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BACKGROUND: Increased body mass index and weight gain are risk factors for psoriasis, and the prevalence of obesity in patients with psoriasis is higher than in the general population. Limited data exist regarding the role of diet in psoriasis. Here we assessed the impact of a dietary intervention combined with physical exercise for weight loss on improving psoriasis in overweight or obese patients. METHODS: This study included 303 overweight or obese patients with moderate-to-severe chronic plaque psoriasis not achieving clearance after 4 weeks of continuous systemic treatment. They were randomized to receive a 20-week quantitative and qualitative dietary plan associated with physical exercise for weight loss, or simple informative counseling at baseline about the utility of weight loss for clinical control of psoriatic disease. The main outcome was any reduction of the Psoriasis Area and Severity Index (PASI) from baseline to week 20. RESULTS: Intention-to-treat analysis showed a median PASI reduction of 48% (95% confidence interval, 33.3 to 58.3%) in the dietary intervention arm and 25.5% (95% confidence interval, 18.2 to 33.3%) in the information-only arm (P=0.02). Among secondary outcomes, PASI50 significantly differed between study arms (49.7% with dietary intervention vs. 34.2% with information only, P=0.006). The weight-loss target (a ≥5% reduction from baseline) was reached by 29.8% of patients in the dietary intervention arm compared to 14.5% in the information-only arm (P=0.001). CONCLUSIONS: A 20-week dietetic intervention associated with increased physical exercise reduced psoriasis severity in systemically treated overweight or obese patients with active psoriasis. This article is protected by copyright. All rights reserved.

Accuracy in melanoma detection is important to recognize early curable melanomas and to minimize the unnecessary excision of benign lesions. The aim of this paper was to evaluate melanoma screening accuracy of Italian pigmented lesion clinics in terms of number needed to excise (NNE), melanoma thickness, and number of melanomas diagnosed during patient follow-up.Information on all skin tumors excised in 2011 were extracted from the databases of the participating centers. Information whether the lesion was excised at the baseline examination or during patient follow-up was recorded, as well as the overall number of patients examined in each center in 2011.After e-mail solicitation, 22 of 40 centers agreed to participate. A total of 8229 excised lesions were collected. The overall number of examined patients was 86.564, thus 9.5% of screened patients had a lesion removed. Of the excised lesions, 866 were diagnosed as melanoma (1% of examined patients) and 5311 (88.9%) were melanocytic nevi. Three NNE were calculated giving values of 7.9 excised lesions to find 1 melanoma, 7.1 melanocytic lesions to find 1 melanoma, and 3.7 lesions to find 1 skin malignancy. The median melanoma thickness was 0.6 mm, with only 15.1% of melanomas ≥ 1 mm of thickness. Melanomas detected over time were 96 (11.1%; mean thickness, 0.3 mm), with 15.6% of lesions excised after short-term follow-up and 84.4% after long-term follow-up.The NNE values comparable to those achieved in specialized clinical settings and the high number of early melanomas diagnosed at the baseline examination or during patient follow-up indicate a high level of accuracy in melanoma screening achieved by Italian pigmented lesion clinics.

Background Mammary Paget's disease (MPD) is a rare intraepidermal adenocarcinoma of the nipple-areola complex, associated with an underlying breast cancer in approximately 90% of cases. Delayed diagnosis of MPD is common. Its dermoscopic features have been ill defined in the literature. Objectives To determine the clinical and dermoscopic features of MPD versus other dermatologic entities that involve nipple and areola. Methods Members of the IDS were invited to submit any case of histologically confirmed MPD, as well as other benign and malignant dermatoses that involve the nipple and areola complex. A standardized evaluation of the dermoscopic images was performed and the results were statistically analyzed. Results Sixty-five lesions were included in the study, 22 (33.8%) of them MPD and 43 (66.2%) controls. The most frequent dermoscopic criteria of MPD were white scales (86.4%) and pink structureless areas (81.8%), followed by dotted vessels (72.7%), erosion/ulceration (68.2%) and white shiny lines (63.6%). The multivariate analysis showed that white scales and pink structureless areas were significant predictors of MPD, posing a 68-fold and a 31-fold probability of MPD, respectively. Split of the population into pigmented and non-pigmented lesions showed that in pigmented MPD, pink structureless areas, white lines and grey granules and dots are positive predictors of the disease. Among non-pigmented lesions, pink structureless areas, white lines, erosion/ulceration and white scales served as predictors of MPD. Conclusions The most frequent profile of an individual with MPD is an elderly female with unilateral, asymptomatic, erythematous plaque of the nipple, dermoscopically displaying pink structureless areas, fine white scales, dotted and a few short linear vessels. In case of pigmentation we may also observe brown structureless areas and pigmented granules. Limitations Small sample size, retrospective design.

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Polypoid melanoma is a variant of nodular melanoma, whose poor prognosis depends on its thickness and the presence of ulceration at the time of diagnosis. The authors report two cases of polypoid melanoma, presenting as broad, cauliflower-like, polypoid masses. Dermoscopy was characterized by a multicolored pattern, atypical polymorphic vessels, and the fiber sign. Clinical and dermoscopic features can help to diagnose polypoid melanoma and exclude other possible differential diagnoses. However, histology remains mandatory to confirm the diagnostic suspicion.

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.

In this article, we report the sonographic features of vaccination granulomas in three children sensitized to aluminum. Although the recognition of the vaccination granuloma relies on the clinical examination, misdiagnosis is frequent, leading to distressful procedures or prolonged antibiotic administration. In all our cases, sonography revealed a teardrop-shaped echogenic central structure, suggesting the deposition of aluminum crystals along the route of administration with consequent subcutaneous degenerative changes, and a surrounding hypoechoic cap, which reflects the changeable inflammatory reaction and the granuloma formation.

Terra firma-forme dermatosis is an underreported acquired pigmentation disorder caused by keratinocyte retention that is not mentioned in many textbooks. It is characterized by the onset of asymptomatic hyperpigmented patches or velvety plaques potentially involving any part of the body, including the trunk, extremities, and the skin folds such as neck, axilla, inguinal region, and umbilical folds. It affects both sexes equally and all age groups, although it seems more prevalent in children with a mean age of 10.4 years. The prompt regression after rubbing with an alcohol-soaked gauze is diagnostic and curative. The cause of this affection remains unknown, although less rigorous hygiene or an atopic background is contributory.

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Erosive pustular dermatosis of the scalp is a slowly progressive chronic inflammatory disease that predominantly affects elderly male patients with marked actinic damage. The clinical evolution consists firstly of keratotic and erosive plaques surmounted by yellow-brown crusts and non-follicular pustules; later, the active crusting lesions regress in number and the scarring process causes diffuse cutaneous thinning and loss of hair follicles. However, manifestations may be atypical, leading to frequent misdiagnosis. We present a case series of post-traumatic erosive pustular dermatosis on the scalp of 4 elderly patients. The characterising feature was the presence of erosion consisting of abundant hypergranulation tissue, with an almost total lack of crusts and pustules. Dermoscopy showed a unique pattern of stretched and dilated linear, telangiectatic and polymorphous on-focus vessels, milky-red areas and white scarring areas. This clinical entity is rarely reported in the literature. The majority of reported cases were located on the legs.

Background: Actinic keratosis (AK) is a form of premalignant keratinocyte dysplasia. Recently, the role of photosensitizing drugs in the development of AK has been postulated. Objective: This study evaluated a possible association between the use of photosensitizing drugs and the development of AK. A secondary aim was to identify a possible association between any medication other than those primarily examined and AK. Methods: A single-center, case-control study assessed the cumulative drug exposure of 90 patients with AK and 90 controls visiting a dermatology service for other skin ailments. Before the visit, patients were interviewed to collect data on daily therapy and the lag-time of discontinued drugs within the last 2 years, and to record the drug’s active ingredient, dosage, and duration of therapy. In addition, sociodemographic characteristics including age, sex, educational level, skin phototype, and cumulative sun exposure habits were gathered. Results: By logistic regression, exposures to angiotensin II receptor blockers (ARBs) and antiplatelet agents were identified as independent risk factors for the development of AK. ARB intake was associated with AK only at high exposure (OR = 13.6; 95% CI, 2.0-93.8). The use of antiplatelet drugs was borderline, yet not significant, at low exposure (OR = 3.31; 95% CI, 0.86-12.7), but increased in a dose-dependent manner. The strongest correlation was found at the highest cumulative dose (>1100 dose unit-years (OR = 4.38; 95% CI, 1.16-16.6). Conclusions: High exposure to ARBs and antiplatelet agents may promote AK carcinogenesis in at-risk patients.

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BACKGROUND/OBJECTIVES: Little is known about the dermoscopic features of atypical fibroxanthoma. METHODS: This was a case-control study. Atypical fibroxanthoma lesions were compared with a control group with non-melanoma skin cancer. RESULTS: Altogether 40 atypical fibroxanthoma were collected. Most developed in men (93%), appearing mainly as nodular (63%), amelanotic (93%) and ulcerated (78%) lesions. Most lesions were located on the scalp (55%) and the ears (13%). Dermoscopically, most atypical fibroxanthoma displayed red (83%) and white (70%) structureless areas and irregular linear vessels (43%). A series of features achieved statistical significance when comparing atypical fibroxanthoma with non-melanoma skin cancer. The presence of red and white structureless areas and white lines, and the absence of yellowish-white opaque scales, hairpin vessels and arborising vessels were predictive of atypical fibroxanthoma in univariate analysis. However, when squamous cell carcinoma was excluded from the analysis, none of the criteria achieved statistical significance. When basal cell carcinoma was excluded, three variables achieved statistical significance in predicting atypical fibroxanthoma: red, structureless areas, the absence of opaque yellowish-white scales and absence of white circles. CONCLUSIONS: Atypical fibroxanthomas seem to be barely distinguishable from basal cell carcinoma dermoscopically, but they are more easily distinguishable from a well to moderately differentiated squamous cell carcinoma. A histopathological examination is needed for the final diagnosis.

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Background: The hair whorl denotes the spiral disposition of hairs around an axis, which is determined by the follicle growing direction. Atypical variants of scalp hair patterns, identified by abnormally placed or multiple whorls, have been associated with early brain developmental disorders and several dysmorphic syndromes. Materials and Methods: A 6-month case-control, prospective monocentric study included an overall number of 557 children. A logistic regression analysis was performed to evaluate the relationship between localization, the number of scalp hair whorls, and their association with neurofibromatosis type 1 (NF1). Results: NF1 positively correlates with a frontal localization, whereas a negative association was found with a parietal whorl pattern (P < 0.001). Conclusion: Evaluation of scalp whorls gains importance in the neonatal settings and may contribute to suspect the early diagnosis of NF1, as the related National Institutes of Health diagnostic criteria cannot be usually observed at an early age.

Congenital melanotic macules of the tongue (CMMT) are a rare and benign condition that is probably underestimated. We report the case of an African infant with multiple congenital hyperpigmented macules of the tongue. To avoid a difficult-to-perform procedure such as a tongue biopsy, focused clinical monitoring was performed every 3 months for 30 months to detect significant changes. A clinical diagnosis of CMMT was made in the absence of concomitant systemic diseases using the clinical findings, the location on the tongue, the negative family history for melanoma, and the absence of drugs and toxic exposure. Clinical follow-up may be sufficient to monitor CMMT rather than performing a tongue biopsy.

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We report here a new case of neutrophilic figurate erythema of infancy in a 1-year and 9-month-old white boy. Neutrophilic figurate erythema of infancy is a rare inflammatory dermatosis which is part of the figurate inflammatory dermatoses of infancy and is considered a variant of annular erythema of infancy. The disease is clinically characterized by annular erythematous lesions, sometimes with a polycyclic configuration, and histologically by a dermal neutrophilic infiltration with leukocytoclasia. Differential diagnosis mainly includes clear-cut severe diseases with a well-known etiology, such as neonatal lupus erythematosus and its variant erythema gyratum atrophicans transiens neonatale, erythema chronicum migrans and erythema marginatum rheumaticum, and diseases of unknown origin and with less clear limits, such as erythema annulare centrifugum and its variant familial annular erythema. Anamnesis, laboratory findings, clinical features, and histology allow the correct diagnosis and therefore, having excluded severe diseases, parents should be reassured as neutrophilic figurate erythema of infancy, as the annular erythema of infancy, is a benign disease, in most cases unassociated with other conditions and usually self-limiting over a few months, even though a chronic course may rarely occur. Our case was characterized by a chronic persistent course and by a complete resolution of the lesions only during febrile episodes.

The term "isotopic response" describes the occurrence of a new skin disorder at the site of another, unrelated and already healed one. We report here the case of a 38-year-old woman who referred to us for an infiltrated, red-brownish plaque localized on her left cheek. The patient had been treated for a cutaneous leishmaniasis, confirmed by the histologic examination, localized at the same site. She was completely healed after an appropriate local and systemic treatment. She experienced the occurrence of the new plaque at the site of the previously healed cutaneous leishmaniasis three month later. Histologic examination and laboratory tests were consistent with a diagnosis of discoid cutaneous chronic lupus erythematosus. Treatment with hydroxychloroquine, topical clobetasol and topical tretinoin resulted in flattening and clearing of the lesion. Our case is the first case of isotopic response where a discoid chronic lupus erythematosus had occurred at the site of an already healed cutaneous leishmaniasis. We speculate that the activation of type-1 interferon system may be involved in the pathogenesis of our case.

The eutectic mixture of local anesthetic cream, a 1 : 1 mixture of prilocaine and lidocaine, 2.5% each, is frequently used in pediatric and dermatologic practice to obtain local anesthesia. Side effects include transient skin blanching, erythema, urticaria, allergic contact dermatitis, irritant contact dermatitis, hyperpigmentation, and purpura. We report two children with a purpuric reaction after application of this mixture cream. Purpura after application of this anesthetic cream is a rare nonallergic reaction and only 17 occurrences have been reported, to our knowledge, in the literature. Patch tests could not be performed in our two patients because of lack of parental consent but we suggest that the purpuric reactions were most probably of toxic origin. The pathogenesis of purpura after application of eutectic mixture of local anesthetics cream, which resolves within 2 weeks without dermatologic sequelae and without any specific therapy, is complex. The lesions are probably caused by the direct effect of the cream components on the vessels but many other factors, such as atopic dermatitis, prematurity, subjective predisposition to purpura, trauma, and thrombocytopenia may play important pathogenetic roles.

In early infancy, a congenital area of alopecia of the scalp may be the clinical presentation of various diseases, with the two most common being sebaceous naevus and aplasia cutis congenita. Typical lesions are easily diagnosed, but soon after birth, the differential diagnosis may be difficult if the clinical features of the lesion are not distinctive. In this paper, we report the usefulness of dermatoscopy in such cases.

Tattooing has become increasingly popular in today’s society, although it has been practiced for over 8000 years (1). Following this new fashion trend, physicians have documented an increasing number of tattoo-associated skin disorders.The most common dermatological tattoo compli-cations concern hypersensitivity reactions to tattoo pigments, for example, irritant and allergic contact dermatitis (2), development of lichenoid areas (1, 3–5), and granulomatous responses such as sarcoid granulo-mas or foreign body granulomas (1). Less frequently patients developing discoid lupus erythematosus have been reported (2).Pseudolymphoma confined to the tattoo area is an unusual tattoo reaction that, to the best of our knowledge, has been described in only seven cases in the literature (6–10). We report here a new case of pseudolymphoma developing in the green portion of a multicoloured tattoo, which was treated with a systemic anti-malarial drug.CASE REPORT

Background Plasma cell balanitis is a disorder of the middle-aged and older uncircumcised male. Several treatments have been proposed to treat this disease, but plasma cell balanitis is often resistant to conventional therapy. Methods We decided to evaluate the efficacy and tolerability of pimecrolimus 1% cream in resistant Zoon's balanitis. We report two cases of resistant Zoon's balanitis treated with topical pimecrolimus 1% cream. Results One of the two patients had a complete regression of the lesion after 2 months of therapy. The other one had a great improvement of the lesion, but a hyperpigmented patch persisted on the glans. Conclusion Pimecrolimus 1% cream may be a valuable second-line treatment for patients with steroid related side effects or with steroid and other conventional therapy resistant Zoon's balanitis, as well as for those rejecting circumcision.

This article does not have an abstract.

Sir, A 60-year-old man came to our observation because of hyperkeratotic plaques on the lower limbs, of 8 weeks duration. On physical examination, his legs showed indurated, cobblestone-like, grayish lesions, pink verrucous projections, and nonpitting edema (Figure 1). Kaposi–Stemmer sign was evident. Few psoriatic plaques were present on the trunk and the upper limbs. The patient was affected by morbid obesity (body mass index 41 kg/m). His medical history was relevant for heart failure, venous insufficiency, lymphedema, autoimmune hypothyroidism, and psoriasis. At the time of the first visit, he was receiving furosemide 25 mg/d, enalapril 20 mg/d, thyroxine 100 μg/d, citalopram 20 mg/d, acetyl salicylic acid 100 mg/d, omeprazole 20 mg/d, acitretin 10 mg/d, emollients, and calcipotriol/betamethasone dipropionate ointment. The patient referred a worsening of the peripheral edema and effort dyspnea in the past week. A chest X-ray was taken and revealed pulmonary congestion due to congestive heart failure. He was hospitalized and blood tests were all within normal limits, except for an elevated reactive C protein (45 mg/L). An arteriovenous color Doppler ultrasonography (model MyLab40, Esaote, Genova, Italy) using a 7.5 to 12 MHz linear array transducer confirmed mild to moderate venous insufficiency. Filarial elephantiasis was excluded on the basis of the anamnesis and a diagnosis of elephantiasis nostras verrucosa (ENV) was made. Intravenous furosemide treatment was started, followed after 72 hours by the oral administration of the drug, in association with the increase of oral acitretin to 50 mg/d (0.4 mg/kg/d). Daily cleaning of the legs with chlorhexidine 2% aqueous solution was done to prevent over-infections. The patient initially used compressive bandages and after 2 weeks began to carry graduated support stockings (compression index 23-32 mm Hg). At follow-up visit, 2 months later, the patient had lost 15 kg and the lesions had resolved almost completely (Figure 2). Elephantiasis nostras verrucosa is a rare condition considered an exaggerated form of secondary lymphedema that usually involves lower extremities, deformed by progressive fibrosis of the skin. The term “nostras” refers to elephantiasis involving individuals resident in areas where filariasis is not endemic. ENV is clinically characterized by hard, thick, warty, or papillomatous projections and cobblestone-like lesions, with nonpitting edema. ENV mainly affects the lower limbs, even though it has been reported in external genitals, abdomen, buttocks, upper limbs, and face. The diagnosis of ENV is based on clinical history and physical examination. Skin biopsy, computed tomography, magnetic resonance imaging, lymphangiography, and 486156 IJLXXX10.1177/1534734613486156The International Journal of Lower Extremity WoundsSavoia et al research-article2013

ejd.2012.1767 Auteur(s) : Francesco Savoia1,2 francesco.savoia@ausl.ra.it, Caterina Stinchi1, Lorenzo Valenti1, Laura Baldassari1, Giuseppe Gaddoni1, Federica Giacomini2, Annalisa Patrizi2, Loredana Cardinale3, Silvia Zago3 1 Unit of Dermatology, 2 Department of Internal Medicine Division of Dermatology, University of Bologna, Italy 3 Unit of Pathologic Anatomy, AUSL Ravenna, viale Dante 10, 48022 Lugo, Ravenna, Italy A 77-year-old Caucasian man, with a 10-year history of actinic keratoses treated [...]

Annalisa Patrizi, Francesco Savoia, Francesca Negosanti, Annio Posar, Margherita Santucci and Iria Neri Department of Specialistic and Experimental Clinical Medicine Section of Dermatology and Child Neurology and Psychiatry Unit, Department of Neurological Sciences, University of Bologna, Clinica Dermatologica, via Massarenti 1, CAP 40138, Bologna, Italy. E-mail: annalisa.patrizi@unibo.it Accepted June 7, 2004.

Methotrexate may rarely provoke serositis, even with low doses and after just a few weeks of therapy. We report here a rare case of pleuropericarditis due to methotrexate. The effusion resolved after the withdrawal of the drug and the beginning of anti-inflammatory therapy; there was no relapse during a 10-month follow-up.