M. Maurer,* S. Altrichter, M. Metz, T. Zuberbier,
M.K. Church, K.-C. Bergmann
Department of Dermatology and Allergy, Charit
e – Universit
Berlin, Berlin, Germany
*Correspondence: M. Maurer. E-mail: firstname.lastname@example.org
1 Zuberbier T, Aberer W, Asero R et al. The EAACI/GA
Guideline for the deﬁnition, classiﬁcation, diagnosis, and management of
urticaria: the 2013 revision and update. Allergy 2014; 69: 868–887.
2 Maurer M, Metz M, Brehler R et al. Omalizumab treatment in patients
with chronic inducible urticaria: a systematic review of published evi-
dence. J. Allergy Clin. Immunol. 2017; in press.
3 Zhao Z, Ji C, Yu W et al. Omalizumab for the treatment of chronic spon-
taneous urticaria: A meta-analysis of randomized clinical trials. J Allergy
Clin Immunol 2016; 137: 1742–1750e4.
4 Maurer M, Ortonne J-P, Zuberbier T. Chronic urticaria: an internet sur-
vey of health behaviours, symptom patterns and treatment needs in Euro-
pean adult patients. Brit J Dermatol 2009; 160: 633–641.
urk E, Maurer M, Metz M, Grattan C. Looking forward to new tar-
geted treatments for chronic spontaneous urticaria. Clin Transl Allergy
6 Busse WW, Sedgwick JB. Eosinophils in asthma. Ann Allergy 1992; 68:
7 Kay AB, Ying S, Ardelean E et al. Elevations in vascular markers and eosi-
nophils in chronic spontaneous urticarial weals with low level persistence
in uninvolved skin. Brit J Dermatol 2014; 171: 505–511.
8 Magerl M et al. Beneﬁt from mepolizumab treatment in a patient with
chronic spontaneous urticaria. JDDG 2017; in press.
9 Garcia-Diez I, Curto-Barredo L, Weller K, Pujol RM, Maurer M, Gimenez-
Arnau AM. Cross-cultural adaption of the urticaria control test from
German to Castilian Spanish. Actas Dermosiﬁliogr 2015; 106:746–752.
10 Weller K, Grofﬁk A, Church MK et al. Development and validation of
the urticaria control test – a patient reported outcome instrument for
assessing urticaria control. J Allergy Clin Immunol 2014; 133: 1365–
11 Ohanyan T, Schoepke N, Bolukbasi B et al. Responsiveness and minimal
important difference of the urticaria control test (UCT). J Allergy Clin
Immunol 2017. http://doi.org/10.1016/j.jaci.2017.04.050.
Not a simple plantar wart: a case
A 62-year-old Caucasian woman complained of a painful nodu-
lar lesion on her right heel that restricted her walking. She had
noticed the onset of the itching after approximately 3 weeks of
travel in Brazil. She was initially treated by her general practi-
tioner with topical salicylic acid, suspecting a plantar wart. After
a week of increased itching and unbearable pain, the patient was
referred to our dermatological service. The lesion was roundish
and approximately 1 cm in diameter, hard in consistency
Fig. 1). After gentle curettage, dermoscopy was performed. We
noticed a white halo of hyperkeratosis with an incomplete, dark
brownish ring, blue-black blotches, and a central oriﬁce
surrounded by white ovoid structures (
Fig. 2). After a few
insightful questions, she was diagnosed with tungiasis. We curet-
ted out the eggs and faecal material and further performed spray
cryotherapy, instructing her to apply a topical antibiotic oint-
ment for 2 weeks; this resulted in her full recovery. The patient
also received tetanus prophylaxis.
Tungiasis is a cutaneous parasitosis which is caused by a ﬂea,
Tunga penetrans. This infection is widely distributed among
mammals, affecting humans and small animals. It is endemic to
South and Central America, sub-Saharan Africa and, rarely,
The infestation cycle of the ﬂea lasts
nearly 1 month. The female penetrates the skin of mammalian
hosts and causes a hypertrophic, rounded lesion with a central
black dot. This represents the abdominal and genital opening
where the ﬂea produces and expels its eggs.
To avoid severe
complications such as digit deformation, chronic lymphedema,
tetanus and sometimes sepsis, early diagnosis is decisive. This
holds especially in endemic areas where severe infestation often
Diagnosis in these areas is usually straightforward; nev-
ertheless, it can be tricky in non-tropical areas, due to a low
index of suspicion. As skin lesions are one of the most common
reasons for returning travellers to seek medical evaluation, in
case of a somewhat uncharacteristic plantar wart, we believe it is
important to ask the patient whether he or she recently visited a
‘Zebra retreat’ refers to the hesitation with which one consid-
ers a rare diagnosis (zebra) even though it may be the most likely
Figure 2 Dermoscopy of same lesion.
Figure 1 Nodular lesion on right heel.
© 2017 European Academy of Dermatology and Venereology
2018, 32, e86–e121
Letters to the Editor