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BACKGROUND Distinguishing weak allergic reactions from irritant patch test reactions may be difficult. OBJECTIVES To describe the dermoscopic features of allergic reactions (especially weak allergic ones) and irritant patch test reactions, and to assess the suitability of dermoscopy in supporting differential diagnosis. METHODS Eligible participants for this observational, cross-sectional study included consecutive adult outpatients patch tested during a 12-month period, who developed any skin reaction. Healthy volunteers were patch tested with sodium lauryl sulfate as irritant controls. At the 72-hour reading, patch test reactions were recorded both with a digital camera and a digital dermoscopic system. For each reaction, clinical and dermoscopic variables were separately assessed, scored, and then compared. RESULTS Erythema, vessels, and vesiculation were constant dermoscopic features of allergic reactions (n = 173). In 46 weak (+) allergic reactions, dermoscopy showed (a) erythema (100%), (b) dense polymorphic vessels (100%), and (c) whitish vesicles (78.3%). Scores for vesicles and dotted vessels were significantly higher in weak allergic than in irritant reactions. Vesicles were identified as the chief dermoscopic parameter for correctly distinguishing weak allergic from irritant reactions. CONCLUSIONS Dermoscopy can improve accuracy in the differential diagnosis between weak allergic and irritant patch test reactions.

Background previous research on the risk of subsequent, primary non-cutaneous malignancies among patients with non-melanoma skin cancers (NMSCs) led to conflicting results. We aimed to investigate a possible link between NMSC and second primary malignancies by using the population-based data available in cancer registries. Methods this observational study retrospectively assessed the risk of occurrence of both synchronous and methachronous second primary tumours in a cohort of cancer patients whose first diagnosis was NMSC. The cohort came from the network of general cancer registries of the Emilia-Romagna Region, northeast Italy, in the period between 1978 and 2012, and was compared with the general population living in the same area. Two main indexes were used: i) Standardized Incidence Ratio (SIR), calculated as the ratio between the observed and the expected number of second cancers and ii) Excess Absolute Risk (EAR), expressing the absolute excess or deficit of second cancer incidence. Results in the period analysed (1978–2012, 72,503,157 person/years, PYs), 89,912 primary NMSC were found in 76,414 patients. Among them, 14,195 developed a second primary cancer in the subsequent 501,763 follow-up PYs. NMSC patients showed an overall SIR of 1.22 (CI 95% 1.20-1,24) and an EAR of 5.11 cases/1000 PYs (CI 95% 4.48–5.74). Conclusions the study results showed that NMSC patients had an increase in relative risk and, at least for some tumours, in absolute risk of developing a second cancer when compared with the general population. Genetic, environmental and personal risk factors may influence this finding.

The aim of the study was to assess the association between eruptive cherry angiomas (CAs) and malignant melanoma (MM). Secondary objectives included investigating (i) this association in different age subgroups, and (ii) the association of eruptive CAs with other variables such as malignant tumours, in general, and immunosuppressive treatments. This cross-sectional study involved all patients referred to the outpatient Dermatology-Oncology Units of the universities of Ferrara and Bologna, Italy, and submitted to total body skin examination. These patients were included in a previously collected series. We recorded age, sex, cutaneous and noncutaneous malignancies, immunosuppressive treatments, and presence of CAs. CAs were arbitrarily considered as 'eruptive' when more than or equal to 10. Variables significantly associated with eruptive CAs were included in the logistic regression analysis, also stratified by age. A total of 1693 patients were included in the present study: 500 patients had malignancies, 460 malignant skin tumours, 263 had MM; 150 patients were immunosuppressed; 804 (47.49%) patients had eruptive CAs. In the whole study population, age, immunosuppressive treatment, MM, other skin and nonskin malignant tumours were significantly associated with eruptive CAs at the multivariate analysis. Multivariate analysis in each age subgroup revealed that the association between MM and eruptive CAs was highly significant in younger patients (≤50 years), significant in the 51-70 year-old subgroup, whereas it lost significance in older patients. These findings suggest an association between MM and eruptive CAs, particularly in the lower and intermediate age groups. Both the nature of this association and its possible impact in clinical practice, especially in MM screening, are yet to be established.

Background Antibiotic (AB) treatment is one of the first steps in the management of hidradenitis suppurativa (HS). Bacteria, in HS patients, may play a double role, as triggering factors of inflammatory reactions and/or agents of infection. Objectives The aims of this study are as follows: (i) to assess prevalence and AB resistance of bacterial growths in HS patients (ii) assessment of the clinical relevance of obtained data in guiding the selection of the most effective AB therapy. Methods Purulent material from 137 skin lesions of HS patients was collected with swabs. Bacterial flora and AB sensitivity were determined using microbiological cultures for aerobic and anaerobic bacteria. Results A total of 114 samples resulted positive for bacteria. Sample was collected from the axillae, groin and perianal areas. A total of 163 single bacterial growths were observed; 55% were Gram-positive and 44% were Gram-negative. Among them, 18.4% were anaerobic. The most frequent bacterial families included enterobacteriaceae (30.7%), Staphylococcus (25.2%) and Streptococcus (14.1%). The most frequent genus or species were proteus spp. (13.5%) and Escherichia coli (9.8%). The prevalence of AB resistance observed was clindamycin 65.7%, rifampicin 69.3%, penicillin 70.0%, ciprofloxacin 74%, tetracycline 84.7% and erythromycin 89.0%. A limitation of the study is represented the short culture period adopted which may have impaired the isolation of anaerobes. Conclusions Bacterial growth in HS patients has shown a high level of resistance to ABs, including rifampicin, clindamycin and tetracyclines, cited as an empiric choice in HS therapeutic guidelines. A targeted and specific AB therapy, driven by microbiological evaluations with prolonged culture periods, seems more appropriate than empiric, generic, non-specific, therapeutic approaches. Current knowledge regarding HS bacterial AB resistance should be considered in the update of current therapeutic guidelines for HS.

Background The evidence on the safety of topical preparations containing emulsifiers is limited. Objectives The aims of the study were to assess (1) the prevalence of sensitization to some emulsifiers commonly found in topical products, (2) the sensitization to emulsifiers in relation to sex, age, and predisposing factors, and (3) the frequency of concomitant sensitization to other common allergens. Methods All consecutive patients presenting to the Allergy Unit of our Dermatological Department for allergological investigation were enrolled. All patients were patch tested with the Italian Societa Italiana di Dermatologia Allergologica Professionale ed Ambientale baseline series and an additional emulsifiers series. Doubtful patch test reactions were not considered. Results Of 310 patients, 50 (16%) were sensitized to emulsifiers with 72 positive reactions. Lauryl polyethylene glycol/polypropylene glycol-18/18 methicone gave 26 positive reactions, glyceryl oleate 19, myristyl alcohol, and Amerchol L101 11. Concomitant sensitization to emulsifiers was found in 16 patients. Patients allergic to emulsifiers showed concomitant allergic reactions to allergens commonly found in cosmetics. No significant differences by sex, age, atopic diathesis, and clinical pattern at presentation were noticed. Conclusions Contact allergy to emulsifiers is more frequent than reported. Patients allergic to emulsifiers show frequent positive patch tests to other constituents of cosmetics and topical products.

The modern conveniences and enjoyment brought about by electronic devices bring with them some health concerns. In particular, personal electronic devices are responsible for rising cases of several skin disorders, including pressure, friction, contact dermatitis, and other physical dermatitis. The universal use of such devices, either for work or recreational purposes, will probably increase the occurrence of polymorphous skin manifestations over time. It is important for clinicians to consider electronics as potential sources of dermatological ailments, for proper patient management. We performed a literature review on skin disorders associated with the personal use of modern technology, including personal computers and laptops, personal computer accessories, mobile phones, tablets, video games, and consoles.

With the aim to assess changes in both clinical and dermoscopic features of vulvar lichen sclerosus (VLS) after a treatment with topical corticosteroid, 29 VLS patients treated with mometasone furoate 0.1% ointment for 12 weeks were evaluated for symptoms, objective signs and dermoscopic variables at baseline and treatment completion. Numeric scores were assigned to each parameter. Mean itching and burning values had decreased significantly at the 12-week control visit compared with baseline, as well as values referring to pallor, hyperkeratosis and purpuric lesions. Among the dermoscopic variables, the vessel score increased while the scores of patchy, structureless, whitish areas, whitish background, purpuric globules and scales decreased significantly after treatment. Scores referring to gray-blue dots, comedo-like openings and structures like ice slivers did not change significantly throughout the treatment. Based on these findings, dermoscopic features may change, even significantly, with topical corticosteroids and may be useful for monitoring the response to treatment.

Background: Due to the sensitizing constituents of eye cosmetics, allergic contact dermatitis is considered a frequent cause of eyelid dermatitis. An association between eyelid dermatitis and nickel contained in make-ups remains controversial. Objective: The study aimed to assess the association between nickel allergy, the use of pigmented makeup products and self-reported eyelid dermatitis. Method: This multi-centric, cross-sectional study enrolled 165 women sensitized to nickel (patients) and 103 women without intolerance to metals (controls). We recorded: demographics, atopy, use of pigmented eye cosmetics (mascara, eyeshadow, eyeliner, eyebrow pencil), and previous eyelid dermatitis. Among the patients, any co-sensitization to cosmetics or metals was recorded. Results: 87.3% of the patients and 91.3% of the controls reported their use of eye make-up; 44.9% and 52.4%, respectively, reported previous episodes of eyelid dermatitis, without significant differences. The occurrence of eyelid dermatitis was significantly associated with the use of eye make-up products, both in general and considering each product separately. Age, atopy, or co-sensitization to other metals or cosmetics did not affect the occurrence of eyelid dermatitis. Conclusion: Nickel allergy should not be considered the main risk factor for eyelid dermatitis. The use of pigmented eye make-up may be a triggering factor for eyelid dermatitis, probably due to an irritant action.

Diagnosis of genital inflammatory disorders may be difficult for several reasons, such as their similar appearance, possible misdiagnosis with infectious and malignant conditions, and peculiar anatomic conditions that may lead to modification of clinical features. Dermoscopy could be included as a part of the clinical inspection of genital diseases to support diagnosis, as well as to ideally avoid unnecessary invasive investigation. Practical guidance for the use of dermoscopy in the assessment of the main inflammatory genital diseases is provided, namely for lichen sclerosus, lichen planus, psoriasis, lichen simplex chronicus, and plasma cell mucositis.

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To assess the effectiveness and safety of a 24-week application of tretinoin 0.025% cream, with an alternate-day regimen, in achieving control of VLS signs and symptoms.17 patients affected with VLS were included. The main efficacy parameters were the response rate, as defined by protocol parameters, the rate of patients achieving an improvement from baseline of ≥75% in the subjective and objective scores, and the mean reduction in subjective and objective scores throughout the treatment. The safety of the treatment was also assessed.By the end of the 24-week treatment, 12 patients (70.6%) experienced a response; 35.3% and 17.6% of patients achieved an improvement of at least 75% in subjective and objective scores, respectively. Mean scores of itching, leukoderma (pallor) and hyperkeratosis decreased significantly in the study patients, and none presented itching-related excoriations. Erythema increased compared with baseline. Six patients (35.29%) experienced some side effects related to tretinoin, mainly mild erythema and burning. None of the subjects discontinued the treatment because of side effects.Tretinoin 0.025% cream applied for 24 weeks may represent a useful alternative option to corticosteroids in the treatment of active VLS, acting particularly on hyperkeratosis and pallor.

Acne vulgaris is a chronic dermatological disorder that affects the majority of teenagers in the Western world. Topical therapy is widely used to treat mild-moderate acne and is known as well-tolerated thanks to its low systemic toxicity, although associated to skin adverse effects. Acne seems to be associated also to an intrinsic alteration of the epidermal barrier, regarding both the upper and the follicular stratum corneum that promotes the onset of such local side effects. The commonest one is irritant contact dermatitis, an event of frequent observation occurring with erythema, burning, dryness, scaling, and itching, usually characterized by low severity and limited duration. Among topical acne drugs, retinoids are the most irritating ones. Another side effect is allergic contact dermatitis: it is rare and mainly associated to benzoyl peroxide.

The efficacy and safety of acitretin was evaluated retrospectively in a cohort of 46 patients with moderate to severe plaque psoriasis (Psoriasis Area and Severity Index (PASI) range 10-42). Patients were treated at an initial dose of 10 mg/day acitretin, which was then gradually increased until the best therapeutic effect with the fewest adverse effects was reached (< 50 mg/day) and later decreased and maintained at the lowest effective dosage. Efficacy measures were: (i) PASI75 (75% improvement) and PASI50 between 10 and 16 weeks; and (ii) PASI75 even after 16 weeks of treatment. At weeks 10-16, PASI75 and PASI50 were achieved by 47.8% and 87% of the patients, respectively. Overall, 67.3% reached PASI75. Adverse events occurred in 18 patients (39.1%); among these, 4 (8.7%) discontinued acitretin. Our findings suggest that acitretin at an initial low, gradually escalating dose, and subsequently maintained at the minimal effective dose, is a suitable treatment option for plaque psoriasis as it provides clear-cut improvement in most treated patients while minimizing the risks of side-effects.

To assess the effectiveness, tolerability, and convenience of the cream formulation of mometasone furoate 0.1% (MMF) in the treatment of active vulvar lichen sclerosus (VLS) and to compare the cream with the ointment formulation.The following efficacy parameters were assessed in 27 VLS patients treated with MMF cream for 12 weeks (group A): (i) response rate, (ii) percentage of patients achieving an improvement from baseline of ≥75% in subjective and objective scores, and (iii) mean reduction in subjective and objective scores. These efficacy assessments, as well as those regarding safety and adherence, were compared with the assessments recorded among 37 VLS patients treated with MMF ointment (group B).59.3% (group A) and 78.4% (group B) of patients were considered responders; 44.4% and 40.7% of patients in group A and 54.1% and 45.9% in group B achieved an improvement of at least 75% in subjective and objective scores, respectively. MMF ointment obtained a significantly higher improvement in symptom scores in comparison with the cream formulation.MMF in ointment formulation seems to be more effective in treating active VLS in comparison with MMF cream. Both formulations are well tolerated and there is no difference in patient adherence and satisfaction.

Background Skin diseases caused by mites and insects living in domestic environments have been rarely systematically studied. Objectives To study patients with dermatitis induced by arthropods in domestic environment describing their clinical features, isolating culprit arthropods and relating the clinical features to the parasitological data. Methods The study was performed in 105 subjects with clinical and anamnestic data compatible with the differential diagnosis of ectoparasitoses in domestic environments. Clinical data and arthropods findings obtained by indoor dust direct examination were studied. Results Indoor dust direct examination demonstrated possible arthropods infestation in 98 subjects (93.3%), more frequently mites (56.1%) (mainly Pyemotes ventricosus and Glycyphagus domesticus) than insects (43.9%) (mainly Formicidae and Bethylidae). Strophulus (46.9%) and urticaria-like eruption (36.7%) in upper limbs and trunk with severe extent were prevalent. Itch was mostly severe (66.3%) and continuous (55.1%). Ectoparasitoses occurred frequently with acute course in summer (44.9%) and spring (30.6%). Conclusions Possible correlation between clinical and aetiological diagnosis of arthropods ectoparasitoses in domestic environments needs the close cooperation between dermatologist and parasitologist. This is crucial to successfully and definitely resolve skin lesions by eradicating the factors favouring infestation.

Abstrract Purpose: To assess efficacy and safety profile of combining a potent corticosteroid with a retinoid in the treatment of vulvar lichen sclerosus (VLS).We retrospectively compared 21 VLS patients treated with tretinoin (T) in short-contact therapy and mometasone furoate (MMF) (group A) and 20 treated with cold cream (CC) and MMF (group B) for 5 consecutive days/week for 12 weeks. The efficacy parameters were the response rate, the percentage of patients achieving an improvement from baseline of ≥75% in subjective and objective scores and the mean reduction in subjective and objective scores.Thirteen patients (75.2%) were considered as responders in group A and 15 (78.9%) in group B; 50% and 61.1% of patients in group A and 100% and 63.1% in group B achieved an improvement of at least 75% in subjective and objective scores, respectively. The scheme combining MMF and CC was better tolerated than the combination of MMF and T.The combination with a topical retinoid did not enhance the effectiveness of a potent corticosteroid in the treatment of VLS. Either the scarce efficacy of the short-contact therapy regimen or a less favorable safety profile of such combination may account for these findings.

Background Evidence on the treatment of plasma cell vulvitis (PCV) is scarce and comparative studies are lacking. Objective To assess and compare the effectiveness and safety, on a long-term basis, of three topical interventions for the treatment of PCV. Methods Retrospectively collected efficacy and safety data of a cohort of PCV patients treated with fusidic acid 2% and betamethasone valerate 0.1% cream fixed combination (FA/BM, 14 patients), clobetasol propionate 0.05% ointment (CP, six patients) and tacrolimus 0.1% ointment (TC, four patients) at different regimens between January 2000 and June 2013 were analysed. Treatment outcome was assessed according to Investigator Global Assessment (i) symptoms and (ii) signs, at 12, 24 and 52 weeks. Results After 12 weeks, 85% of all patients achieved satisfactory improvement in PCV-related symptoms and maintained the improvement across a 52-week observation period. About 45% achieved a satisfactory result in clinical signs after 12 weeks, without further improvement during the following 9 months. No statistical differences in response were found among treatment groups at 12, 24 and 52 weeks. All study treatments were significantly more effective in improving PCV symptoms rather than clinical signs. With regard to treatment tolerability, one patient (7.1%) in FA/BM group and one (25%) in TC group discontinued the treatment due to local side-effects. Conclusions CP, FA/BM and TC are effective and safe in treating PCV, inducing both a rapid improvement of the disease, notably of symptoms, and stabilizing its control.

SummaryBackground The prevalence of occupational and non-occupational textile dermatitis seems to be increasing, probably because of changed textile manufacturing techniques. Objective Evaluation of the clinical features and epidemiology of textile contact dermatitis (TCD) in Italy. Methods Demographic data, clinical history aspects, atopy and positive patch test reactions to occupational and non-occupational allergens were investigated in 277 textile dermatitis patients. Results Contact dermatitis was the most frequent clinical presentation (95.3%). TCD was more common in females, in the fourth to fifth decades of life, and in atopic dermatitis patients. The lesions were prevalently eczematous (74.2%), and mostly located on the trunk and lower limbs in non-occupational cases, and on the hands in textile workers. Allergic TCD (58.3%) was more frequent than irritant TCD. The dyes (Disperse Blue 124, Disperse Blue 106, and Disperse Yellow 3) were most frequently responsible (79.8%), especially in non-occupational TCD. Formaldehyde and resins were more important in occupational TCD. Concomitant reactions among textile dyes and/or finishing resins were observed in 50.0% of patients. Conclusions Some strategies (sensitization potential of new textile chemicals, more stable dyes, reduced levels of formaldehyde in clothing, and collaboration with textile industry and trade associations) should be adopted to decrease the TCD incidence and update the textile patch testing series.

Vulvar lichen sclerosus (VLS) is a chronic inflammatory disease with a huge impact on a person's quality of life. On the basis of the immunologic changes in VLS, treatment with a high potency topical corticosteroid is recommended. The currently available guidelines identified the ultra-potent corticosteroid clobetasol propionate 0.05% (CP) as the first-line recommended treatment but growing evidence supports the use of the potent corticosteroid mometasone furoate 0.1% (MMF). We reviewed the available studies assessing MMF in the treatment of VLS. Both non comparative and comparative studies were included in this review. Findings from clinical trials indicate that MMF is an effective and safe option in the treatment of VLS both in the active phase and in long-term maintenance treatment. Consistent with the findings from the comparative studies, MMF shows similar efficacy and safety to CP.

Summary Background The evidence on the safety of topical preparations containing botanical extracts is limited. Objectives To assess (i) the use of botanically derived compounds in a large population, (ii) the incidence of cutaneous side-effects, and (iii) the diagnostic usefulness of patch testing. Methods A questionnaire was used in 2661 patients to assess both the prevalence and type of topical botanical preparations used, and the occurrence of adverse skin reactions. Patients declaring adverse reactions were patch tested with (i) the Italian (SIDAPA) baseline series, (ii) an additional botanical series, and (iii) the patients' own products. Results Of the patients, 1274 (48%) reported the use of topical botanical products; 139 patients (11%) commented on adverse cutaneous reactions; 75 (54%) showed positive reactions with the Italian baseline series. Among the 122 patients tested with the botanical series, 19 (16%) showed positive reactions, in many cases with concomitant relevant positivity to at least one allergen of the Italian series connected with cosmetics. The commonest botanically derived allergens were propolis, Compositae extracts, and Melaleuca alternifolia (tea tree) oil. Conclusions Contact allergy is a possible adverse effect of natural products. Baseline series supplemented with the commonest botanical allergens may be adequate for detecting most of the cases of contact allergy to natural topical products.

A case of rapidly relapsing pyoderma gangrenosum (PG) of the left preauricular area with no undermined borders is described. This might be considered a case of malignant pyoderma (PM), a rare variety of PG. Five months after complete healing obtained with systemic corticosteroids, the preauricular lesion of PG relapsed. As retreatment with oral methylprednisolone induced glucose intolerance and high arterial pressure, sulfa drugs were initially employed with a transitory recovery of the skin lesion. A successive prolonged course with minocycline induced a new complete resolution. To date, at six months' follow-up, the patient is relapse-free. This case confirms that sulfa drugs and minocycline may also be considered alternative therapies in PM. PM is a variety of PG characterized by specific morphological features, a higher tendency to relapse, and poor responsiveness to treatment.