Acrodermatitis Chronicum Atrophicans
Selected Studies & Abstracts
2005-2013
Vasudevan B, Chatterjee M.
Indian J Dermatol. 2013 May;58(3):167-74. doi: 10.4103/0019-5154.110822.
"The antibiotic of choice is Doxycycline 100 mg orally twice daily for 14 to 21 days in case of ECM, while a 3-4 week course is advocated for BL and ACA. Azithromycin 500 mg twice daily on the first day, followed by 500 mg once daily for the next four days has also been found to be equally effective in few studies for erythema migrans.[57]
Amoxicillin, Cefuroxime and Erythromycin can also be used. Parenteral ceftriaxone intravenous (IV) 2 g once daily, or Penicillin G IV 18-24 million units daily divided four hourly for 10-14 days, can be more useful in cases with multiple EM lesions and in the subset of pregnant and immunodeficient patients.[58] The same regimes may also be required in persistent cases of ACA.
The dosage and duration of treatment for the above drugs in cutaneous manifestations of borreliosis are as given in Table 3. In children below 8 years of age, the duration is the same as for adults; however, the doses of various antibiotics used per day are as follows: Amoxicillin 25-50 mg/kg, Azithromycin (20 mg/kg for day 1 with 10 mg/kg for the remaining days) and Cefuroxime 30-40 mg/kg.
Doxycycline is contraindicated in children younger than eight years of age and in pregnant and breast feeding women. In pregnant women, the drugs of choice are Amoxycillin, Azithromycin and third generation cephalosporins in the same dose and duration as for non-pregnant ladies."
Table 3
Dosage and therapy duration of various drugs used in Lyme borreliosis (recommendations based on evidence based studies and meta-analysis)
Link to above article & Table 3
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3667275/
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The expanding spectrum of cutaneous borreliosis.
Eisendle K, Zelger B.
G Ital Dermatol Venereol. 2009 Apr;144(2):157-71. Review.
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[Borrelial erythema of the face].
de Heller-Milev M, Peter O, Panizzon RG, Laffitte E.
Ann Dermatol Venereol. 2008 Dec;135(12):852-4. doi: 10.1016/j.annder.2008.05.021. Epub 2008 Oct 26. French.
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Ljøstad U, Skogvoll E, Eikeland R, Midgard R, Skarpaas T, Berg A, Mygland A.
Lancet Neurol. 2008 Aug;7(8):690-5. doi: 10.1016/S1474-4422(08)70119-4. Epub 2008 Jun 21. Erratum in: Lancet Neurol. 2008 Aug;7(8):675.
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Lyme disease: European perspective.
Stanek G, Strle F.
Infect Dis Clin North Am. 2008 Jun;22(2):327-39, vii. doi: 10.1016/j.idc.2008.01.001. Review.
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Skin manifestations of lyme borreliosis: diagnosis and management.
Müllegger RR, Glatz M.
Am J Clin Dermatol. 2008;9(6):355-68. doi: 10.2165/0128071-200809060-00002. Review.
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[Dermatological aspects of Lyme borreliosis].
Lipsker D.
Med Mal Infect. 2007 Jul-Aug;37(7-8):540-7. Epub 2007 Mar 27. French.
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Focus floating microscopy: "gold standard" for cutaneous borreliosis?
Eisendle K, Grabner T, Zelger B.
Am J Clin Pathol. 2007 Feb;127(2):213-22.
"Stages may overlap or be skipped. Many other tissues such as muscle, soft tissues, and internal organs may be involved, and unusual clini- cal manifestations may be seen.4,5"
"ECM, BL, and ACA are well accepted as Borrelia-asso- ciated disorders.4 Yet, study of the literature also reveals diagnostic problems. On the one hand, the results of direct detection of microorganisms by histochemical and immuno- histochemical methods and culture are frequently negative. Moreover, comparison of different direct methods with PCR may reveal discrepancies. In ECM, culture may be negative, whereas PCR is positive or vice versa.25,26 Similar discrep- ancies occur in BL (including serology) and ACA.27-30 On the other hand, serology is not a direct method and is beset with false-positive and false-negative results, and the techni- cal and logistic requirements limit the broad application of culture techniques.8
We are not aware of a reliable and fast direct detection method of Borrelia microorganisms in tissue specimens.Studies by Aberer et al12 and Neubert et al29 confirm that detection of Borrelia in tissue is usually a difficult, time-consuming, and often frustrating task.
Immunohistochemical analysis combined with FFM seems to solve this problem. The key point to this technique is an almost holoscopic approach to the slide by tuning the focus of the microscope through the thickness of the slide (3-4 μm). This technique takes into consideration the scant presence of these spirochetes in many infections, their tiny structure (0.2 μm thick- ness), their intimate relationship to collagen bundles (which are 1-2 μm thick), and their variable appearance according to the relation to the section plane.31 This technique can be applied suc- cessfully on fresh material, nitrogen-frozen material, and paraf- fin-embedded material, in many cases on blocks older than 30 years. Nearly all cases of borreliosis were positive in our series.
This FFM technique proved to be more sensitive (96.0% vs 45.2%) than and nearly equally specific (99.4% vs 100%) to PCR- and ELISA-PCR–controlled cases of borreliosis. Cases of prominent Borrelia detection were usually positive by PCR, which became negative in later stages as the number of microorganisms dropped (threshold around 5-10 immuno- histochemically detected Borrelia per section). Such a thresh- old might explain why up to 40% of classic ACA cases may be false-negative with PCR.18,20,22
As our study and previous studies have shown, immuno- histochemical analysis works on proteins that may be associ- ated with what seemed to be vital and degenerative forms. In contrast, DNA seems to be more sensitive to degradation. This is a particularly significant problem in laboratories working with paraffin specimens fixed with unbuffered formalin in which PCR results are usually negative. Formalin causes DNA fragmentation and cross-linking, impeding PCR methodology.
Another explanation for the comparatively modest results with PCR might be that these techniques used primers highly specific for human pathogenic strains, whereas FFM used immunohistochemical analysis with a much less specific poly- clonal antibody that, in addition to B burgdorferi, also reacts with B hermsii and B parkeri. When establishing the tech- nique, we noted that staining with a monoclonal antibody was successful in fewer than half of the cases. False positivity due to cross-reactivity with T pallidum presents no serious diag- nostic problem because clinicopathologic manifestations plus serology easily characterize syphilis. The reaction of the poly- clonal antibody with other spirochetes raises the question whether ECM, BL, and ACA might not be caused by the B burgdorferi complex alone.32
The possibility that our findings are artifacts of other tissue components or contamination is implausible because they should be seen in all specimens, including control samples. It would have been ideal to further investigate the presence of Borrelia by techniques such as culture or electron microscopy. Unfortunately, we worked exclusively with paraffin-embedded material, making culture and electron microscopy unfeasible."
Link to Above Article- http://ajcp.ascpjournals.org/content/127/2/213.long
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Course of Borrelia burgdorferi DNA shedding in urine after treatment.
Aberer E, Bergmann AR, Derler AM, Schmidt B.
Acta Derm Venereol. 2007;87(1):39-42.
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[Stage-oriented treatment of Lyme borreliosis].
Fingerle V, Wilske B.
MMW Fortschr Med. 2006 Jun 22;148(25):39-41. Review. German.
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[Skin manifestations of Lyme borreliosis].
Nammous AH, Zubacki D, Dobrzycki I.
Przegl Lek. 2006;63(4):227-30. Review. Polish.
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[Lyme borreliosis. Cutaneous manifestation].
Hofmann H.
Pre- 2005 Abstract Quote
"A total of 33% of ACA patients had elevated IgM titers, and all had high IgG titers in their sera. Only 30% of specimens from patients with EM and none from patients with ACA were positive by culture. All culture-positive specimens were also positive by PCR. Thus, the sensitivities of the PCR were 80 and 92%, respectively, for patients with EM and ACA on the basis of the clinical and histopathological diagnoses of Lyme disease. From these results, we conclude that PCR is a suitable method to detect B. burdorferi sensu lato DNA in skin biopsy samples and could be applied as an additional diagnostic tool."
http://www.ncbi.nlm.nih.gov/pubmed/7883886
Lucy Barnes