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Submitted by Fabio Sobreira Campos da Costa (fabio.sobreira@ufpe.br) on 2016-04-07T15:40:50Z No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) DAYANNE MOTA VELOSO BRUSCKY DISSERTAÇÃO 2015.pdf: 1467970 bytes, checksum: fee0da8b1c22b7ab32211b2ce92d54d9 (MD5) / Made available in DSpace on 2016-04-07T15:40:50Z (GMT). No. of bitstreams: 2 license_rdf: 1232 bytes, checksum: 66e71c371cc565284e70f40736c94386 (MD5) DAYANNE MOTA VELOSO BRUSCKY DISSERTAÇÃO 2015.pdf: 1467970 bytes, checksum: fee0da8b1c22b7ab32211b2ce92d54d9 (MD5) Previous issue date: 2015-05-29 / CNPq / A dermatite atópica acomete em torno de 10% da população pediátrica no mundo e causa importante interferência negativa na qualidade de vida relacionada à saúde dos pacientes e seus familiares principalmente relacionada ao prurido. É recomendada a utilização de pelo menos dois instrumentos para medir adequadamente este sintoma e, no Brasil, dispomos atualmente apenas da escala visual analógica. O objetivo deste estudo foi realizar a adaptação transcultural e validação para português (cultura brasileira) da Itch Severity Scale, instrumento para medir a gravidade de prurido. Trata-se de estudo metodológico de validação de instrumento. Baseado nos protocolos propostos por Beaton et al. (2010) e Reichenheim e Moraes (2007) para obter as equivalências conceitual, de itens, semântica, operacional e de mensuração. Participaram do estudo 7 alergologistas, 3 professores de inglês, 1 professor de linguística, 1 professor com experiência em validação de instrumento, 42 responsáveis por portadores de dermatite atópica entre 02 a 18 anos incompletos de idade e 42 responsáveis por crianças de mesma faixa etária sem doença cutânea pruriginosa. Resultados da escala foram comparados com gravidade da dermatite atópica e controle da doença, e entre os dois grupos. Da população selecionada, 98,8% participaram e 100% das questões da escala foram respondidas. Houve clareza das questões maior que 90%. A Escala de Gravidade de Prurido mostrou forte correlação positiva com a gravidade da dermatite atópica (índice de Pearson 0,74 p<0,001) e boa correlação com o controle da dermatite (coeficiente de correlação ponto-bisserial 0,65 p<0,001). Foi demonstrada ótima consistência interna (alfa de Cronbach 0,96) e adequada reprodutibilidade pela concordância do teste e reteste (coeficiente de correlação intraclasse variando de 0,89 a 0,99 com IC95% e p<0,001. A Escala de Gravidade de Prurido (ISS-Ped) apresentou-se viável, válida e confiável, podendo ser utilizada no Brasil para avaliar a gravidade do prurido em crianças e adolescentes com dermatite atópica, permitindo comparações na prática clínica e entre pesquisas de diferentes centros. / Atopic dermatitis affects around 10% of the pediatric population in the world and has important negative impacts the quality of life related to health of patients and their families particularly related to the itch. It is recommended to use at least two instruments to properly measure this symptom, and in Brazil, we currently only visual analogue scale. The aim of this study was to adapt cross-culturally and validate an instrument to measure the severity of itching, the Itch Severity Scale, into Brazilian Portuguese. It is a methodological instrument validation study. Based on the protocols proposed by Beaton et al. (2010) and Reichenheim and Moraes (2007) was obtained the conceptual, item, semantic, operational and measurement equivalences. Seven allergists, 3 English teachers, one professor of linguistics, one teacher with experience in instrument validation, 42 parents of children with atopic dermatitis between 02-18 years of age-old and 42 parents of children of the same age group without itchy skin disease. Scale results were compared with severity of atopic dermatitis and disease control, and between the two groups. In the sample, 98.8% participated and 100% of the scale of the questions were answered. There was clear understanding > 90% of the questions. The Pruritus Severity Scale showed a strong positive correlation with the severity of atopic dermatitis (Pearson index 0.74 p <0.001) and good correlation with the control dermatitis (correlation coefficient 0.65 bisserial point p <0.001). Excellent internal consistency was demonstrated (Cronbach's alpha 0.96) and adequate reproducibility for the test and retest agreement (intraclass correlation coefficients ranging from .89 to 0.99 with 95% CI p <0.001. The Escala de Gravidade de Prurido (ISS-Ped) proved to be feasible, valid and reliable and can be used in Brazil to assess the severity of itching in children and adolescents with atopic dermatitis, allowing comparisons in clinical practice and research between different centers.

INTRODUÇÃO: O aumento da prevalência das doenças alérgicas tem sido associado a vários fatores de risco e a detecção destes e a avaliação da prevalência em diferentes regiões é fundamental. O protocolo padronizado ISAAC (International Study of Asthma and Allergies in Childhood), possibilitou a comparação destes dados epidemiológicos. Os OBJETIVOS deste estudo foram: avaliar a prevalência da asma, rinite e eczema alérgicos e sintomas relacionados, entre escolares de 13 a 14 anos, da região oeste da cidade de São Paulo, utilizando-se o questionário escrito ISAAC e identificar possíveis fatores de risco associados à presença de asma ou à positividade ao teste cutâneo de hipersensibilidade imediata (TCHI). MÉTODOS: Entre fevereiro de 2002 e outubro de 2003 foi aplicado questionário escrito ISAAC em 3181 alunos. Após amostragem sistemática, 528 alunos foram submetidos ao TCHI para o diagnóstico de atopia e responderam a um questionário complementar sobre antecedentes familiares e condições ambientais. Foram constituídos grupos de alunos com ou sem asma, considerando-se a presença de sintomas de asma nos últimos 12 meses, e com ou sem TCHI positivo a pelo menos um aeroalérgeno. A análise dos fatores de risco foi realizada pelo teste do qui-quadrado ou teste exato de Fisher e por regressão binária logística (Backward Stepwise). RESULTADOS: As prevalências encontradas foram: asma de 21,9%, diagnóstico médico de asma 8,9%, rinite de 30,1%, rinoconjuntivite de 19,8% , diagnóstico médico de rinite 18,9%, eczema atópico de 9,7% e o diagnóstico médico de eczema 8,6%. Houve associação entre asma, rinite e eczema atópico em 2,3% dos adolescentes. O sexo feminino foi prevalente em todas as questões sobre asma, rinite e eczema atópico. Houve associação entre TCHI e a presença de asma (OR = 2,6) e de rinite (OR = 1,9). Em relação à asma, os fatores de risco foram: sintomas de rinite no último ano (ORajustado = 3,2); positividade ao TCHI (ORajustado = 2,8); parto prematuro (ORajustado = 3,8); nunca consumir vegetais cozidos (ORajustado = 2,6); presença de eczema em locais característicos (ORajustado = 2,9) e mãe alérgica (ORajustado = 2,0). Em relação à positividade do TCHI, os fatores de risco foram: presença de asma (ORajustado = 2,3); sintomas de rinite no último ano (ORajustado = 1,9); pai alérgico (ORajustado = 2,2) e parto cesáreo (ORajustado = 1,7). CONCLUSÕES: A prevalência de asma neste estudo mostrou valores elevados em comparação ao diagnóstico médico de asma. A prevalência da rinoconjuntivite foi comparável ao diagnóstico médico de rinite, que foram menores que a prevalência de rinite no último ano. A prevalência de eczema atópico foi maior que aquela avaliada pelo critério combinado. Houve predomínio do sexo feminino nas respostas positivas para todas as doenças atópicas. Houve associação entre TCHI e presença de rinite ou asma. Os fatores de risco associados à asma foram: mãe alérgica, rinite, parto prematuro, eczema em locais característicos, dieta sem vegetais cozidos e TCHI positivos e os relacionados à positividade do TCHI: pai alérgico, cesárea, asma e rinite no último ano. / INTRODUCTION: The increase of allergic diseases has been associated to several risk factors, the detection of them and prevalences evaluations from different areas are essential. The written questionnaire standardized by "International Study of Asthma and Allergies in Childhood" - ISAAC, made possible the comparison of epidemiologic data. The aims of the present study were: to evaluate the prevalence of asthma, rhinitis and allergic eczema and related symptoms, among students from 13 to 14 years in the west area of São Paulo city, through the written questionnaire from the ISAAC study and to identify possible risk factors associated to asthma or positive skin prick test in this population. METHODS: In the period from February/2002 to October/2003 written questionnaire was applied to 3181 students. After selection by systematic samples, 528 students were submitted to skin prick test regarding the atopic diagnose and they answered a complementary questionnaire about family history and environmental conditions. The students' groups were constituted with or without asthma according the positive answer to asthma symptoms in the last 12 months, and with or without positive skin prick test at least one aeroallergen. The risk factors analysis was accomplished by univariated (qui-square or Fisher’ exact test) and multivariated analysis by binary logistic regression (Backward Stepwise). RESULTS: The prevalence found were: asthma 21,9%, medical diagnosis of asthma 8,9%, rhinitis 30,1%, rhinoconjunctivitis 19,8%, medical diagnosis of rhinitis 18,9%, atopic eczema 9,7% and the medical diagnosis of eczema 8,6%. There was association among asthma, rhinitis and atopic eczema in 2,3% of the adolescents. Female sex was prevalent in all of the subjects on asthma, rhinitis and atopic eczema. There was association between skin prick test and asthma (OR = 2,6) and rhinitis (OR = 1,9). In relation to asthma, the risk factors were: rhinitis symptoms in the last year (ORadjusted = 3,2); positive skin prick test (ORadjusted = 2,8); premature delivery (ORadjusted = 3,8); never to consume cooked vegetables (ORadjusted = 2,6); eczema presence in characteristic areas (ORadjusted = 2,9) and allergic mother (ORadjusted = 2,0). In relation to positive skin prick test, the risk factors were: asthma (ORadjusted = 2,3); rhinitis symptoms in the last year (ORadjusted = 1,9); allergic father (ORadjusted = 2,2) and cesarean section (ORadjusted = 1,7). CONCLUSIONS: This study showed high prevalence of asthma when compared with medical diagnosis of asthma. The prevalence of rhinoconjunctivitis was similar to medical diagnostic of rhinitis that was lower than the rhinitis prevalence in the last year. The prevalence of atopic eczema was higher than combined criteria. The female gender predominates in all positive responses regarding allergic diseases. There was association between skin prick test and asthma or rhinitis. The risk factors associated with asthma were allergic mother, rhinitis, premature delivery, eczema at characteristic areas, diet without cooked vegetables and positive skin prick test. The risk factors associated with positive skin prick test were: allergic father, cesarean section, asthma and rhinitis in the last year.

INTRODUÇÃO: O aumento da prevalência das doenças alérgicas tem sido associado a vários fatores de risco e a detecção destes e a avaliação da prevalência em diferentes regiões é fundamental. O protocolo padronizado ISAAC (International Study of Asthma and Allergies in Childhood), possibilitou a comparação destes dados epidemiológicos. Os OBJETIVOS deste estudo foram: avaliar a prevalência da asma, rinite e eczema alérgicos e sintomas relacionados, entre escolares de 13 a 14 anos, da região oeste da cidade de São Paulo, utilizando-se o questionário escrito ISAAC e identificar possíveis fatores de risco associados à presença de asma ou à positividade ao teste cutâneo de hipersensibilidade imediata (TCHI). MÉTODOS: Entre fevereiro de 2002 e outubro de 2003 foi aplicado questionário escrito ISAAC em 3181 alunos. Após amostragem sistemática, 528 alunos foram submetidos ao TCHI para o diagnóstico de atopia e responderam a um questionário complementar sobre antecedentes familiares e condições ambientais. Foram constituídos grupos de alunos com ou sem asma, considerando-se a presença de sintomas de asma nos últimos 12 meses, e com ou sem TCHI positivo a pelo menos um aeroalérgeno. A análise dos fatores de risco foi realizada pelo teste do qui-quadrado ou teste exato de Fisher e por regressão binária logística (Backward Stepwise). RESULTADOS: As prevalências encontradas foram: asma de 21,9%, diagnóstico médico de asma 8,9%, rinite de 30,1%, rinoconjuntivite de 19,8% , diagnóstico médico de rinite 18,9%, eczema atópico de 9,7% e o diagnóstico médico de eczema 8,6%. Houve associação entre asma, rinite e eczema atópico em 2,3% dos adolescentes. O sexo feminino foi prevalente em todas as questões sobre asma, rinite e eczema atópico. Houve associação entre TCHI e a presença de asma (OR = 2,6) e de rinite (OR = 1,9). Em relação à asma, os fatores de risco foram: sintomas de rinite no último ano (ORajustado = 3,2); positividade ao TCHI (ORajustado = 2,8); parto prematuro (ORajustado = 3,8); nunca consumir vegetais cozidos (ORajustado = 2,6); presença de eczema em locais característicos (ORajustado = 2,9) e mãe alérgica (ORajustado = 2,0). Em relação à positividade do TCHI, os fatores de risco foram: presença de asma (ORajustado = 2,3); sintomas de rinite no último ano (ORajustado = 1,9); pai alérgico (ORajustado = 2,2) e parto cesáreo (ORajustado = 1,7). CONCLUSÕES: A prevalência de asma neste estudo mostrou valores elevados em comparação ao diagnóstico médico de asma. A prevalência da rinoconjuntivite foi comparável ao diagnóstico médico de rinite, que foram menores que a prevalência de rinite no último ano. A prevalência de eczema atópico foi maior que aquela avaliada pelo critério combinado. Houve predomínio do sexo feminino nas respostas positivas para todas as doenças atópicas. Houve associação entre TCHI e presença de rinite ou asma. Os fatores de risco associados à asma foram: mãe alérgica, rinite, parto prematuro, eczema em locais característicos, dieta sem vegetais cozidos e TCHI positivos e os relacionados à positividade do TCHI: pai alérgico, cesárea, asma e rinite no último ano. / INTRODUCTION: The increase of allergic diseases has been associated to several risk factors, the detection of them and prevalences evaluations from different areas are essential. The written questionnaire standardized by "International Study of Asthma and Allergies in Childhood" - ISAAC, made possible the comparison of epidemiologic data. The aims of the present study were: to evaluate the prevalence of asthma, rhinitis and allergic eczema and related symptoms, among students from 13 to 14 years in the west area of São Paulo city, through the written questionnaire from the ISAAC study and to identify possible risk factors associated to asthma or positive skin prick test in this population. METHODS: In the period from February/2002 to October/2003 written questionnaire was applied to 3181 students. After selection by systematic samples, 528 students were submitted to skin prick test regarding the atopic diagnose and they answered a complementary questionnaire about family history and environmental conditions. The students' groups were constituted with or without asthma according the positive answer to asthma symptoms in the last 12 months, and with or without positive skin prick test at least one aeroallergen. The risk factors analysis was accomplished by univariated (qui-square or Fisher’ exact test) and multivariated analysis by binary logistic regression (Backward Stepwise). RESULTS: The prevalence found were: asthma 21,9%, medical diagnosis of asthma 8,9%, rhinitis 30,1%, rhinoconjunctivitis 19,8%, medical diagnosis of rhinitis 18,9%, atopic eczema 9,7% and the medical diagnosis of eczema 8,6%. There was association among asthma, rhinitis and atopic eczema in 2,3% of the adolescents. Female sex was prevalent in all of the subjects on asthma, rhinitis and atopic eczema. There was association between skin prick test and asthma (OR = 2,6) and rhinitis (OR = 1,9). In relation to asthma, the risk factors were: rhinitis symptoms in the last year (ORadjusted = 3,2); positive skin prick test (ORadjusted = 2,8); premature delivery (ORadjusted = 3,8); never to consume cooked vegetables (ORadjusted = 2,6); eczema presence in characteristic areas (ORadjusted = 2,9) and allergic mother (ORadjusted = 2,0). In relation to positive skin prick test, the risk factors were: asthma (ORadjusted = 2,3); rhinitis symptoms in the last year (ORadjusted = 1,9); allergic father (ORadjusted = 2,2) and cesarean section (ORadjusted = 1,7). CONCLUSIONS: This study showed high prevalence of asthma when compared with medical diagnosis of asthma. The prevalence of rhinoconjunctivitis was similar to medical diagnostic of rhinitis that was lower than the rhinitis prevalence in the last year. The prevalence of atopic eczema was higher than combined criteria. The female gender predominates in all positive responses regarding allergic diseases. There was association between skin prick test and asthma or rhinitis. The risk factors associated with asthma were allergic mother, rhinitis, premature delivery, eczema at characteristic areas, diet without cooked vegetables and positive skin prick test. The risk factors associated with positive skin prick test were: allergic father, cesarean section, asthma and rhinitis in the last year.

The thesis deals with atopic eczema in children and its health and social impact. The work is divided into a theoretical and a practical part. The theoretical part is focused on explaining the basic concepts in dermatology, presenting the anatomy and physiology of skin and its specific qualities in childhood, defining the atopic eczema and outlining its etiopathogenesis, clinical presentation, treatment and nursing care as well as health and social impacts of eczema. The practical part of the thesis set up three goals. The first objective was to determine the impact of the disease on children and their families. The second objective of the research was to determine the role of a nurse in the treatment of children with atopic eczema. The third objective was to create an educational brochure for parents of children with atopic eczema. To achieve these objectives, a qualitative research based on two semistructured interviews was carried out. The first of the two interviews was conducted with mothers of sick children. The research group consisted of ten mothers, five from Prague and five from České Budějovice. The second interview was performed with nurses in GP surgeries for children and adolescents and in surgeries of dermatologists and allergists. The second research group consisted of eight nurses, four of which worked in GP surgeries for children and adolescents, two with dermatologists and two with allergists. Nurses, as well as mothers, came from Prague and České Budějovice. Attention was paid to problems that mothers and children find the most annoying. Small children under four years of age are most bothered by the itching and pain; part of these children also dislike daily skin care. Children from five years up are upset about insufficient contact with their peers and limitations in performing their activities of interest. They have to make sure they do not swear while enjoying their hobbies and their skin must not come into contact with irritants. Their mothers suffer from the unpredictability of the disease and from not knowing whether the eczema will ever disappear. They also fear that the eczema might get worse. The medical complications related to atopic eczema include Staphylococcus aureus, Candida albicans, warts, Molluscum contagiosum and herpes in eczema-affected areas. Other complications include itching, pain, sleep disorders in the mother and child, subsequent fatigue, impaired performance at school and/or work. Generally, children and mothers have positive relationships with others, yet sometimes the have to face curious looks. Mothers tend to spend less time with their partners than they would desire. As for nurses, it was found out that the primary role in patients? education is played by doctors, whereas nurses, in addition to performing their administrative duties, provide additional information and educational materials and respond to parents? practical questions. The research results may serve mainly to parents and their children with atopic eczema as a source of information about the problems they might encounter, helping them to address such problems. The output of the thesis will be an educational brochure for parents of children with atopic eczema.

Abstract An excess of atopic allergies has been found in patients with depression, and conversely, increased amounts of depressive symptoms have been reported in patients with atopic disorders. Thus far, however, the findings have mainly been based on clinical samples. In this thesis, the association between atopic disorders and depression was investigated at epidemiological level by using data from the Northern Finland 1966 Birth Cohort. An unselected cohort of 12058 liveborn children was followed prospectively from prenatal stages until 1997. During the 31-year follow-up, 6025 cohort members underwent skin prick tests. Data on lifetime depression diagnoses and atopic conditions were obtained from postal questionnaires and Finnish Hospital Discharge Registers, and the severity of the depressive symptoms was assessed with Hopkins Symptom Checklist-25. Information on the family histories of the atopic disorders was obtained from questionnaires of the 31-year follow-up. Females with positive skin prick test responses and self-reported histories of allergic symptoms exhibited a 2.7-fold probability of developing lifetime depression. The corresponding probability increased in line with the increased severity of depressive symptoms in atopic but not in non-atopic females, ranging from 3.0 to 4.7-fold. Among males, the atopy-depression association was seen only in the highest depression scores, the odds ratio being up to 6.3-fold. While the most severe, hospital-treated manifestations of both disorders were considered, atopic disorders increased the risk of depression 3-fold independently of the subject's gender and sociodemographic characteristics. When investigating the effect of familial atopy on a child's depression, maternal atopy increased the probability of lifetime depression nearly 2-fold in females, and over 4-fold, when a female cohort member's own atopy was also present. At epidemiological level, the presence of atopic conditions seemed to increase the probability of lifetime depression especially in females. Since both atopic disorders and depression are illnesses of major public health importance in Western countries, also the co-morbidity between these disorders should be seriously taken into account in clinical practice. Further investigations are called for in evaluating whether this association is specific to atopic disorders, since increased risks of depression have been noted in connection with many other physical diseases as well.

This master thesis focuses on atopic eczema in children and adolescents from a psychological perspective. The aim of this text is to describe and emphasize the psychological aspects of this disease and characterize the areas it may concern and affect. Regarding the structure, the thesis is divided into three parts. The introductory theoretical part is focused on a description of the explored subject-matter, the aim was to submit a comprehensive perspective on this disease and outline a relevant psychological basis for the empirical enquiry. The second empirical part is focused on the intrinsic aspects of the experience of this disease in children and adolescents. The quantitative research was designed to map out the specific phenomena, incidence of depressive symptoms and family upbringing style. The quantitative research is complemented by a qualitative inquiry with the aim to get further into depth of the issue by means of two case studies. These were focused on the overall experience related to the diagnosis of atopic eczema. The final part reflects acquired findings and the conclusive discussion summarizes the results of the exploratory assumptions including the limits and the possibilities of future psychological work with this disease. Keywords Atopic eczema, psychosomatic approach,...

Atopic eczema is an incurable disorder of the skin. Sufferers are afflicted with hypersensitivity to environmental agents such as soaps (detergents), animal dander, pollen, specific foods and sometimes even water. Genetic mutations in atopic eczema compromise the development of the stratum corneum resulting in xerotic skin that is prone to cracking and increased permeability which leads to irritation due to the influx of exogenous material through the skin. The causes of atopic eczema are due to a combination of genetic and environmental factors and it is, therefore, a difficult disease to manage. Emollients and topical corticosteroids are the mainstay treatments for eczema. However, they do not treat the underlying cause of the flare-ups frequently seen in the condition; the damaged skin barrier. Defects in the skin barrier arise from premature desquamation of the stratum corneum. The main contributors to barrier breakdown are the up-regulation of skin proteases that are located in the skin. Since zinc is a known protease inhibitor, it would thus follow that a topical treatment for skin barrier repair should be developed. Therefore, the main objectives of this thesis are to successfully incorporate zinc into a formulation to develop a novel class of treatment for eczema and to assess the delivery of the element into the skin. In this thesis, methods to assess and characterise changes to skin barrier function and to extract and quantify zinc in the stratum corneum have been established. The development of two novel topically applied formulations containing zinc lactate as the active ingredient (1% w/w zinc lactate cream and a 2% w/v zinc lactate formulation) has been achieved and the uptake of zinc from the preparations in vitro determined. Further, the in vitro percutaneous penetration of zinc from three commercially available preparations has been investigated and compared to that recovered from the stratum corneum after passive diffusion with the novel zinc formulations. Additionally, in vivo uptake of zinc into human stratum corneum from Sudocremis ® reported. Scanning electron microscopy has revealed the distribution of zinc on the surface of skin treated with various formulations and has also allowed the efficiency of two cleaning procedures to be ascertained. The delivery of zinc from the novel topical formulation; 1% w/w zinc lactate cream, was more efficient than that the three commercial formulations and shows promise as a new approach to treat atopic eczema.

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Background: Evidence-based treatment algorithms, successfully established for asthma, are missing for atopic eczema (AE). Objectives: To investigate whether treatment according to an evidence-based algorithm is an effective and applicable concept for the management of AE. Methods: Based on a systematic literature review, we developed an evidence-based severity-score-oriented treatment algorithm for AE and compared its effectiveness to that of an individualised symptom-oriented treatment (individual therapy) in a randomised controlled trial. Sixty-three participants were randomised to algorithm (n = 32) or individual therapy (n = 31) and treated accordingly for 12 months. Study end points included difference between baseline SCORAD and mean SCORAD under treatment (primary end point), quality of life and treatment utilisation. Analysis was by intention to treat (registration: ClinicalTrials.gov:NCT00148746). Results: No statistically significant differences in clinical or subjective response were observed between groups. Treatment following the algorithm and individual treatment both effectively controlled AE. Mean SCORAD reductions were 47% (95% confidence interval, CI = 38–55; algorithm) and 42% (95% CI = 29–54; individual). Clinical response was paralleled by improved quality of life in both groups. Physicians adhered to the algorithm option in 93% of their treatment decisions. Conclusion: Treatment following an evidence-based algorithm is an effective and applicable concept for the management of AE but does not show clear advantages compared to individualised treatment in a dermatological setting. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.