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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 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

Introduction: Treat-to-target strategies are used in several chronic diseases to improve outcomes. Treatment goals have also been suggested for psoriasis, but there is currently no consensus on targets, and guidance is needed to implement this strategy in clinical practice. The project ‘Treat to Target Italia’ was launched by a scientific board (SB) of 10 psoriasis experts to generate expert consensus recommendations. Methods: On the basis of the published literature, their clinical experience, and the results of a survey among Italian dermatologists, the SB identified four relevant topics: (1) clinical remission; (2) quality of life; (3) abrogation of systemic inflammation; (4) safety. They drafted 20 statements addressing these four topics and submitted them to a panel of 28 dermatologists, in a Delphi process, to achieve consensus (greater than 80% agreement). Results: Consensus was reached on all statements. Treatment goals defining clinical remission should include a 90% improvement from baseline in the Psoriasis Area and Severity Index (PASI90 response) or an absolute PASI score of less than or equal to 3. Patient’s quality of life and satisfaction are important targets. If PASI targets are achieved, there should be no or very low impact of psoriasis on quality of life [Dermatology Life Quality Index (DLQI) score less than or equal to 3]. If PASI or DLQI goals are not achieved within 3–4months, treatment should be changed. Abrogation of systemic inflammation may be crucial for preventing or delaying inflammatory comorbidities. Safety is an equally important target as efficacy. Conclusion: These 20 consensus statements define the parameters of a treat-to-target strategy for psoriasis in Italy. It is hoped that use of these in the management of patients with psoriasis will improve treatment outcomes and patient health-related quality of life.

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.

Aim To evaluate the distinct contribution of obesity and diabetes (DM) to the skin modification in metabolic diseases. Methods We analysed all patients admitted for bariatric surgery in our hospital with BMI between 38 and 47 kg/m2, with (Group 1) or without (Group 2) DM and compared them with a group of nonobese diabetic patients (Group 3) and healthy volunteers (Group 4). The following features were evaluated: hardness, temperature, hydration and thickness alongside with anthropometric measures of foot and leg. Results For the general characteristics, patients differed in age and body mass index. As predictable all circumferences (dorsal foot, sovramalleolar and under the knee) were significantly higher in obese with no differences depending on DM (all parameters: p

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.

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.

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.

Objective: The recently completed EUREKA study confirmed the efficacy and safety profile of fluorescent light energy (FLE) in treating hard-to-heal wounds. To supplement the EUREKA prospective, observational, uncontrolled trial results, researchers selected one of the EUREKA clinical centres to conduct a retrospective analysis of matching wound care data for 46 venous leg ulcers (VLU) patients who had received standard wound care over a five-year period, compared with 10 EUREKA VLU subjects. Method: The study centre selected 46 patients with VLUs based on the matching criteria (wound age and size, patient's age and gender). They compared the healing rates of these matching VLUs with 10 VLU patients treated at the same centre during the EUREKA study. Results: The EUREKA patients had larger and significantly older wounds (pConclusion: These findings show that the system based on FLE was well-tolerated and efficacious, with better clinical outcome results compared with the wounds analysed in this retrospective matching study and treated with standard of care alone.

BACKGROUND A rationalized model of clinical and therapeutic management of hidradenitis suppurativa (HS) should place the patients at the heart of the process, facilitating their access to diagnostic tests and treatments, providing the appropriate care for each grade of disease severity and optimizing the use of healthcare resources, both in economic and human terms. MATERIAL AND METHODS This paper reports the results of a Consensus of the Tuscany HS working group for a rationalized model of diagnosis and management of HS. RESULTS The diagnostic and therapeutic protocols, the available technological equipments and the management models, are presented in the light of today's scientific evidence. CONCLUSION The goal of the Consensus is to bring the issue of HS management to the attention of the Tuscan regional government, in order to create unanimously accepted diagnostic and therapeutic protocols.

The omentum is a large peritoneal fold. Its main function is to protect abdominal organs, exerting a defensive action against infective agents. The tissue promotes repair after several types of injury. An extensive vascularisation is the key characteristic of this tissue and the omentum has the highest level of production and content of vascular endothelial growth factor (VEGF). A component of omentum is the lipid compound, which carries out important activities for the organism. Omentum is rich in neutral glycerides, phospholipids, glycolipids and gangliosides. Dermatological products containing purified omental lipids are commercially available and topical omental extracts have been useful in the softening, moisturising and smoothing of skin. Animal-derived omental lipids could be use in topical products with different textures (creams, fluids, emulsions and cleansers) and at different concentrations (10–25%) for the treatment of fragile skin or skin conditions causing risk of ulcer formation. This review summarises the pharmacological rationale of purified omental lipids in topical formulations for use in fragile skin conditions, the clinical efficacy data available in the scientific literature and the potential future perspectives. Efficacy of topical purified omental lipids have been demonstrated in numerous clinical controlled trials involving a total of 320 subjects. These studies demonstrated that this product helps prevent the formation of pressure ulcers (PU) in hospitalised high-risk subjects, improves wound healing process, normalises skin hydration in diabetic subjects with moderate-severe skin xerosis and improve the clinical evolution of diabetic foot. Therefore, purified omental lipid could be an effective tool for the management of fragile skin and the skin at high risk of PU formation.

A 71-year-old man presented with a 4-month history of a slow-growing, violaceous vegetation in the umbilical area (figure 1). There was no history of immunosuppression or treatment for other disorders. The lesion was 5 cm in diameter, involving and overflowing the umbilicus, and had a bad odour. Suspecting a …

Atopic dermatitis (AD) is a chronically relapsing skin disease. Although a definitive cure is not available, appropriate treatment can control the disease. The advent of biologic drugs has led to the need for a clear definition of the disease severity and treatment response. A standardized list of outcomes that defines clinician-reported disease severity and patients' reported severity are therefore essential. Solid criteria to define the response to treatment and treatment failure are lacking to date.This systematic review defines treatment goals in terms of clinician-reported disease severity and patient-reported outcomes, referring to the published moderate-to-severe AD clinical trials. The application of these goals in daily clinical practice will ensure a better selection of available treatment options, thus increasing patient quality of care.A systematic literature search was performed to identify the treatments goals of randomized controlled clinical trials (RCTs) on moderate-to-severe adult AD published between January 2000 and October 2020.In total, 14 studies met the eligibility criteria. The most widely used tools in terms of clinician-reported disease severity were the Scoring of Atopic Dermatitis (SCORAD) followed by the Eczema Area Severity Score (EASI) and Investigator Global Assessment (IGA). For disease severity scales as efficacy outcome in RCTs, the greatest standardization and reproducibility was for improvement of at least 50% in EASI score and IGA score reduction of ≥2 grades from baseline. The most widely used tools from the patients' perspective were the Dermatology Life Quality Index (DLQI), Numeric Rate Scale (NRS)-itch and Patient Oriented Eczema Measure Score (POEM). In terms of patients' reported efficacy outcomes in RCTs, a numerical DLQI, NRS-itch and POEM score improvement of at least 4 points from baseline was reported.This systematic review highlights the need for collaboration between experts in order to define and optimize treatment outcomes. Despite considerable progress in harmonizing outcome measures, promoted by the foundation of the Harmonizing Outcome Measures for Eczema (HOME) initiative in 2008, our results demonstrate that this endpoint is still an unmet need. Based on the literature data we propose a minimum treatment goal algorithm for use in daily clinical practice aimed at stimulating a discussion on how the care of AD patients could be further improved.

In spite of the large heterogeneity, limited data exist on hidradenitis suppurativa (HS) phenotypes. To identify the HS phenotypes that best explain the disease heterogeneity, a cross-sectional study using latent class (LC) analysis was conducted on a cohort of patients examined at 17 dermatological centers participating in the Italian Registry of Hidradenitis Suppurativa and being enrolled between January 2015 and January 2020. Overall, 965 patients aged 32.0 ± 12.4 years (mean ± SD) were evaluated. A three-class model in LC analysis best fitted the data. Patients in LC1 (20.1%) were females, mostly obese, with a high probability of axillary‒groin (0.85) and mammary (0.59) lesions and the highest HS severity. Patients in LC2 (29.6%) were nonobese males, with moderate disease severity; with a high probability of gluteal (0.50) and genital (0.17) lesions, besides axillary‒groin involvement; and with acne and pilonidal cysts. Patients in LC3 (50%) were nonobese females with a milder disease mostly limited to axillary (0.52) and groin (0.66) areas. The stratification of patients with HS into a severe axillary‒mammary‒groin phenotype with predominantly anterior body involvement in females, an axillary‒gluteal‒groin phenotype of intermediate severity mainly affecting males in the posterior body areas, and an axillary‒groin phenotype with mildest clinical symptoms and limited skin involvement may help in optimizing HS management.

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.

Dear Editor, Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disease characterised by alterations in the skin barrier and a predominant Th2 immune response. It may be associated with an increased incidence of bacterial ( Staphylococcus aureus ) and viral ( herpes simplex, molluscum contagiosum, papilloma virus ) skin infections.1 We report the case of a 53-year-old man who presented to our department with AD, from which he had been suffering since the age of 1 year and that …

Pyoderma gangrenosum (PG) is a neutrophilic dermatose (ND) characterized by a dense neutrophilic infiltrate in the affected tissue. Neutrophil extracellular traps (NETs) are web‐like structures released by neutrophils and composed of cytosolic and granule proteins assembled on a scaffold of decondensed chromatin. Very little is known about the role of NETosis in PG. Here, we assessed the possible implication of NETosis in the pathogenesis of PG by investigating the NETosis in the ulcers of 26 PG patients. We demonstrated that neutrophils in the PG skin lesions undergo an aberrant level of NETosis in 100% of the analysed cases (N = 26). All control and abscess biopsies were instead negative for the NETosis. In addition, neutrophils from peripheral blood of PG patients showed a significantly higher rate of spontaneous, but not induced, NETosis. Overall, this study suggests that the NETosis may contribute to systemic inflammation and tissue destruction in PG, thus representing a possible novel therapeutic target.

Background 223Ra is currently used for treatment of metastatic castration resistant prostate cancer patients (mCRPC) bone metastases with fixed standard activity. Individualized treatments, based on adsorbed dose (AD) in target and non-target tissue, are absolutely needed to optimize efficacy while reducing toxicity of α-emitter targeted therapy. This is a pilot first in human clinical trial aimed to correlate dosimetry, clinical response and biological side effects to personalize 223Ra treatment. Methods Out of 20 mCRPC patients who underwent standard 223Ra treatment and dosimetry, in a subset of 5 patients the AD to target and non-target tissues was correlated with clinical effects and radiation-induced chromosome damages. Before each 223Ra administrations, haematological parameters, PSA and ALP values were evaluated. Additional blood samples were obtained baseline (T0), at 7 days (T7), 30 days (T30) and 180 days (T180) to evaluate chromosome damage. After administration WB planar 223Ra images were obtained at 2–4 and 18–24 h. Treatment response and toxicity were monitored with clinical evaluation, bone scan, 18F-choline-PET/CT, PSA value and ALP while haematological parameters were evaluated weekly after 223Ra injection and 2 months after last cycle. Results 1. a correlation between AD to target and clinical response was evidenced with threshold of 20 Gy as a cut-off to obtain tumor control; 2. the AD to red marrow was lower than 2 Gy in all the patients with no apparently correlation between dosimetry and clinical toxicity. 3. a high dose dependent increase of the number of dicentrics and micronuclei during the course of 223Ra therapy was observed and a linear correlation has been found between blood AD (BAD) and number of dicentrics. Conclusions This study provides some interesting preliminary evidence to be further investigated: dosimetry may be useful to identify a more appropriate 223Ra administered activity predicting AD to target tissue; a dose dependent complex chromosome damage occurs during 223Ra administration and this injury is more evident in heavily pre-treated patients; dosimetry could be used for radioprotection purpose. Trial registration The pilot study has been approved from the Ethics Committee of Regina Elena National Cancer Institute (N:RS1083/18–2111).

BACKGROUND The anti-tumour necrosis factor (TNF)-α adalimumab is the only licenced biologic for moderate-to-severe hidradenitis suppurativa (HS). No predictors of response have been identified so far. OBJECTIVES To identify clinical parameters predicting response to adalimumab and confirm its efficacy/safety. METHODS The data of 389 patients with HS treated with adalimumab in 21 Italian centres were reviewed. Sex, age at onset/diagnosis/baseline, body mass index, smoking, phenotype, previous treatments, concomitant antibiotics and 'therapeutic delay', defined as the time from HS onset to adalimumab initiation, were assessed. Response to adalimumab and its impact on quality of life (QoL) were evaluated using the Hidradenitis Suppurativa Clinical Response (HiSCR) and the Dermatology Life Quality Index (DLQI) or the Visual Analogue Scale for pain (VAS pain), respectively. Logistic regression analysis was performed. RESULTS The therapeutic delay correlated to lack of response to adalimumab at week 16 [odds ratio (OR) 1·92 for therapeutic delay > 10 years; 95% confidence interval (CI) 1·28-2·89; P = 0·0016). HiSCR was achieved in 43·7% and 53·9% patients at week 16 and 52, respectively. Significant reductions in both DLQI and VAS pain were found between week 16 vs. baseline (P < 0·0001 for both) and week 52 vs. baseline (P < 0·0001 for both). Previous immunosuppressants inversely correlated to HiSCR at week 52 (OR = 1·74, 95% CI 1·04-2·91, P = 0·0342). CONCLUSIONS Inverse correlation between therapeutic delay and clinical response was found, supporting early adalimumab use and providing evidence for a 'window of opportunity' in HS treatment. Adalimumab efficacy and safety were confirmed, along with patients' QoL improvement. Immunosuppressants could negatively influence the response to adalimumab inducing a switch to non-TNF-α-driven pathways.

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.

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.

Atopic dermatitis (AD) is an inflammatory disease with a chronic-relapsing course that is intensely itchy. A correct diagnosis of AD in adults and consequently appropriate clinical therapeutic management is a critical issue for extreme clinical expression heterogeneity and various grades of disease severity. In order to ensure high levels of care and standardization of clinical therapeutic management of Adult AD, the decision was taken to create an AD Tuscan Consensus Group (the Group), to work on and validate a consensus based regional clinical-therapeutic management model. The aims of the Group were to find agreement on the criteria for diagnosis, scoring of severity, multidisciplinary approach and treatment of adult atopic dermatitis and to create an easier way for patients to access specialized dermatology outpatient services and importantly to reduce waiting lists and costs related to the management of AD. The Tuscan Consensus Group adopted a simplified Delphi method, in three principal steps: 1) literature metanalysis and critical review of patient's clinical experience to identify the main areas considered questionable or uncertain; 2) discussion of those areas requiring consensus and statement definition through four different sub-committees (diagnosis, severity evaluation, scoring and comorbidities); 3) a consensus based simplified process with final approval of each statement by plenary vote with approval >80% of the participants. The Group here presents and discusses the consensus based recommendation statements on adult atopic dermatitis.

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

Background Patients with multiple actinic keratoses (AKs) should be treated with field-directed therapy. Such treatments challenge patients' adherence due to out-of-pocket costs, length of treatment and severity of local skin reactions (LSRs). Effective physician-patient communication (PPC) may buffer therapy-related distress, thus improving quality of life, treatment satisfaction and adherence. Objectives We evaluated the interplay between PPC, LSR intensity (safety) and lesion clearance rates (effectiveness) on treatment satisfaction, quality of life and treatment adherence among patients with multiple AKs receiving topical field-directed therapies. Methods In this observational, multicentre, longitudinal, cohort study, we included 1136 adult patients with discrete, clinically detectable, visible, multiple (three or more lesions in a 25 cm2 area), Grade I/II AKs, for whom the attending dermatologist has prescribed treatment with a topical field-directed therapy. We matched self-reported data and medical information recorded by dermatologists in standard clinical forms. Patients were followed up at two time points (T1: 8 days; T2: 25-30 days) RESULTS: Most patients were elderly, married, men with poor socio-economic status and multiple lesions of the scalp or face. The majority (n = 961) had a prescription of ingenol mebutate (IMB) and 175 received either diclofenac 3% in hyaluronic acid (DHA) or imiquimod 5% (IMQ). Clearance rate at 1 month was 84%. Most patients felt very supported (n = 819, 73%) and rated dermatologist's explanations very clear (n = 608, 54%). Treatment satisfaction (effectiveness and convenience scales) increased along the follow-up, especially for those on IMB (Δpre-post = -4.00; other: Δpre-post = -0.25; interaction P Conclusion Communication clarity was associated with patient-reported outcomes and adherence beyond AK-related clinical parameters. Our study questions the current episodic approach to AK management and provides the rationale to develop chronic care models fostering patients' engagement and treatment alliance.

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.

Malignant fungating wounds (MFWs) represent a major problem for public health. The most common symptoms associated with MFWs are pain, exudate, bleeding and odor. The aim of the study was to optimize the local management and dressing of MFWs. We developed a standardized 4- step approach to MFWs based on Pain, Exudate, Bleeding and Odor management in a case series of 24 patients: we call this the PEBO approach. We analyzed etiologies, localization, Quality of Life (QoL), pain and clinical signs and symptoms. We assessed the ulcers at baseline, after two weeks and after one month. In our study, most patients showed an improvement in the QoL using PEBO approach, although some experienced a deterioration in their general clinical conditions. Non-cytolesive cleansing, atraumatic dressings were applied to allow pain relief. Non-adherent dressings were combined with a secondary dressing in the case of exudate. Achieving hemostasis with dressing or medication is a priority in MFW management. Antibacterial dressings and odor absorbent dressings were used for odor absorption. Surgical debridement, adherent dressing and occlusive dressings were avoided. Dressing changes were programmed twice a week for four weeks. PEBO simplified the complex aspects of this type of ulcer, and could help physicians, nurses, and also the rest of the team, including the patients themselves and their family, in the multidisciplinary palliative care of MFWs.

Digital ulcers (DUs) represent one of the major burdens for patients with systemic sclerosis (SSc), especially when associated with skin calcinosis (SC). The aim of this work is to evaluate the impact of SC in DUs of patients with SSc for clinical characteristics and prognosis assessed by the wound bed score (WBS). We prospectively enrolled 55 patients with DUs and SSc followed in our dedicated wound care clinic. For all the patients we collected clinical and anthropometric data and characteristics of the DU, and we calculated the WBS for each DU. Ninety-nine DUs were evaluated (24 with SC). SC was prevalent in limited cutaneous SSc (75%) and in patients with longer disease duration (P = 0.02). SC-DUs were prevalent at the fingertip (P = 0.04). The healing time was significantly higher in patients with SC (10.4 ± 7.9 weeks) compared with non-SC (7.0 ± 5.7 weeks) P = 0.03. The WBS negatively correlated with the time to achieve complete healing (r = -0.237 P = 0.023) and the correlation was maintained in the non-SC (r = -0.46, P = 0.033). DUs in SSc patients with SC are common and difficult to heal. When DUs are treated in dedicated centres, the prognosis is good. The WBS is fast and easy and maybe commonly applied in clinical practice.

Background: Hidradenitis suppurativa (HS) is a chronic, debilitating disease with a considerable effect on patient quality of life. Its clinical severity can be measured using different scoring systems; however, few of them include patient-centred parameters. Objective: To create a new scoring system for HS that includes a quality-of-life instrument, the HIDRAdisk. Methods: This post hoc analysis was carried out within the framework of a multicentre, longitudinal, epidemiologic study conducted over 9months on quality-of-life aspects of HS. The new severity score was created using as reference a question from the Subject Satisfaction Questionnaire (SSQ) concerning the severity of HS as evaluated by the patient. Associated variables were selected using univariable and multivariable logistic regression models. The discriminant capabilities of the final model and of the final score were evaluated by the area under the receiver operating characteristic curve and the Hosmer–Lemeshow test. Results: The study population included 308 patients with HS of any severity grade. According to the results of the regression models, the variables associated with the reference SSQ measure were number of inflammatory nodules, abscesses and draining fistulas; the HIDRAdisk score; and the number of subumbilical lesions. The HIDRAscore is obtained by the sum of the scores associated with the number of these parameters. Possible scores range from 0 to 10. Conclusion: The HIDRAscore is a new scoring system for HS severity which, in addition to the clinical evaluation by the physician, includes a validated patient-reported outcome measure, the HIDRAdisk.

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 (

Biologics are a new class of drugs which mimic the action of human proteins and interact with circulating proteins or cellular/extracellular targets, blocking their activities. The main application of biologics in dermatology concerns psoriasis, atopic dermatitis, and recently hidradenitis suppurativa, with a growing interest in chronic wound management. Inflammatory wounds such as pyoderma gangrenosum and vasculitic ulcers are the main indications for biologics, according to the pathogenesis of them. Wondering the use of this drugs we have to consider the possible contraindications, side effects, and the remarkable costs. Checking the literature we can find just case reports or small case series about their use in chronic wound therapy.

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.

Matrix metalloproteinases (MMPs) are a large family of ubiquitously expressed zinc-dependent enzymes with proteolitic activities. They are expressed in physiological situations and pathological conditions involving inflammatory processes including epithelial to mesenchymal transition (EMT), neuronal injury, and cancer. There is also evidence that MMPs regulate inflammation in tumor microenvironment, which plays an important role in healing tissue processes. Looking at both inflammatory and neuronal damages, MMP9 is involved in both processes and their modulation seems to be regulated by two proteins: tumor necrosis factor-alpha (TNF-alpha) and interleukin 6 (IL-6). However other important genes are involved in molecular regulation of transcription factors, protein-kinase B (AKT), and p65. In addition, Triticum vulgare extract (TVE) modulated the biological markers associated with inflammatory processes, including p65 protein. While there are no evidence that TVE might be involved in the biological modulation of other inflammatory marker as AKT, we would like to assess whether TVE is able to (1) modulate phosphorylation of AKT (pAKT) as an early marker of inflammatory process in vitro and (2) affect MMP9 protein expression in an in vitro model. The BV-2 cells (microglial of mouse) have been used as an in vitro model to simulate both inflammatory and neuronal injury pathologies. Here, MMP9 seems to be involved in cellular migration through inflammatory marker activation. We simulate an inflammatory preclinical model treating BV-2 cells with lipopolysaccharide (LPS) to induce proinflammatory activation affecting pAKT and p65 proteins. TVE is revealed to restore the native expression of AKT and p65. Additionally, TVE extract modulates also the protein concentration of MMP9. Nevertheless, immunofluorescence confocal analyses revealed that both AKT and MMP9 are regulated together, synchronously. This work seems to demonstrate that two important genes can be used to monitor the beginning of an inflammatory process, AKT and MMP9, in which TVE seems able to modulate their expression of inflammation-associated molecules.

Background: Ixekizumab (anti-IL-17A) is a biological agent used for the treatment of moderate-to-severe psoriasis. Real-life data on the effectiveness and safety of ixekizumab are currently scarce. Objective: The objective of this study was to evaluate the effectiveness and safety of ixekizumab in a cohort of psoriatic and psoriatic arthritis patients. Methods: We conducted a retrospective study involving 201 patients affected by moderate-to-severe psoriasis and treated with ixekizumab at seven Italian University centers. Data analysis focused on 110 patients who started ixekizumab at baseline and completed at least 24 weeks of treatment. Results: Significant reduction of mean (± standard deviation) baseline Psoriasis Area Severity Index (PASI) score (14.3 ± 5.8) was detected at 4 weeks of ixekizumab therapy (4.9 ± 4.2, p < 0.001), with a further significant improvement at weeks 12 and 24 (1.9 ± 2.9 and 0.9 ± 1.6, respectively) (p < 0.001). Our analysis showed 90%, 72%, and 57% of patients achieving PASI 75, 90, and 100 responses (75%, 90%, and 100% reduction in PASI score), respectively, after 24 weeks’ therapy. For patients with arthritis (28%), a significant reduction in the mean (± standard deviation) baseline Disease Activity Score (DAS)-28 score (4.6 ± 5.1) was detected at week 4 (2.5 ± 3.9, p < 0.01), with a further significant improvement at weeks 12 and 24 (2.1 ± 1.2 and 1.4 ± 0.9, respectively) (p < 0.001). The bio-naïve group showed significantly higher PASI 90 and 100 response rates at week 12 than the bio-exposed one (p < 0.05). This trend in terms of PASI 100 response was also maintained at week 24 (p < 0.05). Furthermore, PASI 90 responses were significantly higher in anti-interleukin (IL)-17A-naïve patients at week 24 than in anti-IL-17A-experienced ones (p < 0.05). The dropout rate for adverse events (AEs) was as low as 2% (2/110), while AEs that did not cause treatment interruption were observed in 6% (7/110). Patients withdrawing from the study were defined as non-responders according to the non-responder imputation method. The retrospective design of the study does not allow missing data to be retrieved or homogeneous patient selection. Conclusions: The present study illustrates ixekizumab in real-world clinical practice, confirming its usefulness and safety in the management of psoriasis and psoriatic arthritis.

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

Objectives The aim of the present study was to evaluate the diagnostic efficacy of ultra-high frequency ultrasound (UHFUS) imaging of intraoral soft tissue lesions. Study Design The study included 160 patients presenting with oral soft tissue lesions classified into 4 categories: autoimmune diseases, mucosal growths, potentially (pre)malignant lesions, and oral cancer. Each lesion was evaluated by means of intraoral UHFUS, through B-mode and C-mode acquisitions of the area of interest. The UHFUS findings were compared with the histopathologic findings. Results All values for sensitivity, specificity, and negative predictive value exceeded 90%. Sensitivity was perfect (100%) for mucosal growths and oral cancer. Specificity was almost perfect for all 4 categories of lesions, ranging from 97% to 99%. Values for positive predictive value ranged from 83% to 99%. Conclusions UHFUS was beneficial in imaging the oral mucosa and the superficial aspects of the underlying soft tissue in detail because of the high spatial resolution of the technique. Consistent patterns were recognized for different categories of lesions. UHFUS holds the promise of being a valuable support to the clinician in terms of diagnosis, treatment, and follow-up of oral lesions.

MolecuLight i:X is a noninvasive, portable device that captures images, measures wound areas, and allows the evaluation of the bacterial environment in real time. The aim of the study was to correlate the different fluorescence (light green, red, cyan) and dark red–purple–black color areas with average pH values in these areas and with average wound bed score (WBS). During a 4-week period, we enrolled 43 adult patients (23 females and 20 males) with clinically infected and uninfected chronic ulcers. In our study, the mean age was 68 years old. The etiologies were 21 venous ulcers, 3 arterial ulcers, 4 vasculitis, 7 pyoderma gangrenosum, 7 traumatic ulcers, and 1 neoplastic ulcer. The average area was 16.92 cm2 and the average WBS was 9.17. A total of 16 ulcers (37%) were positive for clinical signs and symptoms of infection and 27 ulcers were negative (63%). Thirty-six ulcers emitted a single fluorescence: cyan (n = 13), red (n = 1), light green (n = 14), and dark red-purple–black (n = 8). Six wounds showed a double fluorescence area: red and cyan (n = 1) and cyan and light green (n = 5). One ulcer emitted a triple fluorescence area: red, cyan, and light green. Overall in 43 ulcers, we found 43 fluorescence and 8 dark red–purple–black color. We found significant data between pH and fluorescence. pH values on wound bed confirm in a noninvasive way the correlation between fluorescence and bacterial burden. Moreover, MolecuLight i:X is able to detect objectively the bacterial proliferation, in contrast with pH which cannot distinguish different types of bacteria.