Search

Atopic dermatitis (AD) therapeutic approach calls for a long-term treatment. Treatment options for AD have recently undergone a revolutionary change by the introduction of the first biologic drug. Availability in daily practice of the last version of international AD guidelines, taking peculiarities of the country into account, can contribute to good clinical practice in Italy. To adapt European Dermatology Forum (EDF) guidelines for AD to the Italian medical–legal context, the EDF guidelines were assessed independently by two independent Italian renowned experts in the field and further integrated with articles published and systematically reviewed before May 2019. The first draft was collegially corrected and updated by the members of the SIDEMAST, ADOI, and SIDAPA. Recommendation levels (A; B; C; D) were graded based on the evidence levels (1–4). The adapted guidelines presented here focus on topical and systemic therapies in AD patients, both children and adults. As opposed to previous Italian guidelines, they include indications about biologics. New relevant evidence available from very recent literature and peculiarities of the Italian medical and legal context have been integrated in the revision process. If compared to general guidelines for AD not adapted to a specific national and cultural context, a revision for specific Italian needs is now available: It comprises the option of implementing the new biologic treatments and is likely to provide an important contribution to the improvement of clinical practice in Italy. Cooperation between patients, dermatologists, allergologists, and pediatricians remains mandatory in AD management. The authors of the present revision recommend an update of the Italian guidelines to be performed at least every second year.

Patch testing is the standard procedure used to diagnose allergic contact dermatitis. It is an in-vivo test, which reproduces the reaction to a contact allergen. This in-vivo test aims to reproduce the elicitation phase of allergic contact dermatitis and is performed applying allergens under occlusion on the skin under standardized conditions. These guidelines for the best practice in performing patch test have been developed by an Italian group of experts taking in account the Italian legislation and local pharmacological governance. Guidelines are adapted from the original article under the guidance of the European Society of Contact Dermatitis (ESCD) and on the basis of the SIDAPA guidelines.

Pemphigus is a life threatening autoimmune epidermal blistering disease involving skin and mucous membranes. Pemphigus usually affects middle age men and women involving oral mucosa first and then spreading on the skin. It is caused by the presence of autoantibodies (IgG and less frequently by IgA) directed against desmogleins, and/or other glycoproteins that plays a critical role in cell-cell attachment. Upon a predisposing genetic background, different agents have been shown to act as triggers for the pathogenesis of pemphigus. This guideline for the diagnosis and treatment of pemphigus has been developed by an Italian group of experts taking in account the Italian legislation and local pharmacological governance. Guidelines are adapted from the original article under the guidance of the European Dermatology Forum in collaboration with the European Academy of Dermatology and Venereology. It summarizes evidence-based and expert-based recommendations (S2 level).

Bullous pemphigoid is the most common autoimmune subepidermal blistering disease of the skin and mucous membranes. This disease typically affects the elderly and presents with itch and localized or generalized bullous lesions. In up to 20% of affected patients blister may be completely absent, and only excoriations, prurigo-like lesions, eczematous lesions, urticated lesions, and/or infiltrated plaques are observed. The disease is significantly associated with neurological disorders. The morbidity of bullous pemphigoid and its impact on the quality of life are significant. So far, a limited number of national treatment guidelines have been proposed, but no common European consensus has emerged. This guideline for the treatment of bullous pemphigoid has been developed by an Italian group of experts taking in account the Italian legislation and local pharmacological governance. Guidelines are adapted from the original article under the guidance of the European Dermatology Forum (EDF) in collaboration with the European Academy of Dermatology and Venereology (EADV). It summarizes evidence-based and expert-based recommendations (S2 level).

Alopecia Areata (AA) is an organ-specific autoimmune disorder that targets anagen phase hair follicles. The course is unpredictable and current available treatments have variable efficacy. Nowadays, there is relatively little evidence on treatment of AA from well-designed clinical trials. Moreover, none of the treatments or devices commonly used to treat AA are specifically approved by the Food and Drug Administration (FDA). The Italian Study Group for Cutaneous Annexial Disease of the Italian Society of dermatology (SIDeMaST) proposes these Italian guidelines for diagnosis and treatment of Alopecia Areata deeming useful for the daily management of the disease. This article summarizes evidence-based treatment associated with expert-based recommendations.

A 47-year-old man presented with a 3-year history of asymptomatic, erythematous papules and nodules located on his trunk, buttocks and limbs (Fig.1). Lesions were at different stages of clinical development: some were crusted or ulcerated, other necrotic or cicatricial. The patient's medical history was not relevant. This article is protected by copyright. All rights reserved.

Several types of B-cell lymphomas, including both primary cutaneous lymphomas and systemic lymphomas, may affect the skin, with partially overlapping clinical, morphological and immunohistochemical features. Currently, the World Health Organization (WHO) classification of primary cutaneous B-cell lymphomas does not include diffuse large B-cell lymphomas (DLBCL) and considers leg-type DLBCL the only primary cutaneous DLBCL. Here we report the case of a 72-year-old white woman with a primary cutaneous neoplasm comprised of large cells with round nuclei, irregularly clumped chromatin and one or more inconspicuous nucleoli. The immunohistochemistry demonstrated positivity for CD20 and MUM1, with no significant genetic translocations detected by fluorescence in-situ hybridization. After staging, we considered this neoplasm a primary cutaneous DLBCL with a non-germinal center phenotype, not otherwise specified, inconsistent with a leg-type DLBCL. Because of this view, we underscore the need for greater knowledge of the molecular landscape of B-cell lymphomas in order to reconsider the classification of such neoplasms in the skin.

Background: Giant basal cell carcinoma (GBCC) is a basal cell carcinoma (BCC) enlarged in a diameter more than 5cm. Since GBCCs are a highly infrequent entity and the occurrence rate is approximately 0.5–1% out of all BCC types, only anecdotal cases are reported, and causes and characteristics inducing development of this tumor are not defined. Objectives: Evaluate causative factors and clinico-histological characteristics of GBCCs. Methods: The study is a 6-month, hospital-based case series study performed in 12 Italian dermatologic centers. Results: A total of 59 cases and 458 control BCCs were collected. No significant differences existed between the two groups if we take into account social or cultural factors. The average duration of GBCCs is considerably longer than controls. GBCCs are located on unexposed areas while BCCs are on areas not usually covered by clothes. Superficial histological subtype was more frequent in the BCCs group, while infiltrative in GBCCs. GBCCs showed significantly higher local invasiveness, and greater metastatic capacity. More than half of GBCCs had been previously treated with one or more treatments. Conclusions: Patients with GBCCs appear to belong to two categories: (i) those who present with GBCC due to delay in accessing medical attention, and (ii) those who have BCCs previously treated with inappropriate strategies. Only very few cases can be carried out with intrinsic biological features of tumor aggressiveness. Social and cultural conditions do not appear to be involved in the development of GBCCS. These observations may help clinicians in selecting correct therapeutic strategies in the treatment of BCCs, which give rise to GBCC.

Chest pain following a trans-thoracic biopsy often has multiple etiologies, especially in patients with lymphomas. Pathological neuronal mechanisms integrate with an overproduction of IL-6, TNF-α, IL1-β by macrophages and monocytes, which amplifies inflammation and pain. In consideration of this complex pathogenesis, international guidelines recommend diversified analgesia protocols: thoracic epidural, paravertebral block, and systemic administration of opioids. This study reports an attempt to reduce chest pain and prevent chronic pain in 51 patients undergoing trans-thoracic biopsy for mediastinal lymphoma. The entity of pain, measured 72nd hour after biopsy by the Numerical Rating Scale (NRS), was compared with that seen at a 6th month checkpoint in 46 patients. The pain decreased in all cases. At the 6th month checkpoint, among 31 opioid-treated patients, none of the 16 patients with NRS &lt, 6 within the 72nd hour post biopsy had developed chronic chest pain, while 8 of the 15 with higher values did (p &lt, 0.01). Of 10 patients undergoing thoracotomy and treated with opioids, eight had a NRS of no more than 2, of which six had no chronic pain. Of the twenty-one patients who underwent VATS biopsy and were treated with opioids, fifteen had NRS no greater than 2, of which ten had no chronic pain. Subgroups of patients biopsied under mediastinotomy or video-assisted thoracoscopic surgery (VATS) and treated with thoracic epidural analgesia (TEA) or PVB were too small for such analysis.

Background: Cutaneous warts are an extremely common problem, whose eradication can be challenging. Topical PDT involves applying a porphyrin precursor, 5-aminolevulinic acid (ALA) or methyl aminolevulinate (MAL) to the affected area. ALA-PDT has been well documented to be successful in the treatment of recalcitrant warts. PDT has a limited role in the treatment of thicker lesions because the photosensitizer does not penetrate keratotic lesions well, though this is vehicle dependent. Objective: The aim of this study was to evaluate the efficacy and safety of curettage + microneedling + ALA-PDT for the treatment of resistant acral warts. We hypothesized that microneedling may increase the efficacy of PDT, providing a channel to deliver the ALA to deeper areas of warts. Methods: Our study was carried out between November 2017 and July 2018. Eligible participants had one or more resistant plantar or palmar warts. Thirteen patients were recruited. They underwent a thorough curettage, followed by the application of 5-ALA 10% cream on the wart, and by microneedling. Later, the pricked skin was covered for three hours by an occlusive polyurethane dressing, and finally irradiated with a red-light source. Patients performed one session every three weeks for a total of three cycles. Results:After 3 treatments of curettage + microneedling + ALA-PDT, 11 patients (84.6%) showed complete remission (defined as complete disappearance of their warts). One patient (7.7%) showed partial remission (defined as greater than 50% decrease in the wart area) after 3 sessions; this patient needed other 2 sessions to achieve complete remission. The mean follow-up period after healing was 4.3 months. Adverse effects were recorded. Conclusion: We have demonstrated, for the first time to our knowledge, that the combination of curettage + microneedling + topical ALA-PDT may offer an effective and safe alternative for the treatment of acral resistant warts, even when PDT alone has already been insufficient.

Lymphomas usually involve lymph nodes and other lymphoid tissues, but sometimes occur in non-lymphoid organs, called extra-nodal sites. Primary diffuse extra-lymph node large B-cell lymphoma (DLBCL) of the thyroid and parotid gland have been observed rarely. According to the most accredited guidelines, primary extra-nodal DLBCL of the parotid and thyroid glands should be treated with three cycles of R-CHOP followed by radiotherapy of the involved site (ISRT). Surgery alone is not enough to treat DLBCL. We describe two unusual cases of primary extra-nodal DLBCL in elderly patients treated exclusively with surgical resection, given the inability to apply chemotherapy. Both patients achieved clinical recovery, which was maintained after a follow-up of more than 18 months, despite not having performed the indicated chemotherapy protocol. The two cases presented here, and a few others reported in the literature, should be considered exceptions to the rule, and do not allow the conclusion that surgery alone might be sufficient for complete remission.

Background Hyperhidrosis is a disorder of excessive sweating severely impacting on patient's quality of life (Qol). Several studies have been published about oral oxybutynin, but no studies focused on the achievement of complete clinical and Qol response. Objectives the aim of this study was to report our real-life experience with oral oxybutynin in patients with severe hyperhidrosis significantly affecting their Qol. Methods In this cohort retrospective study we enrolled, in a 3-year period, patients affected by severe hyperhidrosis with poor Qol, continuously treated with oral oxybutynin. Our outcome was the obtainment of complete clinical and Qol improvement. A systematic review of the literature was also performed reporting efficacy and safety of oral oxybutynin for primary hyperhidrosis. Results We enrolled 62 patients, of which 53 (85.5%) received a mean daily dose of 10 mg and 9 (15.5%) of 5 mg. Complete clinical response was achieved in 77.4% (48/62) of cases, while complete Qol improvement occurred in 51.6% (32/62) of cases. Adverse events were only reported as mild, with dry mouth being the most frequently observed (16.1%). Kaplan-Meier survival analysis highlighted that both median clinical and Qol complete responses were reached after 1 year of continuous therapy with oral oxybutynin. The main limitation of our study is the small number of patients enrolled. Conclusions Long-term therapy with oral oxybutynin for severe hyperhidrosis, continuously administered at a mean daily dosage of 5 to 10 mg, allowed the majority of our patients to reach both clinical and Qol complete improvement, without significant adverse events. This article is protected by copyright. All rights reserved.

Background: Congenital melanocytic nevi (CMN) are benign proliferations of melanocytes usually present at birth. The magnitude of the melanoma risk for CMN is controversial, generating an ongoing debate on the best approach to manage these lesions. Objective: To perform a retrospective, observational study with the aim to evaluate the prevalence of CMN-associated melanomas in tertiary referral centers, as well as the eventual correlation between clinical, dermoscopic, and histological features of CMN-associated melanomas. Methods: A single-center retrospective observational study was performed on all clinical and dermoscopic images of histologically confirmed melanomas arising on CMN over a 14-year period (January 2005 to March 2019). Results:Our database included 2,159 melanomas in the considered period. Of those, 27 (1.3%) were CMN-associated melanomas. The mean age of patients with CMN-associated melanoma was 33 years (range, 11–70 years). The mean diameter of CMN-associated melanoma was 18 mm (range, 6 mm to 20 cm), and 56% were located on the back. Twenty-one (77.8%) of CMN-associated melanomas arose on small CMN (50% of the nevus surface (0.8 and 0.7 mm, respectively). Conclusions: In our series, small CMN was the most frequent type of CMN-associated melanoma. Although the risk of melanoma is increasing by the increasing size of CMN, our finding is definitely related to the much higher prevalence of small CMN in the general population as compared to the prevalence of intermediate-sized and large CMN. Limitations: Small sample size, single-center experience, retrospective design.

Background In the practice of dermatology, many tools are available to help the physician measure the patient's quality of life. "Pictorial Representation of Illness and Self Measure" (PRISM) is a novel and simple method to measure personal suffering. Methods The aim of our study is to evaluate, through the use of PRISM, whether the reduction of the ulcers' size positively correlates with an improvement of the patients' suffering. This is a multicenter national prospective study. 143 patients from five dermatological centers were enrolled in the study. At times T0 and T1 (after 1 month), the size of the ulcers was collected for each patient. At the same time, the PRISM test was also administered, in order to calculate the Self-Illness-Separation (SIS). Results First, a substantial decrement of the size of the ulcer seems to correlate with a significant difference between the SIS score obtained at T0 and T1. On the contrary, the duration of the wound doesn't seem to influence the SIS value. No relationship between the age of the patient and the SIS value was found either. Conclusions Our study shows that the decrease in the wound dimension positively affects the patient's suffering. In fact, ulcer's size reduction is correlated with an improvement in the patient's disease perception.

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by painful, necrotic ulcerations. PG is described as a rare disease: the world‐wide incidence is estimated to be around 3 to 10 cases per million population per year. These estimations are based mostly on case reports and retrospective case series; there are no prospective, multicentre studies on the matter. The apparent rarity of PG is in contrast with our clinical perception as dermatologists: in our opinion, PG is not so uncommon. Therefore, we decide to investigate the epidemiology of PG in the Italian population and confirm our clinical suspicions that it is not an orphan disease. We enrolled all patients diagnosed with PG in 8 Italian Dermatological Departments from 1st October 2014 to 1st November 2015, and we recorded their features. Our data, collected from 64 patients, are in accordance with those of the published literature regarding the epidemiology and features of PG. In an Italian population of roughly 8 million inhabitants of 7 provinces, we found an incidence of 5.17 new cases per million population per year. Unlike our predictions before the study, we confirmed the world‐wide incidence of PG. To our knowledge, this is the first observational, multicentre study on PG. We hope that it provides a stimulus for further researches on PG and for the creation of an Italian register.

Drug reactions and systemic diseases often involve the skin. In particular, most drug-induced reactions and many infectious diseases present with dermatologic manifestations localized acrally, that is on distal portions of limbs (hand, foot) and head (ears, nose). A detailed review of all acral dermatologic signs of drug reactions and systemic diseases is beyond the scope of this paper, although some of these disorders will be discussed specifically here.

Locus minoris resistentiae (lmr) can be defined as a site of the body that offers lesser resistance than the rest of the body to the onset of disease. The well-known Köbner phenomenon is itself a clear example of lmr in dermatology. The new term locus maioris resistentiae (LMR), a site of the body that offers greater resistance than the rest of the body to the onset of disease, defines the opposite condition. Renbök phenomenon (reverse Köbner's isomorphic response) typically represents an example of LMR.

Alopecia areata (AA) is a complex immune-mediated disorder, which is difficult to treat. The available treatment options seem to have limited benefit, help only some patients and have a high relapse rate. We evaluated a new therapeutic option for moderate to severe AA based on the combination of photodynamic therapy (PDT) with 5-aminolaevulinic acid (ALA) and microneedling (MN). In total, 14 patients were enrolled, and these were randomly divided into 3 groups: Group A (MN alone; n = 9), Group B (ALA-PDT alone; n = 15) and Group C (combination of MN and ALA-PDT; n = 17). All patients were treated once every 3 weeks for a total of six treatments. The best clinical outcome was achieved in Group C, with complete hair regrowth observed in three patients, and an improvement of >= 50% and < 50% of the treated areas obtained in seven and six patients, respectively. Our report suggests that combination of ALA-PDT with MN could be an additional therapeutic option in moderate to severe AA, as MN allows better skin penetration of ALA and subsequent indirect immunosuppression.

Lately, the innovative concept of an immunocompromised cutaneous district (ICD) has been introduced to explain why a previously injured cutaneous site may become in time a privileged location for the onset of opportunistic infections, tumors, and immune reactions. The injuring events capable of rendering a skin region a potential ICD are various, numerous, and most of the time identifiable by means of a careful clinical history. The reason that only a small minority of injured skin areas actually becomes ICDs, with subsequent opportunistic localization of a second and unrelated skin disorder, is presently unknown. The ICD is a conceptual entity that is not limited to human dermatology. It can also apply to veterinary medicine. Development of sarcomas at the injection site in cats after routine vaccination and, occasionally, administration of pharmaceutical products, as well as insertion of any foreign body, is a repeatedly documented event. Antigen load, persistent inflammation, and fibroblastic proliferation are thought to be important factors predisposing to the onset of fibrosarcoma in cats. Recently, it has been hypothesized that a local immunosuppression caused by inhalant glucocorticoids may have favored the development of regional demodicosis in cats. In our opinion, injection-site sarcomas and feline localized demodicosis can be considered examples of veterinary ICDs.