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Background Anti-tumour necrosis factor alpha are a well-documented class of disease-modifying therapy for inflammatory bowel diseases, including Crohn's disease and ulcerative colitis. The monoclonal anti-TNFα antibody Infliximab and Adalimumab are the current approved drugs in Italy, showing high efficacy, but also variable clinically significant adverse effects. Method From 2012, an observational prospective study was activated at the Dermatology Clinic of Cagliari University, to screen all patients with inflammatory bowel diseases treated with Infliximab and Adalimumab for cutaneous adverse reactions and skin cancers. A basal visit, complete of melanocytic lesions digital image recording was performed in all patients referred from the Gastroenterology Unit of the same University Hospital. Subsequent visits were performed when new lesions or modification of the skin appearance occurred. All cutaneous adverse reactions associated with anti-TNF treatment were reported to the Italian Pharmacovigilance network. Results Ninety-one patients were included in the study: 58 (31 women and 27 men) patients affected by Crohn's disease, (the age range was between 16 and 69 years), and 33 patients with ulcerative colitis (15 women and 17 men; age range between 21 and 68 years). Proportion of patients treated with infliximab (52%) was similar to adalimumab (48%). Cutaneous adverse reactions were observed in 38 patients (42%): 20 were taking Infliximab (52%) and 18 Adalimumab (48%). Adverse reactions observed by frequency included: infections (32%), eczematous dermatitis (23%), infusion systemic reactions and at the injection site (5.7%), psoriasis paradoxical reaction (5.7%), followed by a mixture of different cutaneous reactions, including urticaria, photosensitivity, chronic lupus erythematosus, lichenoid eruption, alopecia areata, hypertrichosis. Benign skin tumors eruption (15%) and basal cell carcinoma (2.8%) occurrence were also noted. Patient with dysplastic melanocytic nevi (10%) at screening were regularly followed with digital dermoscopy, but no one showed changes in the study period. Conclusion Our sample of patients had a high rate of skin adverse reactions (42%), but considering severity, no case required definitive discontinuation of therapy. Dermatologist support might be critical to optimize biological agent management in inflammatory bowel diseases, performing a careful basal screening, strict monitoring of adverse reactions and prompt intervention, as well as educating the patient towards skin cancer prevention, considering the long-term drug exposure.

To evaluate, in the context of a randomized study, the 'Sole Si Sole No GISED' project, the effectiveness of an educational intervention to improve sun protection behaviour in schoolchildren.A large number of primary schools (classes II and III) in Italy were randomized to an educational intervention or control group: The intervention was conducted by trained teachers using ad hoc developed materials. Attitudes toward sun exposure and behaviour while in the sun were assessed at baseline and 1 year after concluding the educational intervention. In a subgroup of children, melanocytic naevi were counted on the upper limbs at the same intervals. The pilot phase of the study was started in 2001.During the pilot phase, a total of 4,233 children was recruited. Of these, 2,116 were randomized to the active intervention and 2,117 to the control group. No difference for any of the study variables was documented between the 2 groups at baseline. About 20% of the children reported intense sun exposure during the year preceding the study. About 88% of the children reported adequate modalities of sun protection. Sunscreens were commonly used. A total of 508 children (12%) reported a history of sunburns in the year preceding the start of the study. Melanocytic naevi were counted in a total of 1,503 children (852 in the experimental and 651 in the control group). No differences in terms of skin, hair and eye colours were documented between the experimental and the control groups. The mean naevus count at baseline was 9.6 (median 7) in the experimental group and 10.1 (median 8) in the control group.About 50% of the total expected number of children was recruited during the pilot phase of the study. Randomization proved to be an excellent modality to select 2 samples similar for all the important study variables examined. A history of sunburns was reported less frequently than expected. The 'Sole Si Sole No GISED programme' is one of the few examples of a controlled evaluation of the effectiveness of an educational intervention in Italy.

Scleredema adultorum of Buschke is a rare fibromucinous, scleroderma-like connective tissue disease most commonly found in a post-infectious setting or linked to hematological disorders or diabetes. Lichen sclerosus et atrophicus is an autoimmune condition only in 2.5% of cases localized exclusively at an extragenital site, occurring in up to 34% of patients in association with other autoimmune diseases such as vitiligo, thyroid disorders, alopecia areata, lichen planus, morphea, pernicious anemia and systemic lupus erythematosus. In particular, a stronger link with an autoimmune background in lichen sclerosus et atrophicus has been observed in women who showed higher prevalence for autoimmune conditions and circulating autoantibodies. Literature reveals a genetic susceptibility linked to specific HLA types. We report three patients who developed lichen sclerosus et atrophicus superimposed on skin involved by scleredema adultorum of Buschke. Although the association of lichen sclerosus et atrophicus with scleredema adultorum of Buschke could be coincidental, both diseases could be considered part of the spectrum of sclerodermoid disorders with common underlying pathogenetic mechanisms; which could explain the sequential or simultaneous occurrence of both lesions in our patients.

Psoriasis is a chronic complex multisystem, inflammatory, skin disorder that causes vasodilatation and hyperproliferation of keratinocytes, whose clinical expression includes a thickened, erythematous skin, often covered with silver grey scales. Psoriasis is a unique disease where both autoimmune and autoinflammatory responses coexist and the balance between the two components is essential in determining its clinical and histopathological presentation. Adaptive immune responses prevail in chronic plaque psoriasis while innate and autoinflammatory responses predominate in pustular psoriasis. The histopathology of psoriasis is easily recognizable when the disease involves the typical sites such as the extensor surfaces. Although a biopsy is rarely required in case of classic psoriasis, in atypical and controversial conditions, histopathological examination remains the main diagnostic tool that can help in differentiating psoriasis from other dermatoses. In this review, we will discuss the histopathological pictures of the different clinical variants of psoriasis giving some clues to drive the correct diagnosis when the clinical aspects are not enough indicative of the disease.

Bullous morphoea is a rare variant of localized scleroderma whose pathogenesis has been widely discussed. We retrospectively reviewed the records of all histopathologically confirmed cases of morphoea followed from 2005 to 2015 at the Dermatology Clinic and Pathology Institute of the University of Cagliari, Sardinia, Italy. Among 137 patients with morphoea, 2 cases of the bullous variant were identified, which were successfully treated with methotrexate. Thus, the bullous form comprised 1.4% of all cases of morphoea, which is much lower than the 7.5% previously reported. In one of the cases, histopathological examination revealed a peculiar 'stretching' pattern of basal keratinocytes attached to the epidermal roof of the bulla, together with increased lymphatic vessels, which were either collapsed or dilated, stressing the role of lymphatics and possibly of excessive skin trauma and friction in the development of bullous lesions.

Background Granulomatous reaction is a well-known complication following soft filler procedures. However, the diagnosis of filler-induced granulomas may be challenging because of the occasional reluctance of patients to report the previously performed aesthetic procedure. Objective To describe a new clinical situation in which some patients, in the quest for physical perfection, become addicted to multiple sequential cosmetic injections, increasing the risk of adverse reactions. Methods We describe three women who developed diffuse facial nodular tumefaction after multiple procedures of filler injections into their face that occurred at different times in the previous years. Results Histopathology showed a granulomatous reaction including different combined substances that were identified with different types of micro-implants in the same biopsy. Conclusions Excessive demand of multiple cosmetic injections may increase the frequency of skin granulomatous reactions and can be included in the spectrum of similar addictive dysmorphophobic behaviours. Histopathology is the best mean to achieve the diagnosis.

Diffuse dermal angiomatosis is a form of cutaneous reactive angiomatosis characterized clinically by painful erythematous or violaceous lesions with ulcers that may mimic cutaneous vasculitis/vasculopathy. Histologically it shows a benign, diffuse proliferation of endothelial cells with tiny blood vessels in the papillary and reticular dermis. Herein, we report four patients with diffuse dermal angiomatosis in the setting of calciphylaxis and monoclonal gammopathy and review the cases previously published in the literature. Comorbidities and management will also be discussed.