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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.

Squamous cell carcinoma (SCC) is the most common neoplasm in organ transplant recipients (OTR) on long-term immunosuppression and occurs 60- to 100-fold more frequently than in the general population. Here, we present the receptor for advanced glycation end products (RAGE) and S100A8/A9 as important factors driving normal and tumor keratinocyte proliferation. RAGE and S100A8/A9 were transcriptionally upregulated in SCC compared to normal epidermis, as well as in OTR compared to immunocompetent patients (IC) with SCC. The proliferation of normal and SCC keratinocytes was induced by exposure to exogenous S100A8/A9 which in turn was abolished by blocking of RAGE. The migratory activities of normal and SCC keratinocytes were also increased upon exposure to S100A8/A9. We demonstrated that exogenous S100A8/A9 induces phosphorylation of p38 and SAPK/JNK followed by activation of ERK1/2. We hypothesize that RAGE and S100A8/A9 contribute to the development of human SCC by modulating keratinocyte growth and migration. These processes do not seem to be impaired by profound drug-mediated immunosuppression in OTR.

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.

Das Ulcus hypertonicum Martorell gehort zu den haufigen Ursachen chronischer Wunden am Unterschenkel. Die korrekte Diagnose wird aber oft verpasst und falschlich ein Pyoderma gangraenosum oder eine Vaskulitis diagnostiziert.

Background: Split-thickness skin graft (STSG) donor sites sometimes cause more postoperative morbidity for patients than the wound covered with the graft. Yet, there is no consensus on which dressings are best suited to treat these donor sites. Objective: To evaluate two commonly used modern wound dressings in the postoperative healing of STSG donor sites in a prospective randomized controlled trial. Methods: 38 patients were randomly assigned to treatment of an STSG donor site with an alginate dressing or a polyurethane film dressing. The primary outcome measures were postoperative pain scores, secondary outcome variables were time to epithelialization, dressing changes and complications. Results: Postoperative pain on day 1 was significantly lower in the polyurethane film group (2.05 vs. 0.79, p = 0.035) as compared to the alginate group. This difference was not detected on day 5 (0.89 vs. 0.53, p = 0.52). Time to epithelialization did not differ significantly between the two dressing groups. There were more dressing changes in the polyurethane film group and problems with leakage. Conclusion: Whereas film dressings resulted in initially lower pain scores, alginate dressings caused fewer additional dressing changes and less leakage.

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.

Background Neisseria gonorrhoeae can rapidly develop resistance to antimicrobial agents. Over the last years, decreased gonococcal susceptibility to third-generation cephalosporins, especially cefixime, emerged worldwide. Therefore, current international guidelines recommend dual therapy for gonorrhoea with ceftriaxone plus either azithromycin or doxycycline. Gonococcal susceptibility data in Switzerland are sparse. Methods We investigated the prevalence of antibiotic susceptibility of N. gonorrhoeae in specimens collected between 1990 and 2012 at the University of Zurich, Switzerland. Minimum inhibitory concentrations (MICs) for cefixime, ceftriaxone, ciprofloxacin, and penicillin were determined by Etests. The European Committee on Antimicrobial Susceptibility Testing (EUCAST) breakpoints were used to define reduced susceptibility. Results A total of 320 isolates were tested. Between 1990 and 2006 all tested samples were susceptible to both cephalosporins. Subsequently, the prevalence of elevated MICs for cefixime increased to 10.4% (2007/2008), 11.5% (2009/2010), and 11.4% (2011/2012); and for ceftriaxone to 2.4% (2007/2008), 4.7% (2009/2010), and 0% (2011/2012), respectively. The prevalence of resistance to ciprofloxacin (72.7%) and penicillin (22.7%) was high in 2011/2012. Conclusions Decreasing susceptibility of N. gonorrhoeae to third-generation cephalosporins in Switzerland supports treatment recommendations with ceftriaxone plus azithromycin or doxycycline. Health-care providers need to be aware of possible treatment failures with cephalosporins. Continued surveillance of gonococcal antimicrobial resistance is essential.

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.

Approximately one quarter of all patients with leg ulcers do not have a "vascular" ulcer, i.e. an ulcer of venous, mixed venous-arterial, or arterial origin. The differential diagnosis encompasses approximately 70 entities, amongst a selection of particular clinical relevance. Martorell hypertensive-ischemic leg ulcer and its two "imitators" pyoderma gangrenosum and necrotizing vasculitides of the skin, necrotic skin infections (e.g., ecthyma, tropical ulcer, and others), chronic wounds caused by physical trauma (contusion (deep dissecting hematoma), radiotherapy or cryotherapy of skin cancers at the leg), leg ulcers in the context of congenital diseases (e. g., Klinefelter syndrome or sickle cell anemia), skin ulcers caused by medical toxicity (hydroxyurea, anagrelide, methotrexate), and last not least ulcerating skin cancer at the legs, primary or secondary in an area of chronic inflammation. Clinical presentations and a pragmatical algorhythm to diagnosis and treatment of these entities are discussed.

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.

Venous diseases are highly prevalent and chronic wounds cause high morbidity and costs. Prevalence of severe forms of chronic venous insufficiency is on the decline. This is due to improved diagnosis and treatment of venous thromboembolism, and to improved surgery of varicose veins and their sequelae. The spectrum of chronic wounds has shifted from venous ulcers towards more complex pathologies. At the same time, new treatment options are available. Modern phlebology effectively treats varicose veins, prevents sequelae of varicosis and deep venous thrombosis, and offers help to the great majority of patients with chronic wounds.

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.

Dermatologic surgery represents the surgical mainstay of the medical-surgical specialty of dermatology. The steep increase in incidence of skin cancer impressively raised the demand for competent dermatological surgery. Skin cancer is a plausible example to demonstrate that dermatology deserves a leading role in the diagnosis, differential indication and conduction of conservative, semi-invasive and surgical treatment as well as in the cooperation with the plastic reconstructive specialties. Through the last two decades, dermatological surgery has set valuable impulses in micrographic surgery of skin cancer, refinement of local anesthesia, nail surgery, wound and scar treatment, cutaneous laser surgery and sentinel node biopsy in cutaneous malignant melanoma.

BACKGROUND: Whereas until 2003 Lymphogranuloma venereum (LGV) was rare in industrialised countries, there have been increasing reports of cases of LGV proctitis in men having sex with men (MSM) over the last six years in Europe, America and Australia. PATIENTS AND METHODS: After the alarming message from the Netherlands in 2003, physicians in a dermatological and STI private clinic in Zurich started examining rectal swabs from patients with proctitis for LGV serovars of C. trachomatis on a regular basis. A test system based on PCR with sequencing and databank comparison was used. Clinical files of all patients with proctitis observed in this time period were examined. RESULTS: Since 2003 twelve cases of proctitis, all in MSM, caused by the LGV serovar L2 C. trachomatis were observed. Of the overall 11 patients the majority were HIV positive and only 2 were HIV negative. Only one patient reported previous sexual contacts outside Europe (Thailand) as the likely place of infection. The clinical presentation was characterised by anorectal pain, discharge, tenesmus and change in stool frequency. Four patients were successfully treated with a single dose of 1 g azithromycin. In all seven cases treated with doxycycline 2 x 100 mg for 10-20 days clinical cure and a negative PCR result after treatment were observed, except for one patient lost to follow-up. CONCLUSIONS: Zurich has not been spared by the recent outbreaks of LGV proctitis in MSM. Anorectal LGV infections may progress to severe destructive changes, with formation of granulomas, strictures, and perirectal abscesses. Increased awareness of this problem and establishment of reliable diagnostic tools are required.

Even though surgery represents the gold standard for the treatment of many types of non-melanoma skin cancer, medical treatment options have been developed for superficial tumors and actinic keratoses. Drug treatment for non-melanoma skin cancer encompasses topical use of 5-fluorouracil, diclofenac, retinoids, and imiquimod. For patients who are not candidates for surgical excision or who are not amenable to surgery, intralesional injections using interferons may be a therapeutic option (see Chap. 4.1.3).

BACKGROUND: A large variety of therapeutic agents are being used for the treatment of vitiligo, but treatment remains a challenge. Recently, monochromatic phototherapies such as 311-nm narrowband ultraviolet B therapy and 308-nm xenon chloride excimer laser have been reported to be an effective and safe therapeutic option in children and adult patients with vitiligo. Single reports stipulate that the addition of topically applied calcipotriol to phototherapy increases its effectiveness. OBJECTIVE: The purpose of the present pilot study was to determine if the addition of topical calcipotriol increases the efficacy of the 308-nm xenon chloride excimer in the treatment of vitiligo. METHODS: Ten patients with vitiligo with essentially bilateral symmetrical lesions were enrolled in this prospective right/left comparative, single-blinded trial conducted over a 15-month period. All patients received 308-nm XeCl excimer laser therapy three times weekly. Calcipotriol ointment (Daivonex) was applied to lesions on one side of the body twice daily. RESULTS: After 24 treatments (8 weeks), nine patients were evaluated. Eight patients showed evidence of repigmentation on both body sides, with no significant difference between the body side treated with calcipotriol and excimer laser and the side treated with excimer laser alone. The mean repigmentation rate was 22.4% (1-37%). CONCLUSION: The addition of calcipotriol ointment to 308-nm xenon chloride excimer laser phototherapy does not significantly enhance its efficacy. Small additive effects must be investigated in a larger trial.

Nephrogenic fibrosing dermopathy (NFD) is a rare fibrosing skin disease of unknown etiology occurring in patients with terminal renal disease. It was first described in the year 2000. The histology of NFD shows an increased number of dendritic cells, fibroblasts and thickened collagen fibers resembling scleromyxedema. It can be distinguished from scleromyxedema by a different distribution pattern of the skin lesions with indurated plaques mainly on the extremities and the absence of paraproteinemia. As yet, no treatment for NFD has been proven to be uniformly efficient. We describe the case of a 40-year old patient with renal insufficiency who was treated with hemodialysis and who had undergone kidney transplantation. Two years after transplantation, she developed sclerodermiform brownish plaques on her extremities. The induration improved significantly after 4 cycles of extracorporeal photopheresis.

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.To analyze the effectiveness of treatment of viral warts with the CO(2) laser in immunosuppressed patients.Multiple viral warts of 13 patients with immunosuppression, a majority of them renal allograft recipients, were treated with CO(2) laser in local or regional anesthesia. In case of recurrences, the lesions were treated again after 3 months.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.CO(2) 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.

Chronische Wunden heilen auch bei optimaler Behandlung meist sehr langsam. Die Frustration hieruber fuhrt wohl dazu, dass viele betroffene Patienten und auch Arzte besonders empfanglich sind fur alternative Methoden. Dabei reicht die Palette von der Sauerstofftherapie bis zum Einsatz von Fliegenmaden. Welchen Stellenwert haben die „Alternativen“ und wann ist ihr Einsatz gerechtfertigt?

To test the hypothesis that safer sex procedures are less consistently observed by persons under the influence of alcohol, data from the Swiss human immunodeficiency virus (HIV) Prevention Study (HIPS) were evaluated. HIPS is a large prospective cohort study involving 724 HIV-negative and mainly heterosexual subjects who entertain casual sexual contacts. Of the 724 participants, 36% reported that they had had sex while under the influence of alcohol. Of this group, 31% indicated that safer sex procedures were neglected owing to the influence of alcohol. No significant differences with regard to unprotected sexual intercourse were found between subjects who combine sex and alcohol and those who do not. The same was found to be true among subjects with different levels of general alcohol consumption. However, a significant correlation was found between the intensity of alcohol consumption (i.e., the quantity of alcohol intake per sitting) and the incidence of unprotected sexual intercourse. These findings show that the relationship between alcohol consumption and safer sex is complex; they also emphasize the need for preventive efforts to reinforce safer sexual behavior, for example through individual counseling of persons at risk for HIV-infection.

We report on 2 cases of patients with warts underlying the proximal nail fold which presented as tender erythematous nodules. The remarkable feature in both cases was a significant oedema of the proximal nail fold, resembling a reaction to a foreign body. One patient responded well to mild keratolytic treatment. The second patient was treated surgically with crescentic excision of the distal portion of the proximal nail fold. It is important to recognise this tumour variant in order to avoid unnecessary or excessive intervention.