in chronic wounds in both the granulation and epithelialization phases. Therefore, following debridement, vacuum-therapy can be considered as the therapy of choice for many patients with chronic wounds.

Chronic wounds occur in 1-2% of the population. After the age of 80 the incidence raises up to 4-5%. Leg ulcers are the most frequent diagnosed chronic wound. In this most often affected age group malnutrition develops more frequently compared to the total population. The combined presence of chronic wounds and malnutrition suggests a potential causative connection. In this clinical investigation, data evaluating the nutritional status in patients with chronic leg ulcers, derived from clinical examination, medical history and laboratory tests was analyzed for the first time for a German patient collective. Over a time period of one year we evaluated 41 patients for body mass index, diabetes mellitus, restricted mobility, diet, nicotine and alcohol use, and blood levels of vitamins, trace elements, lipids and HbA1c. We further employed the MNA-questionnaire for malnutrition. We rarely found deficiencies but often improper nutritional practices. Thus we consider that it important to evaluate nutritional status even in obese patients with leg ulcers and poorly healing wounds.

In the last years increasing of numbers dermatologic patients with chronic wounds and problem bacteria such as methicillin-resistant Staphylococcus aureus (MRSA) have been reported. Even though it is still unclear if bacterial contamination with MRSA independently interferes with wound healing, both the logistic and therapeutic consequences of identifying MRSA are considerable for the patient and the treatment facility. In this review the practical consequences and the therapy options associated with the identification of MRSA in patients with chronic wounds are considered.

We report on a 46-year old female patient with a 2-year history of ulceration over the dorsum of her right foot associated with a congenital arteriovenous fistula. About 12 years ago she had an ulcer at the same site. Despite an insufficient occlusion of the arteriovenous fistula after coil-embolization complete healing of the ulcer was achieved for a period of 10 years. At present hyperpigmentation could be seen surrounding the ulcer as a clinical sign for a venous insufficiency. The ulcer healed completely under a conservative therapy of the venous component of the arteriovenous fistula. The pathogenesis and therapy of ulcers associated with arteriovenous fistula within a Stewart-Bluefarb syndrome are discussed in this case report.

Sjögren syndrome is a rare chronic systemic autoimmune disease characterized by progressive dryness of the mucous membranes. There are many variable clinical manifestations. A 40-year-old woman presented with painful leg ulcers refractory to various therapies. She had a history of xerostomia and xerophthalmia for several years. Based on clinical, serologic and histopathologic findings, we diagnosed leg ulcers in primary Sjögren syndrome. Combing immunosuppressive therapy with phase-adapted modern wound-therapy resulted in a complete healing of the ulcers. In the case of clinically atypical leg ulcers, Sjögren syndrome should be considered as a rare differential diagnostic possibility.

Tetanus disease is caused by Clostridium tetani and is one of the most common infectious diseases worldwide. Despite international recommendations for patients with a chronic leg ulcer, there has been a distinctive lack of protection provided by vaccination for these patients in the past decades.Within the context of our prospective clinical investigation we consecutively determined the concentrations of immunoglobulin G antibodies against C. tetani in 100 patients with a chronic leg ulcer between January 2005 and November 2006.A total of 38 patients were male, and 62 were female. Their mean age was 71 years (25-94). In a total of 47% (n = 47; 13 male, 34 female, mean age: 76 years) of the patients, insufficient immunoglobulin G antibody concentrations were detected. Particularly the subanalysis indicated an insufficient tetanus protection provided by vaccination in 70% of the people agedor=80 years.A chronic wound, e.g. in the form of a leg ulcer, is known as a potential entrance for C. tetani. Unlike acute wounds, however, it is hardly ever considered to be a reason for assessment of the tetanus immune status. The results of our investigation clarify that particularly elderly people suffering from a leg ulcer have to be tested for tetanus protection provided by vaccination more strictly than ever, and if necessary, vaccinations have to be renewed.

Necrobiosis lipoidica is an inflammatory granulomatous skin disease of unknown etiology which is associated with diabetes mellitus in about 60% of the patients. In 15-35% of the affected patients painful ulcerations may occur after minimal trauma which can be extremely refractory to therapy. Because of the unknown pathomechanisms, current therapeutic options are limited. We report on a 68-year-old patient with an 18 year history of ulcerated necrobiosis lipoidica non diabeticorum of both lower limbs, which responded to systemic cyclosporine A. Based on this case, we discuss the role of cyclosporine A in patients with necrobiosis lipoidica in the context of the disease etiology.

Extremely painful leg ulcers on the lateral aspect of both ankles developed in a 38-year-old man for the first time six weeks after starting treatment with anagrelide for thrombocythemia.Extensive diagnostic tests, including laboratory tests, Doppler and duplex ultrasound of the superficial and deep leg veins, histopathology and bacteriological and mycological tests excluded vascular disease, vasculitis and metabolic causes.Despite adequate local treatment the ulcerations did not improve until anagrelide was discontinued and replaced by hydroxyurea.Anagrelide administration was the most likely cause of the leg ulcerations, even though this possible side effect has only been described once in the literature.

We report the case of a 37-year-old woman presenting with progressive livedo racemosa (panel A), limited physical capabilities and behavioural disorders. Cerebral magnetic resonance imaging (MRI) showed …

Actinic keratosis is a precancerous lesion that is commonly seen in the elderly patient and requires treatment. It shows a predilection for areas of the skin that are exposed to the sun, and usually manifests as multiple skin-colored or discrete reddish scaly verrucous plaques. The diagnosis is usually based on the clinical appearance of the lesion. Therapeutic options include physical, immunological and chemical measures. The choice of treatment is determined by numerous factors, and can be adapted to the individual situation presenting.

Factitial cutaneous lesions result from self-inflicted injury leading to objectifiable clinically relevant damage to the skin. Triggering factors are frequently psychiatric disorders or specific stress situations. Clinical manifestations range from superficial erosions to deep wounds.The establishment of the diagnosis is often a time-consuming and complicated process that precedes acceptance of the underlying pathology by both the therapist and patient. If lasting therapeutic success is to be achieved, the possibility of such cutaneous lesions must be included in differential diagnostic considerations, and early interdisciplinary cooperation is necessary.

Vacuum-assisted closure (V.A.C.) is an established therapeutic option in the management of acute and chronic granulating wounds. In recent years, little data has been published concerning skin graft transplantation and postoperative V.A.C. therapy. We report a consecutive case series of 54 patients with chronic leg ulcer who received a total of 74 mesh grafts. A postoperative V.A.C. therapy was performed in 28 mesh grafts, and 46 mesh grafts were treated with standard gauze therapy. In the V.A.C. group, 92.9 % grafts showed complete healing. In the treatment group without postoperative V.A.C. therapy, 67.4 % of the mesh grafts had taken. Differential analysis revealed a correlation in patients over 70 years of age or in patients suffering from diabetes mellitus or dermato-lipo-sclerosis. Particularly patients with diabetes mellitus and of greater age exhibited improved take rates in the V.A.C. group. The results of our study demonstrate for the first time the significant benefit of V.A.C. therapy after mesh-graft-transplantation in chronic leg ulcer patients as evaluated in a clinical trial with a control group.

The objective evaluation of the course of wound-healing represents a substantial parameter for the quality assurance of a modern wound management in chronic wounds. Established procedures exclusively based on a two-dimensional measurement of the wound surface with planimetry or digital photo documentation in combination with a metric statement of size. Thus so far an objective method is missing for the evaluation of the volumes of chronic wounds. By the linkage of digital photography, optical grid by means of digital scanner and an image processing software in co-operation with the company RSI we were able to do an accurate 3-dimensional documentation of chronic wounds (DigiSkin). The generated scatter-plots allow a visual, computer-assisted 3-dimensional measurement and documentation of chronic wounds. In comparison with available systems it is now possible for the first time to objectify the volume changes of a chronic wound. On the basis of a case report of a female patient with an venous leg ulcer, which has been treated with a vacuum closure therapy before and after performing a mesh-graft transplantation, we would like to describe the advantages and the resulting scientific use of this new, objective wound documentation system in the clinical employment.

Basal cell carcinoma is a semi-malignant epithelial skin tumour with a locally destructive growth pattern but a very low tendency to metastases. Basal cell carcinoma represent the most frequent malignant cutaneous tumour worldwide in white population with a lifetime risk of 30 % and still increasing incidence. Lifetime cumulative UV-exposure, as well as frequent sunburns are the most common exogeneous risk factors, others are ionising radiation, exposure to chemical carcinogens, genetic predisposition, and chronic immunosuppression. Basal cell carcinoma are predominantly located in the central region of the face. The characteristic clinical feature is a single nodule with multiple teleangiectasia, as well as an irregular shaped ulceration with and elevated border. The very rarely observed occurrence of metastases seems to be a result of insufficient therapy or a metatypic basal cell carcinoma type. Therapy of first choice of basal cell carcinoma is the complete, micrographically controlled excision. In addition, radiotherapy, topical immunotherapy with Imiquimod or photodynamic therapy may be considered as therapeutic alternatives in selected cases.

A 71-year old man presented with painful hemorrhagic vesicles and papules over the entire body that had persisted for three days. Type 2 diabetes mellitus type 2 had been diagnosed 20 years ago and had not been treated for the last 5 years. Therapy had been discontinued by the patient.HbA1c (11,9%) and blood glucose levels (up to 360 mg/dl) were abnormal. Varicella-zoster-DNA was replicated by PCR from the vesicle fluid.After the clinical diagnosis of disseminated herpes zoster had been confirmed systemic therapy with aciclovir 10 mg/kg day was started. There was no evidence of malignancy. Insulin therapy was initiated.Dissemination is a rare complication of herpes zoster, aided by immunosuppression. In the presented case there was no evidence of malignancy or other cause of immunosuppression, but the patient also had type 2 diabetes with very high blood glucose levels. The diabetes was thought to be causally related to the ineffective immune response to varicella zoster virus. There has been no previous published report of this relationship.

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disease. Leg ulcers in rheumatoid arthritis may be caused by vasculitis and are an interdisciplinary therapeutic challenge. A 69 year old women with rheumatoid arthritis and many other medical problems presented with widespread vasculitis-induced therapy-resistant ulceration on her right lower leg. Since previous therapeutic efforts had a negative effect on wound healing, we administered intravenous immunoglobulins which led to complete healing of the ulcer was achieved. Both the serological and rheumatologic features of her rheumatoid arthritis also improved. Intravenous immunoglobulins represented an effective therapeutic option with fewer side effects in the therapy of vasculitis-induced leg ulceration in this patient with rheumatoid arthritis.

As an adjuvant measure, physical exercise should be recommended for all patients with an ulcus cruris venosum, and should be a permanent part of the patient's lifestyle on completion of wound healing. Although clinical studies have shown that physical exercise has a positive effect on numerous factors of relevance for the development of an ulcer, sports activities undertaken for therapeutic and prophylactic purposes are still made little use of by patients.

The incidence of chronic wounds is increasing in developed Western countries. There are many causes for chronic or non-healing wounds. A multidisciplinary diagnostic approach and attention to underlying disorders are essential. A modern, moist, and phase adapted wound therapy is also essential. Modern wound dressings include activated charcoal, alginates, hyaluronic acid, hydrofibers, hydrogels, hydrocolloids, impregnated gauze, collagen, moist methods, proteolytic enzymes, foams, semipermeable membranes and silver dressings. Because of the lack of comparative investigations the phase-adapted use of wound dressings is still empiric. Application of modern wound dressings may help to create an optimized wound milieu and accelerate healing. Treatment of the underlying causes is an absolute requirement for long-term complete healing.

Patients with chronic wounds frequently acquire clinically relevant contact sensitization. We examined the results of the skin patch tests in patients with chronic wounds, who were treated between 1999-2004 in the Department of Dermatology, University School of Medicine, Essen, Germany. Altogether 105 patients with chronic wounds underwent patch testing. In 68 individuals, contact sensitization to at least one substance was detected. The most frequent contact allergens were to balsam of Peru, Amerchol L-101, fragrance mix, wool wax alcohols and rosins. Contact sensitization to wound dressing materials was also identified in 4 patients. Our results demonstrate the current spectrum of contact sensitization of patients with chronic wounds. Our results show the importance of paying attention to the ingredients in wound dressings and performing patch testing if there is any clinical suggestion of allergic contact dermatitis.

Calciphylaxis is a potentially life-threatening disease that occurs up to 4% of patients with chronic terminal renal failure and secondary hyperparathyroidism. Clinical symptoms are painful skin erythema and ischemic necrosis as a result of calcification of the small and medium-sized arteries of the subcutaneous tissues. The mortality of the disease is as high as 87% mainly due to sepsis from superinfection. We report on a 59-year-old patient with chronic renal failure and normal calcium-phosphate-product with leg ulcers as a rare manifestation of a calciphylaxis. In spite of an early parathyroidectomy and a temporary complete wound-healing the death because of calciphylaxis could not be prevented.

Malignant melanoma is still the most frequent cause of death due to skin cancer with a rising incidence and mortality. Despite continued progress in understanding the pathophysiology of tumor progression and metastasis, curative therapeutic options are still missing for metastatic melanoma. The ability of a malignant melanoma to metastasize is partially derived from the capacity to avoid destruction by an intact immune system. Thus, a better understanding of the immunological processes that lead to the escape of melanoma cells from immune recognition could help to develop preventive strategies or effective new therapies. Therefore, an analysis of the MHC class I pathway and molecules involved in peptide loading of the MHC class I molecules could provide an important clue to future immune-based melanoma therapies, and might also help to select patients who could be expected to profit from T-cell-based immunotherapy. In this review article, we report on current data and concepts about the generation of MHC class I peptide complexes in human malignant melanoma.

A 62-year-old female patient with a venous leg ulcer developed massive eczema during wound bed preparation with the hydrocolloid dressing Varihesive. The patch testing confirmed a pronounced sensitization to the hydrocolloid dressing apart from the sensitization to colophony. After review of the current literature we found several case reports from the last 10 years about sensitization to hydrocolloids which were identical but distributed under different brand names in different countries. These dressings contain the pentaerythritol ester of hydrogenated rosin as the tackifying agent which is the substance retaining the sensitizing potential of colophony. Especially patients with chronic wounds frequently tend to contact sensitizations, and colophony currently represents the 4th most frequent allergen in Germany. Therefore, highly potent allergens such as colophony should be strictly avoided as a content material of modern wound dressings.

Phototherapy requires an individually adapted therapeutic regime that is based upon the minimal erythema dose for each patient. Whereas this is well established for UV-B broadband, so far no standardized equipment existed that allowed for determination of the MED for UV-B 311 nm narrowband irradiation. Thus, the starting dose for UV-B 311 nm is usually adjusted to the clinical skin type or the MED for broad-spectrum UV-B irradiation.We determined the MED for UV-B 311 nm in a cohort of 110 healthy test persons with a newly constructed hand-held UV-light source and compared it to UV-B broadband MED.For UV-B broadband, the MEDs ranged from 46.2 to 210.9 mJ/cm(2) with an average value of 108.45 mJ/cm(2). For the MED of narrowband UV-B 311 nm, the values ranged from 300.9 to 1.386.0 mJ/cm(2) with an average value of 838.88 mJ/cm(2). Concerning the factor of the MED UV-B broad-spectrum related to MED UV-B 311 nm narrowband, values from 4.01 to 13.68 with a average value of 7.91 resulted. No significant differences could be detected for the MED of UV-B broad-spectrum and narrowband in correlation to age, sex or clinical skin type.Our data emphasize the presence of extensive inter-individual differences in the MED of both UV-B-spectra and point to the necessity to test patients before the first irradiation.

Human antimicrobial peptides play a substantial role in the immune response to various dermatological diseases, such as acne, atopic dermatitis and psoriasis vulgaris, and even mucosal HIV-protection is mediated inter alia by antimicrobial peptides. In wound healing, the antimicrobial and immune-modulating properties of, in particular, human defensins and cathelicidins can affect important controlling factors. For example, the interaction between different antimicrobial peptides and growth factors supports neoangiogenesis. Although further clinical investigations are necessary to identify the exact effects of antimicrobial peptides in chronic wounds, such peptides could be a promising therapeutic option in the near future for the treatment of patients with chronic wounds by promoting endogen expression or exogenous supplementation.