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This article summarizes the main epidemiologic and diagnostic features of seborrheic keratosis-like (SK-like) melanoma. We performed a review of the current literature. The real and current incidence and prevalence of SK-like melanoma are unknown. Many lesions are misdiagnosed and not excised with histopathologic confirmation, or excised without an appropriate surgical approach due to a benign clinical and dermoscopic appearance. SK-like melanoma presents both melanoma and SK features. SK-like melanoma and SK are often clinically indistinguishable even for experienced dermatologists. Clinically, it develops as a black-dark brown or light slightly elevated, papule, nodule or plaque with rapid growth and a regular or irregular shape. SK-like melanoma presents melanocytic and nonmelanocytic dermoscopic features. Irregular dark-brown dots/globules, a blue-grayish veil, streaks, irregular pigmentation or network and brown lines point to a melanoma diagnosis. Among the nonmelanocytic features, milia-like cysts and comedo-like openings have been highlighted. The association of polarized and nonpolarized dermoscopic techniques is more accurate for studying the dermoscopic features of SK-like melanoma. If the dermoscopic features are unclear, further investigations with reflectance confocal microscopy (RCM) or biopsy with histologic examination are essential. SK-like melanoma is a dermatologic challenge. Careful clinical and dermoscopic evaluation favor a correct diagnosis. In unclear cases, it is important to perform a biopsy with histologic examination to confirm the correct diagnosis.

Background Sjogren's Syndrome (SS) is an autoimmune disease characterized by an inflammatory infiltrate of exocrine salivary and lachrymal glands. Diagnosis is complex, and minor salivary gland biopsy and subsequent Focus Score (FS) calculation appear of extreme importance in the diagnostic work-up of the disease. Ultra-high frequency ultrasonography (UHFUS) is a recently introduced diagnostic technique, which is gaining an increasingly important role in intraoral imaging. This study aims at exploring the usefulness of UHFUS for obtaining valuable labial salivary gland samples for the assessment of the histopathological features of SS patients. Methods Patients with clinical suspect of SS and eligible for minor salivary gland biopsy were enrolled. UHFUS scan of the lower lip was performed. Glandular echostructure was classified according to Outcome Measures in Rheumatology (OMERACT) scoring system. The glands to be sampled were selected on the basis of UHFUS evaluation and biopsied. The areas of the samples were recorded and compared with those obtained without UHFUS guidance. The correlation between UHFUS grade and labial gland FS was also assessed. Results The areas of the samples obtained with UHFUS guidance was significantly higher (7.25 ±3.98 mm2 ) than those obtained by conventional procedures (5.79 ±3.49 mm2 ) (p=0.02). UHFUS correlated significantly with the salivary gland FS (r=0.532, p=0.001). Conclusion UHFUS seems a promising tool in SS diagnostic algorithm, being able to provide a valuable support to the biopsy procedure. Further studies are mandatory to confirm the role of UHFUS in SS.

BACKGROUND High-frequency ultrasound (HFUS) is a non-invasive method that detects superficial skin features. Ultra-high frequencies (50-100 MHz) can reveal epidermis and dermis structures. OBJECTIVES In this study, we describe the psoriatic plaque using a new device equipped with a 70 MHz probe (VEVO® MD, Fujifilm, VisualSonics) and we assess the lesion before and after ixekizumab. METHODS We examined the superficial hyperechoic band, the subepidermal hypoechoic band (SLEB), and the vascularization of the plaque in ten patients affected by plaque psoriasis. RESULTS The average superficial hyperechoic band thickness was 0.2157 mm before treatment, 0.1611 mm after 15 days, and 0.1354 mm (P

OBJECTIVES Intraoral ultra-high frequency ultrasound (UHFUS) is an emerging technique in oral medicine, due to its possibility to provide submillimeter resolution imaging of superficial mucosal structures. In this study, the potential role of UHFUS in the diagnosis of oral pemphigus vulgaris (PV) and mucous membrane pemphigoid (MMP) is assessed. MATERIALS AND METHODS Consecutive patients with suspected oral PV or MMP were enrolled. All patients underwent clinical examination, laboratory tests, intraoral UHFUS scan, and biopsy. Histology and direct immunofluorescence were set as benchmark for diagnosis confirmation. The sensitivity and specificity of UHFUS compared to histology were assessed. Mann-Whitney test was performed to evaluate the presence of differences in the echogenicity of PV and MMP. P-value was set at P

Objectives: Ultra-high frequency ultrasonography (UHFUS) is a recently introduced diagnostic technique which finds several applications in diverse clinical fields. The range of frequencies between 30 and 100 MHz allows for high spatial resolution imaging of superficial structures, making this technique suitable for the imaging of skin, blood vessels, musculoskeletal anatomy, oral mucosa, and small parts. However, the current clinical applications of UHFUS have never been analyzed in a consistent multidisciplinary manner. The aim of this study is to revise and discuss the current applications of UHFUS in different aspects of research and clinical practice, as well as to provide some examples of the current work-in-progress carried out in our center. Materials and Methods: A literature search was performed in order to retrieve articles reporting the applications of UHFUS both in research and in clinical settings. Inclusion criteria were the use of frequencies above 30 MHz and study design conducted in vivo on human subjects. Results: In total 66 articles were retrieved. The majority of the articles focused on dermatological and vascular applications, although musculoskeletal and intraoral applications are emerging fields of use. We also describe our experience in the use of UHFUS as a valuable diagnostic support in the fields of dermatology, rheumatology, oral medicine, and musculoskeletal anatomy. Conclusion: Ultra-high frequency ultrasonography application involves an increasing number of medical fields. The high spatial resolution and the superb image quality achievable allow to foresee a wider use of this novel technique, which has the potential to bring innovation in diagnostic imaging.

Background: Lidocaine hydrochloride is frequently used for management of painful wounds. This prospective, multicentre study examined the effects of 5% lidocaine cream on wound pain relief. Material and methods: The study included 78 patients with painful wounds treated with 5% Lidocaine cream for two weeks in two Italian Hospitals. Patients’ perception of pain was recorded by, using the 5-point Visual Rate Scale and the 11-point Numerical Pain Rating Scale. All medications and adverse events were evaluated in a daily diary. The primary outcome of the study was establishing the wound pain relief based on the results of 5-VRS and pain intensity based on the 11-NPRS testing from baseline to the end of treatment. Clinical aspects and adverse events were also collected. Results: Seventy-eight patients had a median age of 67.5 years (range 18-96 years). 62.8% were women. The wounds included traumatic wounds (n = 39), venous ulcers (n = 25), post-surgical wounds (n = 6) pyoderma gangrenosum (n = 6), vasculitis (n = 1) and pressure ulcer (n = 1). The intensity of pain significantly decreased from the baseline level established at the beginning of treatment (mean score 6.7 − 1.90) - to the level at end of treatment (3.0 − 2.23-; p < 0.0001). 9 patients prematurely stopped the treatment for healing (n = 4), wound improvement (n = 2) and adverse events related to the treatment. (n = 3). 13 patients presented a total of 25 adverse events, 4 of them were related to the treatment. Conclusion: The treatment of painful wounds with 5% Lidocaine Cream for 14 days resulted in reduced pain intensity, and showed high safety and tolerability.

The aims of our study were to evaluate with ultra-high-frequency ultrasound (UHFUS) the ultrasound features of congenital melanocytic nevi (CMNs) and malignant melanomas (MMs) arising in CMNs and the correlation between ultrasonographic thickness and histological thickness in MMs. We evaluated 10 patients with small-medium CMNs and 10 patients with MMs arising in small-medium CMNs. We collected patient's data, clinical and dermoscopic features. The UHFUS was performed using a 70 MHz frequency probe to study the ecostructure, shape and vascularization. Breslow thickness was compared with ultrasonographic thickness. In the MMs group the following dermoscopic features were described: hyperpigmentation (n = 9), regression area (n = 6), whitish-blue veil (n = 5), thickened network (n = 5), irregular globules (n = 3), inverse network (n = 2) and striae (n = 1). Hyperpigmentation (n = n = 9), thickened network (n = 7), irregular globules (n = 5), regression area (n = 5), striae (n = 1) and whitish-blue veil (n = 1) were found in the CMNs group. The multicomponent pattern was present in both MMs (n = 4) and in CMNs (n = 5). Moreover, the parameters indicative of suspected malignancy were variously combined in the two groups, without showing significant differences in the statistical analysis; with the exception of the blue veil that correlated with the diagnosis of MM. Ultrasonoghaphic vascularization was an ever-present parameter in MMs (100%), with high intensity of intratumoral signal, as opposed to CMNs. We also found a statistically significant correlation between ultrasound thickness and Breslow thickness. In the future, this technique could implement the diagnostic preoperative phase of MMs arising in CMNs in combination with standard clinical-dermatoscopic evaluation.

PIK3CA-related overgrowth spectrum (PROS) is an umbrella term referring to various clinical entities, which share the same pathogenetic mechanism. These conditions are caused by somatic gain-of-function mutations in PIK3CA, which encodes the 110-kD catalytic α subunit of PI3K (p110α). These PIK3CA mutations occur as post-zygotic events and lead to a gain of function of PI3K, with consequent constitutional activation of the downstream cascades (e.g., AKT/mTOR pathway), involved in cellular proliferation, survival and growth, as well as in vascular development in the embryonic stage. PIK3CA-related cancers and PROS share almost the same PIK3CA mutational profile, with about 80% of mutations occurring at three hotspots, E542, E545, and H1047. These hotspot mutations show the most potent effect on enzymatic activation of PI3K and consequent downstream biological responses. If present at the germinal level, these gain-of-function mutations would be lethal to the embryo, therefore we only see them in the mosaic state. The common clinical denominator of PROS disorders is that they are sporadic conditions, presenting with congenital or early childhood onset overgrowth with a typical mosaic distribution. However, the severity of PROS is highly variable, ranging from localized and apparently isolate overgrowth to progressive and extensive lipomatous overgrowth associated with life-threatening vascular malformations, as seen in CLOVES syndrome. Traditional therapeutic approaches, such as sclerotherapy and surgical debulking, are often not curative in PROS patients, leading to a recrudescence of the overgrowth in the treated area. Specific attention has been recently paid to molecules that are used and studied in the oncogenic setting and that are targeted on specific alterations of the pathway PI3K/AKT/mTOR. In June 2018, Venot et al. showed the effect of Alpelisib (BYL719), a specific inhibitor for the p110α subunit of PI3K, in patients with PROS disorders who had severe or life-threatening complications and were not sensitive to any other treatment. In these cases, dramatic anatomical and functional improvements occurred in all patients across many types of affected organ. Molecular testing in PROS patients is a crucial step in providing the conclusive diagnosis and then the opportunity for tailored therapy. The somatic nature of this group of diseases makes challenging to reach a molecular diagnosis, requiring deep sequencing methods that have to be performed on DNA extracted from affected tissue. Moreover, even analyzing the DNA extracted from affected tissue there is no guarantee to succeed in detection of the casual somatic mutation, since the affected tissue itself is highly heterogeneous and biopsy approaches can be burdened by incorrect sampling or inadequate tissue sample. We present an 8-year-old girl with CLOVES syndrome, born with a large cystic lymphangioma involving the left hemithorax and flank, multiple lipomas, and hypertrophy of the left foot and leg. She developed severe scoliosis. Many therapeutic approaches have been attempted, including Sildenafil treatment, scleroembolization, laser therapy, and multiple debulking surgeries, but none of these were of benefit to our patient's clinical status. She then started treatment with Rapamycin from May 2019, without significant improvement in both vascular malformation and leg hypertrophy. A high-coverage Whole Exome Sequencing analysis performed on DNA extracted from a skin sample showed a mosaic gain-of-function variant in the PIK3CA gene (p.H1047R, 11% of variant allele frequency). Once molecular confirmation of our clinical suspicion was obtained, after a multidisciplinary evaluation, we decided to discontinue Sirolimus and start targeted therapy with Alpelisib (50 mg/day). We noticed a decrease in fibroadipose overgrowth at the dorsal level, an improvement in in posture and excellent tolerability. The treatment is still ongoing.

Background The management of hidradenitis suppurativa (HS) flares with intralesional steroids lacks strong scientific evidence but limited data suggest that it may be useful. Objective To assess the clinical and ultrasound responses of HS flares to ultrasound-guided injections of intralesional triamcinolone (40 mg/mL) with a dilution 1:4 vs 1:2 at 30-day (t1), 60-day (t2) and 90-day (t3) follow-up. Materials and methods We recruited patients with ≤3 acute lesions, unresponsive to topical therapy. At baseline we assessed lesions clinically and by ultra-high frequency ultrasound (48 or 70MHz) and randomly performed an ultrasound-guided injection of triamcinolone. Assessments were repeated at t1, t2 and t3 follow-up, re-injecting the lesion in the case of no or partial response. Results We treated 49 lesions: 38.8% showed improvements at t1; 46.9% at t2; 6% at t3; and 8.3% showed no clinical and ultrasound improvements. Long-term follow-up data confirmed a statistically significant reduction in VAS-pain, Dermatology Life Quality Index (DLQI), and HS-Physician Global Assessment (HS-PGA), as well as edema and vascular signals. No adverse effects were reported. Conclusions Our study suggests that ultrasound-injections with a 1:2 dilution are beneficial for HS flares that do not respond to topical treatment and should be included in the therapeutic algorithm. The preliminary results of this study were presented during the European Hidradenitis Suppurativa Foundation 2020 meeting in Athens and the abstract will be published in the supplements of Experimental Dermatology. This article is protected by copyright. All rights reserved.

Intraoral ultrasonography has been widely employed for the preoperative assessment of tumor margins due to its capability to evaluate depth of invasion (DOI) and tumor thickness (TT). Recently, a novel ultrasonographic technique, ultra-high frequency ultrasound (UHFUS) has been increasingly applied to the study of oral lesions. This study evaluates the potential application of intraoral UHFUS to assess DOI and TT parameters of oral squamous cell carcinoma (OSCC) lesions. Patients clinically suspected of OSCC lesions were enrolled and underwent an intraoral UHFUS examination preoperatively. The parameters of TT, DOI, echogenicity, and vascularization were assessed. The parameters of TT and DOI as evaluated by means of UHFUS were compared to histology, which was set as the benchmark. Ten patients in total were enrolled. UHFUS-based DOI and TT measurements were found to positively correlate with histology (p &lt, 0.05), although UHFUS provided a slight overestimation of DOI. No differences were found in terms of echogenicity or vascularization depending on the site of the lesion. According to these preliminary results, UHFUS could support the preoperative assessment of TT and DOI, potentially enhancing the clinical evaluation of OSCC.

Background Hidradenitis suppurativa is a chronic inflammatory skin disease. An ultrasound staging (SOS-HS) using frequencies from 7 to 18 MHz has been proposed to evaluate the severity of the disease. Materials and methods We retrospectively evaluated the most significant lesions in 50 patients with hidradenitis suppurativa (32 females and 18 males, aged from 12 to 68 years old), who had undergone high-frequency ultrasound (HFUS) (18-22 MHz) and ultra-high frequency ultrasound (UHFUS) (48 and 70 MHz). A MyLab™ Touch system (Esaote) equipped with a 18-22 MHz linear probe was used for the HFUS, and a Vevo® MD (VisualSonics) was used for the UHFUS, equipped with two linear probes (70 and 48 MHz). Results A total of 116 lesions were observed, of which 66 were fluid collections, 32 were tunnels, 6 pseudocysts, 5 bridge scars, 5 tombstone comedones, and 2 granulation tissues. Structures that had already been described with HFUS were then observed with UHFUS but with a better definition. In addition, structures that had not been detected by HFUS were also observed with UHFUS such as drop-shaped hair follicles, micro-tunnels, and microcysts. Conclusion Ultra-high frequency ultrasound provides a better understanding of hidradenitis suppurativa. Patients can be monitored more effectively thereby preventing the most severe changes.

Atypical ulcers show atypical clinical features, histology, localization, and resistance to standard therapies. The persistence of a chronic ulcer despite treatment with standard therapies requires a more specific diagnostic investigation. Diagnosis involves obtaining the history and performing clinical examination and additional tests. A skin biopsy is frequently used to confirm unclear diagnosis. In difficult cases, microbiological and immunohistochemical examinations, laboratory blood tests, or instrumental tests should be evaluated. The treatment of atypical wounds is characterized by local systemic therapy and pain control. Our results highlight the need for early diagnosis, and standardized and targeted management by a multidisciplinary wound healing center.

Vaccination is a well-known trigger for mast cell degranulation in subjects affected by mastocytosis. Nevertheless, there is no exact standardized protocol to prevent a possible reaction after a vaccine injection, especially for patients who have already presented a previous vaccine-related adverse event, considering that these patients frequently tolerate future vaccine doses. For this reason, we aim to share our experience at Meyer Children’s University Hospital in Florence to raise awareness on the potential risk for future vaccinations and to discuss the valuable therapeutic strategies intended to prevent them, taking into account what is proposed by experts in literature. We describe the case of an 18-month-old female affected by a polymorphic variant of maculopapular cutaneous mastocytosis that presented an extensive bullous cutaneous reaction 24 hours after the second dose (booster dose) of inactivated-tetravalent influenza vaccine, treated with a single dose of oral corticosteroid therapy with betamethasone (0.1 mg/kg) and an oral antihistamine therapy with oxatomide (1 mg/kg/daily) for a week, until resolution. To the best of our knowledge, in the literature, no documented case of reaction to influenza vaccine in maculopapular cutaneous mastocytosis is described. Subsequently, the patient started a background therapy with ketotifen daily (0.05 mg/kg twice daily), a non-competitive H1-antihistamine, and a mast cell stabilizer (dual activity). A non-standardized pharmacological premedication protocol with an H1-receptor antagonist (oxatomide, 0.5 mg/kg) administered 12 hours before the immunizations, and a single dose of betamethasone (0.05 mg/kg) together with another dose of oxatomide (0.5 mg/kg) administered 2 hours before the injections was followed to make it possible for the patient to continue with the scheduled vaccinations. Indeed, no reactions were subsequently reported. Thus, in our experience, a background therapy with ketotifen associated with a premedication protocol made by two doses of oxatomide and a single dose of betamethasone was helpful to make possible the execution of the other vaccines. We suggest how in these children, it could be considered the idea of taking precaution when vaccination is planned, regardless of the kind of vaccine and if a dose of the same vaccine was previously received. However, international consensus needs to be reached to manage vaccinations in children with mastocytosis and previous adverse reactions to vaccines.

Netherton syndrome (NS) is a genetic, multisystemic disease classically distinguished by a triad of clinical manifestations: congenital ichthyosiform erythroderma, hair shaft abnormalities, and immune dysregulation. Due to the complex pathogenesis of the disease, there are no specific therapies currently accessible for patients with NS. An early diagnosis is crucial to start the correct management of these patients. A multidisciplinary approach, including specialists in immunology, allergology, and dermatology, is necessary to set up the best therapeutic pathway. We conducted a review with the aim to summarize the different therapeutic strategies currently accessible and potentially available in the future for children with NS. However, given the limited data in the literature, the best-tailored management should be decided upon the basis of the specific clinical characteristics of the patients with this rare clinical condition. Further comprehension of the pathophysiology of the disease could lead to more efficacious specific therapeutic options, which could allow a change in the natural history of NS.

Background/objectives Nail alterations are commonly seen in cases of idiopathic clubfoot and may cause parental concern. The nature of and whether these changes are congenital or develop secondary to treatment has been poorly investigated. The aim of this study was to evaluate toenail morphology in clubfoot patients at presentation, to re-evaluate them during the course of treatment for the clubfoot, and to analyze findings in the light of the few literature reports for healthy children of the same age. Methods Thirty infants (21 males and 9 females) with idiopathic clubfoot were prospectively enrolled at the Anna Meyer Children's University Hospital. Nails of affected and non-affected feet were evaluated by a team of pediatric dermatologists at presentation and re-evaluated once per patient during the bracing period of Ponseti treatment. Results Toenails of affected (47) and non-affected (13) feet were abnormal at presentation in 43.3% of patients, in both clubfeet (40.4%) and non-affected feet (38.5%), but most changes were physiologic or transitory alterations, commonly found in healthy children, with nail concavity (koilonychia) being the most common finding (29.7%). Changes were not related to clubfoot severity or laterality (P > .05). In most (76.9%) unilateral cases, there was concordance of nail changes between clubfoot and non-affected foot. At re-evaluation (follow-up time 410 ± 207 days), nail problems were more frequent (53.3%); ingrown toenail was the most common (21.6%). Conclusions The presence of nail alterations seems not to be caused by clubfoot pathology and could be related to unfavorable local condition in the brace.

Background: Gianotti Crosti syndrome (GCS) is a self-healing condition with a spontaneous resolution in 2–6 weeks but, even if rarely, recurrent episodes have been reported.Objective: The aim of this observational study is to investigate serum Immunoglobulin E (IgE) level in children with GCS, evaluating if there is a relationship between IgE level and clinical course of the disease.Methods: Children with GCS diagnosed at a tertiary care children's university hospital between June 2018 and November 2019 were prospectively enrolled. Demographic, clinical and hematochemical data of children investigated were collected. In particular, IgE level were investigated at symptoms onset and, if available, at the following blood tests. Patients were divided in 2 groups on the bases of the clinical course: children with a chronic relapsing course and children who did not present any relapse.Results: Among 29 patients enrolled in this study, 14 (48.3%) children had a chronic relapsing course and 15 (51.7%) did not present any relapse. A statistically significant difference was present considering the length of the disease: 210 days (IQR: 161.25–255) for patients with a chronic relapsing course compared to 40 days (IQR: 30–75) for the other group (p < 0.0001). About the median IgE level in the 2 groups, a value about 10 time higher was found in children with chronic course compared to the other group (1,144 vs. 116 U/mL) with a statistically significant difference (p < 0.0001).Conclusion: Despite the study limitations, a significant correlation between higher IgE levels and chronic-relapsing course of the GCS can be assumed.

The combination of oral clindamycin with rifampicin is recommended by European guidelines as a first-line treatment in moderate-to-severe hidradenitis suppurativa (HS). Recent studies highlight that oral clindamycin in monotherapy (CM) may be a useful alternative treatment. We included 36 patients with a diagnosis of moderate-to-severe HS. A total of 19 patients were treated with combination oral clindamycin plus rifampicin (C + R) and 17 with oral CM for 12 weeks. The efficacy of CM vs C + R was analyzed by multilinear regression models which showed a higher reduction in mSartorius (Δ = -13.2, P = .058) and AISI (Δ = -4.91, P = .034) in the C + R group. In the C + R group, smoking pack-year was positively correlated with AISI (Spearman's rho = 0.51, P = .036) and with DLQI (0.47, P = .061). In the CM group, a positive correlation was found between BMI and AISI (0.47, P = .041). The data on the efficacy of C + R combination therapy are in line with guidelines, evidence-based approaches, and recommendations from the HS ALLIANCE working group. The rationale for combining these two drugs is to increase bactericidal action and to reduce rifampicin resistance, as rifampicin is highly mutagenic. Our results suggest that the antibiotic combination of C + R is still the treatment of choice in moderate-to-severe HS with abscesses, draining fistulae and ≥ 5 inflammatory nodules. High BMI and smoking habits seem to be predictive factors of a poor response to antibiotics. Further multicenter studies and prospective randomized controlled trials are needed to confirm these results. Potential alternative antibiotic therapies should also be investigated.

Background Propranolol (antagonist of β1-/β2-AR but minimally active against β3-AR) is currently the first-line treatment for infantile hemangiomas (IH). Its efficacy is attributed to the blockade of β2-AR. However, its success rate is ~60%. Considering the growing interest in the angiogenic role of β3-ARs, we evaluated a possible relationship between β3-AR expression and response to propranolol. Methods Fifteen samples of surgical biopsies were collected from patients with IH. Three were taken precociously from infants and then successfully treated with propranolol (responder group). Twelve were taken later, from residual lesions noncompletely responsive to propranolol (nonresponder group). A morphometrical analysis of the percentage of β1-, β2-, and β3-ARs positively stained area was compared between the two groups. Results While no difference was found in both β1- and β2-AR expression level, a statistically significant increase of β3-AR positively stained area was observed in the nonresponder group. Conclusions Although the number of biopsies is insufficient to draw definitive conclusions, and the different β-AR pattern may be theoretically explained by the different timing of samplings, this study suggests a possible correlation between β3-AR expression and the reduced responsiveness to propranolol treatment. This study could pave the way for new therapeutic perspectives to manage IH. Impact Propranolol (unselective antagonist of β1 and β2-ARs) is currently the first-line treatment for IHs, with a success rate of ~60%. Its effectiveness has been attributed to its ability to block β2-ARs. However, β3-ARs (on which propranolol is minimally active) were significantly more expressed in hemangioma biopsies taken from patients nonresponsive to propranolol. This study suggests a possible role of β3-ARs in hemangioma pathogenesis and a possible new therapeutic target.

Pediatric melanoma is a rare form of the tumor whose epidemiology is widely increasing thanks to the improvement of dermoscopic and anatomopathologic diagnostic techniques. Although it is a tumor of considerable interest in adults, little has been described about the pediatric field. The objective of our study was then to identify the possible risk factors for the development of melanoma in the pediatric population. We performed a retrospective study conducted in the Melanoma and Skin Cancer Unit and Unit of Dermatology (Livorno, Italy). We analyzed a population of 38 children under 21 years with a diagnosis of melanoma. This population was compared with a control population of 114 children followed up in our dermatologic clinic. From our combined univariate-multivariate statistics analysis, the number of nevi [regression coefficient (RC) of 1.04 and odds ratio (OR) of 2.8 confidence interval (Cl, 1.2-6.6)], and family history of melanoma [RC of 1.99 and OR of 7.3 (Cl, 2.3-22.7)] emerged as possible risk factors for the development of melanoma. The identification of these elements would allow the physician to carry out a more targeted preliminary assessment of the patient, potentially decisive in cases of diagnostic doubt of the lesion. Our study also lays the foundations for identifying those children who, despite not having received a diagnosis of melanoma on histologic examination, should be considered as patients susceptible to a focused follow-up, because of the presence of the risk factors that emerged from our research.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is an uncommon angioproliferative benign disorder. A 24- year-old Caucasian female patient presented with multiple itchy reddish pearly nodule.

The management of lower extremity wounds is frequently performed by means of clinical examination, representing a challenge for the clinician due to the various conditions that can potentially enter differential diagnosis. Several diagnostic techniques are available in the dermatologist’s arsenal as a support to diagnosis confirmation, including dermoscopy and ultrasonography. Recently, a novel ultrasonographic technique involving the use of ultra-high ultrasound frequencies has entered the scene, and appears a promising tool in the diagnostic workup of skin ulcerative lesions. The focus of this review is to discuss the potential role of ultra-high-frequency ultrasonography in the diagnostic workup of wounds in the light of the current applications of the technique.

Healing rate is the most accurate method to predict healing; however, there are no data in atypical ulcers. We retrospectively analyzed clinical features, associated comorbidities, and therapies of 159 patients with atypical ulcers. In a subgroup of 59 patients, we analyzed the areas, perimeters, and the healing rate (mm/d) as prognostic indicators of wound healing. Atypical ulcers were more frequent among women (n = 98) with an average age of 76 years. Confirmed by biopsy, the etiologies were as follows: inflammatory diseases (38%), neoplastic ulcers (29%), vasculitis (21%), drug-induced ulcers (7%), and infectious ulcers (4%). Systemic therapies were applied based on the different etiologies. Wound bed preparation principles guided the local treatment. The average reduction of the area during the observation interval was 36%, while the average reduction in the perimeter was 41%. Overall, 51 ulcers showed a reduction in wound size and 8 ulcers showed an increase. Neoplastic ulcers were the group with the fastest healing rate, with an average speed of 0.24 mm/d. The slowest healing occurred in the inflammatory group with an average healing rate of 0.032 mm/d. The initial area and perimeters influenced wound healing; however, ulcer etiology and comorbidities significantly altered the healing rate.

Backgroun Blue light (400 and 450 nm) contributes to bringing the inflammatory phase under control, increases angiogenesis, stimulates the metabolism of all cellular processes, reduces scar formation, increases collagen production, and decreases the bacterial burden. Methods The aim of this study was to promote the healing process in 20 hard-to-heal wounds using a portable light-emitting diodes device that emits blue light (Emoled™). The primary endpoint of the study was to calculate in the three etiologic groups the reduction in wound size by the average delta area in square centimeters and as a percentage, and by the average healing rate (mm/Days). The secondary endpoint was to assess the wound bed score and to assess patients' pain (numerical rating scale). Results At week 4 the average healing rate was 0.098 mm/days for venous leg ulcers, 0.353 mm/days for traumatic ulcers, and 0.09 mm/days for vasculitis. Overall 16 patients had a reduction in wound size, two patients were completely healed, and there was no improvement in two patients. At week 4, the average wound bed score had increased to 12.8 and average pain had decreased to 2.35. Almost all patients (n=19) showed pain reduction, and all the patients increased wound bed score. Conclusions The blue LED device is promising in terms of promoting wound healing, improving WBS and reducing pain in patients affected by long-term wounds that do not respond to standard treatment.

The clinical characteristics associated with hidradenitis suppurativa (HS) severity are poorly understood. In this study, 124 patients with HS from 6 Italian dermatology centres participated in this study. Disease severity was assessed using the Hidradenitis Suppurativa Physician's Global Assessment score (HS-PGA) and Hurley score. The impact of clinical characteristics on disease severity was assessed by logistic regression. Clinical characteristics were similar between men (n = 53) and women (n = 71). Disease severity was also similar; 75% of the patients had Hurley stage II or III disease, and > 60% had moderate, severe or very severe HS as judged by HS-PGA. Lesions were more frequent in the gluteal region in men (32.3% in men vs. 8.7% in women, P

Hidradenitis suppurativa (HS) is a chronic, burdensome inflammatory skin disorder mainly affecting adults with an infrequent onset during childhood or adolescence. Guidelines regarding the therapeutic drugs in pediatric HS patients are lacking. We describe the case of a 16-year-old girl affected by HS with a massive impact of the disease on her daily activities. She underwent antibiotics, estroprogestinics, isotretinoin, and drainage procedures with partial and short-term improvement. We treated the patient with adalimumab and assessed disease severity using BMI, pain VAS, Hurley, m-Sartorius, and HS-PGA. The treatment has been continued for 4 years with a strong improvement of clinical and psychological outcome. No side effects were recorded throughout the treatment period.

Background Despite not being licensed for the treatment of infantile hemangiomas (IH) in infants younger than 5 weeks or older than 5 months, propranolol is often used in these age groups to prevent or to treat potentially severe complications. The objective of the present study was to review the experience of 8 Italian pediatric and dermatologic centers regarding propranolol treatment for IH started before 5 weeks or after 5 months of age. Methods We retrospectively reviewed the records of patients followed up for IH, on propranolol treatment started before 5 weeks or after 5 months of age, and collected information on sociodemographic data, treatment indications, IH involution, IH relapse, and treatment side effects. Results A total of 343 patients were enrolled; 15 were started on propranolol before 5 weeks (group 1), 328 were started after 5 months of age (group 2). The most frequent indications were permanent aesthetical disfigurement (91.8%) and function threatening complications (42.6%). In most cases, the treatment was effective. The involution was partial in 67.7% of patients. In 11.8% of cases a relapse was observed. No relapse was observed in group 1. Treatment complications were reported in 15.8% of children, most frequently sleep disorders (6.6%), followed by irritability (5.1%) and diarrhea (2.2%). Only a case of mild constipation was observed in group 1. Conclusion The safety and effectiveness profile of propranolol in infants younger than 5 weeks or older than 5 months may be acceptable. Taking in account propranolol's potential in preventing severe complications, further studies should assess the acceptability of propranolol treatment, especially in the

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis which may be rapidly progressive. Standard guidelines for local treatment are lacking. Through our experience, we suggested a local treatment algorithm based on the tissue, infection, moisture balance, and epithelization (TIME) concept. The clinical and histopathological features of 52 patients with PG, the duration, and the evolution of the lesions were retrospectively evaluated. Systemic therapies, local treatments, and standard wound treatments were reported. We observed ulcerative PG in the majority of the patients (82.6%), followed by the pustular form (9.6%), the peristomal type (3.8%), the vegetative form (1.9%), and the bullous type (1.9%). The lower leg was the most commonly area affected (90.4% of cases). Pathergy was reported in 15.3% of cases. The first-line treatment was the use of oral glucocorticosteroids (GCSs). We observed healing after 3 weeks of GCS in 17.3% of cases. In 25% of all cases, we obtained complete healing with long-term low doses (

Objectives: Ultra-high frequency ultrasound (UHFUS) is a recently developed diagnostic technique involving the use of ultrasound frequencies up to 70 MHz, allowing to obtain 30 µm resolution of targets located within 1 cm from the surface. Oral mucosa can be affected by diverse pathological conditions, which are currently investigated by means of clinical examination. In this scenario, intraoral UHFUS can provide additional information and support clinical assessment of oral mucosa. In this preliminary study, typical features of normal oral mucosa are described, in order to set a benchmark for the future identification of oral soft tissue alterations. Methods: Twenty healthy subjects (10 males and 10 females, mean age 30 years) were enrolled and underwent intraoral UHFUS examination. In all the subjects, tongue, buccal mucosa, gingiva, lip mucosa, and palate were scanned, and images acquired. Intraoral UHFUS scan included Brightness-mode and Doppler mode acquisitions performed with a standardized protocol. UHFUS images were postprocessed and analyzed using a dedicated software. UHFUS-based biomarkers (epithelial thickness, echogenicity, and vascularization) were employed for image description. Results: Normal oral anatomy of the different sites analyzed was described. For all the sites, UHFUS biomarkers were characterized, and information on typical aspect of oral mucosa was retrieved. Conclusions: In this explorative study, we suggest a potential role for intraoral UHFUS in the study of oral mucosa, giving insights into the possibility to improve the assessment, diagnosis, and management of the conditions involving oral mucosa. UHFUS seems a promising tool, which could potentially support clinical examination in daily oral medicine practice.

Oral propranolol (OP) demonstrated high efficacy and safety profile for treatment of critical infantile hemangiomas (IHs). Our aim was to assess the morphologic changes of IHs with standard and high-resolution video dermoscopy (HRVD) from baseline to 18 months either in presence or absence of OP therapy; to investigate if extended anamnestic perinatal data and clinical-dermoscopic characteristics of the IHs can correlate with therapeutic outcome. We enrolled 94 patients (112 IHs): 58 were treated with OP, 35 (42 IHs) for 6 months (group 1), and 23 (25 IHs) for 12-months (group 2); 36 (45 IHs) were followed-up. Clinical-dermoscopic examinations were performed every 3 months during therapy and follow-up. Among 67 treated IHs, superficial and deep IHs with homogenous clinical-dermoscopic aspect developed after the 2 weeks of life achieved the better outcome, stable at 9-month follow-up, independently form treatment duration. Under HRVD, glomerular vessels were prevalent at baseline; corckscrew, comma, and linear-irregular vessels were the prevalent pattern at 1, 3, and 6 months of therapy, respectively. At 12-month follow-up, adequate healing was achieved by 96% of IHs in group 2 and by 78% in group 1, showing dotted vessels. Persistent IHs displayed a reticulated aspect and linear irregular vessels, while arborizing vessels characterized relapsed IHs. A 12-month OP therapy can be considered for newborns presenting with nonhomogenous mixed IHs >3 cm on the perineal area/lower extremities. In conclusion, HRVD allows a real time monitoring of vascular changes in IHs treated with OP and can support physicians in identifying relapses before they become clinically evident.

Background Ultra-High Frequency Ultrasound (UHFUS) is a recently introduced diagnostic technique involving the use of higher frequencies compared to conventional ultrasound. Among the several fields of application, intraoral usage of UHFUS appears still limited. We report the intraoral evaluation of Oral Lichen Planus (OLP) by means of UHFUS and describe typical UHFUS aspect of different forms of presentation of OLP. Materials and methods Patients with clinical and histological diagnosis of OLP were enrolled in the study. OLP lesions were evaluated by means of intraoral UHFUS performed at 70 MHz, using B-mode and C-mode, in order to characterize the echostructure of each form of presentation. Results Fifty patients in total were enrolled, and UHFUS features were described for different OLP forms. All the lesions showed a thick, hypoechoic superficial layer in the mucosal stratum, suggesting that such UHFUS alteration can be pathognomonic of OLP. Conclusion Ultra-High Frequency Ultrasound was able to differentiate superficial alterations of the oral mucosa, giving insight on possible applications of UHFUS in the study of OLP beyond clinical and histological investigations. Due to a limited study sample, we cannot draw firm conclusions. However, it is reasonable to think that UHFUS evaluation of OLP may provide useful information to the clinician.

Background: In the last few decades many studies have investigated the role of major salivary glands ultrasound (SGUS) in the diagnostic work-up of patients with suspected primary Sjogren’s syndrome (pSS). Recent development of ultra-high-resolution ultrasound systems (UHFUS), with frequencies as high as 70 MHz and capability resolution as fine as 30 μm, has permit new diagnostic applications to a variety of superficial targets including labial salivary glands (LSGs). To date, however, no information are available regarding the use of UHFUS for the study of LSGs in humans. Objectives: To evaluate the feasibility and the diagnostic accuracy of UHFUS of LSGs in patients with suspected SS and to assess the correlations between LSG histopathology, UHFUS and SGUS. Methods: Consecutive patients with clinically suspected pSS were included in this study. All patients underwent a complete diagnostic work-up including conventional SGUS and LSG biopsy. The same expert pathologist calculated for all the samples the focus score (FS), number of foci and evaluated the presence of ectopic germinal centers (GCs). UHFUS of LSG was performed by specialized radiologists scanning first the central compartment of the inferior lip, and then both peripheral compartments. The following parameters were evaluated: distribution of the glands, parenchymal inhomogeneity (score 0-3, from normal to evident), fibrosis and eco color-Doppler vascular pattern and grade of vascular intensity. Results: We included 32 patients with suspected pSS. At the end of the work-up, pSS diagnosis was confirmed in 12/32 (37.5%) cases. No differences between pSS patients and no-SS sicca controls were observed in UHFUS findings related to LSG distribution and eco color-Doppler vascular parameters. By contrast, pSS patients presented statistically significant differences in peripheral UHFUS inhomogeneity (p=0.006), and a higher degree of fibrosis (p=0.01). Considering a score ≥2 in parenchymal inhomogeneity as suggestive for pSS, UHFUS appeared less specific than conventional SGUS (UHFUS Sp=70% vs SGUS Sp=95%) but more sensitive (UHFUS Se=83.3% vs SGUS Se = 58.3%). In addition, when we investigated the relationship between UHFUS, SGUS and LSG histopathology we found that the correlation coefficients between UHFUS inhomogeneity and LSG FS (UHFUS r=0.706** vs SGUS r=0.393*), number of foci (UHFUS r=0.712** vs SGUS r=0.445*), and number of ectopic GCs (UHFUS r=0.525** vs SGUS r=0.141), were significantly higher than those observed with conventional SGUS. Conclusion: the application of UHFUS to the study of LSG in pSS appeared feasible and sensitive. Because of the anatomical details obtained with this technique and its stronger correlation with LSG histopathology, UHFUS might offer unique advantages over the existing major salivary gland imaging modalities in pSS assessment. Disclosure of Interests: Chiara Baldini: None declared, Francesco Ferro: None declared, Veronica Iodice: None declared, Rossana Izzetti: None declared, Valentina Donati: None declared, Silvia Fonzetti: None declared, Teresa Oranges: None declared, Valentina Dini: None declared, Dania Cioni: None declared, Nicoletta Luciano: None declared, Rosa Maria Bruno: None declared, Marta Mosca Paid instructor for: GlaxoSmithKline, Lilly, UCB, Saverio Vitali: None declared, Davide Caramella: None declared