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Patients with early stage cutaneous T cell lymphoma (CTCL) usually have a benign and chronic disease course, characterized by temporally response to conventional skin directed therapies and intrinsic possibility to evolve. Using the combination of psoralen plus ultraviolet A irradiation (PUVA) and low-dose interferon-α (INF), the principal treatment goal is to keep confined the disease to the skin, preventing disease progression. Among 87 patients with early stage IA to IIA MF treated with low-dose IFN-α2b and PUVA in our center, complete remission (CR) were reported in 70 patients (80.5%) and the overall response rate (ORR) was 97.8% (n = 85), with a median time to best response to therapy of 5 months (range, 1-30). Among the responders, only the 8% of patients had a relapse with major event. The median follow-up was 207 months (range, 6-295). Survival data showed a median overall survival (OS) not reached (95% CI; 235-NR months), a disease free survival (DFS) of 210 months (95% CI; 200-226 months) and a median time to next treatment (TTNT) of 38.5 months (95% CI, 33-46 months). The long follow up of this study verifies our preliminary results already published in 2006 and confirms the efficacy of INF-PUVA combination therapy in a real world setting, according conventional (OS and DFS) and emerging (TTNT) clinical endpoint of treatment efficacy.

Background: Clinical and pathologic criteria to distinguish drug-induced subacute lupus erythematosus (DI-SCLE) from idiopathic (I-SCLE) are controversial. Objective: The aim of the survey was a retrospective analysis of a consistent number of iatrogenous and idiopathic SCLE cases, by means of clinical and histopathologic investigation. Methods: Eleven European university dermatology units collected all diagnosed cases from January 2000 to December 2016. Board-certified dermatopathologists reviewed the histopathologic specimens. Statistical analysis included Student t test, exact test of goodness-of-fit, Fisher's exact test, and the Cochran-Mantel-Haenszel test for repeated measures. Results: Out of 232 patients, 67 (29%) belonged to the DI-SCLE group. Patients with DI-SCLE were significantly older and reported more systemic symptoms than those with I-SCLE. No statistical differences were found for presentation pattern or serology, while histopathology showed a significant association of mucin deposition (P = .000083), direct immunofluorescence positivity for granular immunoglobulin M, and C3 deposits on the basement membrane zone (P = .0041) for I-SCLE and of leukocytoclastic vasculitis (P = .0018) for DI-SCLE. Limitations: This is a retrospective study. Conclusion: An integrated clinical and immunopathologic evaluation is useful to differentiate I-SCLE from DI-SCLE. Older age at onset and more frequent systemic symptoms characterize DI-SCLE. Mucin deposition and immunofluorescence findings are found in I-SCLE, and leukocytoclastic vasculitis is found in DI-SCLE.

The neutrophilic dermatoses (NDs) comprise a group of heterogeneous disorders characterized by inflammatory skin lesions that histologically show an intense inflammatory infiltrate composed primarily by neutrophils, with no evidence of infection or vasculitis. Although there are distinct clinical differences in the classical lesions of these disorders, many patients have overlapping features. In this review, we describe the clinical aspects of the main NDs, including: Sweet Syndrome, ND of the dorsal hands, pyoderma gangrenosum, erythema elevatum diutinum, subcorneal pustular dermatosis, neutrophilic eccrine hidradenitis, rheumatoid neutrophilic dermatitis, neutrophilic panniculitis, and aseptic abscesses including their association with underlying diseases and the differential diagnoses.

BACKGROUND Switching is a "hot" topic and the main reasons for switching prior biologic agent are for a primary failure, a secondary failure or drug intolerance, patient's dissatisfaction, physician decision. The aim of the study was to assess the optimization of the switching from a biologic agent to another. METHODS Five Dermatological Units have participated to PsOMarche working group have studied thirty-eight patients affected moderate to severe chronic plaque psoriasis at time 0 (patient recruitment at time of switching from biological therapy to another), 8 weeks (T8), 16 weeks (T16). RESULTS Twenty-eight males and 10 females were included in the study. At T0, 18 of 22 patients treated with etanercept had been switched to adalimumab and 4 to ustekinumab. Among 10 patients treated with adalimumab, 5 had been switched to ustekinumab, 2 to golimumab and 3 to certolizumab pegol. One patient treated with Infliximab and 5 patients treated with ustekinumab had been switched to adalimumab. Switching had been performed for primary inefficacy in 9 patients (23.6%) and a secondary failure was evidenced in 29 patients (73.4%). PASI75 was achieved in 53% and in 89.4% of patients after 8 weeks and 16 weeks of switching to the second biologic agent respectively; similarly, PsoDISK score significantly decreased at T8 and T16. CONCLUSIONS The experience of PsOMarche group have shown that the switching to a biologic agent to another is a valuable treatment choice in patients with moderate to severe psoriasis experiencing a treatment failure with one biologic therapy, leading to a good improvement in skin disease and in patient's quality of life.

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

The recognition of a melanocytic tumor as a melanoma is not based upon the search of single, objective and easily reproducible morphological diagnostic features but, instead, it stems from a constellation of diagnostic criteria whose implementation, meaning and relative weight vary considerably from one case to another. We have herein tried to summarize the most reliable criteria. In conclusion, the pathologist should provide the surgeon with a report containing sufficient information to allow an evidence-based patient management planning, and to permit an accurate indication of prognosis to be determined.

Background Psoriasis is an inflammatory disease, that is increasingly being considered as a systemic disorder. Among associated comorbidities, metabolic syndrome plays an important role. The effects of biological therapies on metabolic syndrome is controversial. Methods Thirty-one psoriatic patients with metabolic syndrome, eligible to treatment with anti-TNFα agents, were enrolled. Metabolic parameters were measured during 4 subsequent visits, one every 40 to 60 days. PASI, BSA and DLQI assessed the severity of psoriasis and the impact on quality of life. Results We include 31 patients, 18 treated with etanercept and 13 with adalimumab. Metabolic parameters evaluated at V4 in both groups showed different trends in the blood glucose values: a slight decrease in adalimumab group, an increase in etanercept group, with an almost significant comparison test (P=0.073). Similarly, the lipid profile revealed an opposing trend, with an increase in triglycerides in adalimumab patients, and a decrease in the other group, without statistically significant differences. No statistically significant difference was recorded in HDL cholesterol. An improvement in systolic and diastolic pressure was appreciated in both groups, although not significantly. The waist circumference slightly decreased in both groups. PASI 75 score was reached in 60% of the patients. In addition, BSA and DLQI improved. Conclusions Our study showed a slight improvement of metabolic parameters, at times with a trend toward significance. Additional long-term studies and a larger number of patients are needed to more clearly define the association between psoriasis and cardiovascular disease and understand the effect of biological therapies on metabolic parameters.

Objective. To develop a preliminary power Doppler (PD) US composite score for global assessment of PsA patients. Methods. Sixteen PsA patients receiving anti-TNF-a therapy were enrolled. All patients were involved in multiple psoriatic targets, including joints, tendon, enthesis, skin and nail. The target with the highest PD signal, one for each target area, was selected to be scanned at baseline and at follow-up visit 8 weeks after. For each target, PD was graded according to semi-quantitative scoring systems. Inter- and intra-observer reliability and feasibility was also investigated. The new PD composite score for PsA was called Five Targets PD for Psoriatic Disease (5TPD). Results. Sixty targets (16 joints, 9 tendons, 11 enthesis, 16 psoriatic plaques and 8 psoriatic onychopathies) were assessed. A significant improvement of the clinical scores was found at follow-up with respect to the baseline: HAQ modified for SpA (HAQ-S) (P = 0.0001); Psoriasis Area and Severity Index (P = 0.0001) and Nail Psoriasis Severity Index (P = 0.35). The 5TPD showed a significant change between baseline and follow-up (P = 0.0001). There was no significant correlation between HAQ-S and 5TPD findings. The inter- and intra-observer k-values varied from good to excellent at baseline and follow-up. The time spent on baseline US examinations was mean (S.D.) 10.5 (2.0) min and no more than 7 min for follow-up assessment. Conclusion. The present study provides a new working hypothesis that the sonographic core set may be useful to construct a PDUS composite score for the assessment of PsA. The 5TPD formula provides a feasible and reliable approach for multi-target monitoring of psoriatic disease.

Bexarotene is a synthetic retinoid effective in early and advanced stages of mycosis fungoides (MF)/Sezary Syndrome (SS) both in monotherapy and combination schemes. We aimed to assess disease response to low-dose bexarotene and PUVA in maintenance in refractory and/or resistant patients with early and advanced stage MF/SS.We followed prospectively 21 patients (stages IB-IV): 15 with early stage MF and 6 with advanced disease. "Mini" and standard protocols were respectively applied to patients who failed PUVA or several systemic regimens. The dose of bexarotene and the administration of PUVA were titrated individually and tailored during induction and maintenance according to previous therapy, disease stage and toxicity. We evaluated overall response (OR) at the end of maintenance, safety and event-free survival (EFS).After induction phase, OR was 85.6%, higher in early MF (93.4%) than in advanced disease (66.6%). At the end of maintenance, OR was 76.2%, including 33.3% of CR. Median EFS for the whole group was 31 months. Bexarotene was well tolerated regarding the side effects, with prophylaxis and progressive drug increase in the induction phase of the protocol. Side effects were mainly of low and moderate grades.We observed a favorable rate of therapeutic effects and few, generally mild, side effects with low doses of bexarotene combined with PUVA.

Ultrasound is a rapidly evolving technique that is gaining an increasing success in the assessment of psoriatic arthritis. Most of the studies have been aimed at investigating its ability in the assessment of joints, tendons, and entheses in psoriatic arthritis patients. Less attention has been paid to demonstrate the potential of ultrasound in the evaluation of skin and nail. The aim of this pictorial essay was to show the main high-frequency grayscale and power Doppler ultrasound findings in patients with psoriatic arthritis at joint, tendon, enthesis, skin, and nail level.

STRATOS is the acronym of the "STRuctured Approach to the Treatment of psOriatic patientS". The optimization of the psoriasis's therapeutic management is one of the most important goals for dermatologists. According to Mrowietz's consensus report, the transitioning from conventional therapy to biological therapy is mainly due to the lack/loss of efficacy and/or for safety reasons. The aim of the manuscript was to describe the principal results obtained by the Dermatologic Clinic of Polytechnic University of Marche Region and the Units of Dermatology of the Marche Region applying, in our regional reality, Mrowietz's protocol for the daily management of patients with moderate-to-severe plaque.Forty-seven patients with moderate to severe chronic plaque psoriasis have been monitored during the six-months study period.Psoriatic patients with diabetes showed further concomitant comorbidities compared to non-diabetics, as hypertension and hypercholesterolemia. Moreover, based on WHO classification, overweight was diagnosed in female patients, whereas obesity was prevalent in male patients. This aspect confirms the strict link between the multifaceted aspects of psoriatic patient which is primarily related to the persistent low-grade inflammation. In our psoriatic group, 10% of monitored patients were affected by Crohn disease or ulcerative colitis.The Mrowietz's transitioning protocol is a useful, reliable and feasible tool to manage the therapeutic iter of psoriatic patients in an Italian clinical setting also at regional level.

Background: No studies are available in the literature on the distribution of different melanoma features and risk factors in the Italian geographical areas. Objective: To identify the differences in clinical-pathological features of melanoma, the distribution of risk factors and sun exposure in various Italian macro-areas. Methods: Multicentric-observational study involving 1,472 melanoma cases (713 north, 345 centre, 414 south) from 26 referral centres belonging to the Italian Multidisciplinary Group for Melanoma. Results: Melanoma patients in northern regions are younger, with thinner melanoma, multiple primaries, lower-intermediate phototype and higher counts of naevi with respect to southern patients; detection of a primary was mostly connected with a physician examination, while relatives were more involved in the south. Northern patients reported a more frequent use of sunbeds and occurrence of sunburns before melanoma despite sunscreen use and a lower sun exposure during the central hours of the day. Conclusions: The understanding of differences in risk factors distribution could represent the basis for tailored prevention programmes.

A case of diffuse scleroderma in a 56-year-old woman who received paclitaxel for the treatment of a metastatic ovarian cancer is presented. The clinical cutaneous alterations, as well as the capillaroscopic and histological findings, were indistinguishable from those encountered in definite systemic sclerosis (SSc). In contrast to SSc, Raynaud's phenomenon and cutaneous calcinosis were absent and antinuclear antibodies were negative. The temporal relationship between the onset of skin involvement and administration of the drug may indicate an effect of paclitaxel.

The pathogenesis of psoriasis is complex, with a significant role suggested for pro-inflammatory mediators. There is strong evidence of an association between psoriasis and the metabolic syndrome (MetS), a cluster of cardiovascular risk factors, which impose a substantial disease burden.This study aimed to evaluate the prevalence of MetS and to examine the implications of disease severity, type 2 diabetes mellitus, and cardiovascular disease in a large cohort of Italian psoriatic patients representative of the whole population.This was a cross-sectional study involving 13 dermatological clinics in Italy. The primary study endpoint was a comparison of the prevalence of MetS between psoriatic patients and a non-psoriatic control group; secondary endpoints included the influence of psoriasis severity on the prevalence of MetS, and the relative prevalence and risk of type 2 diabetes mellitus and cardiovascular disorders.A total of 720 patients were enrolled (n = 360 per group). The prevalence of MetS was 26.84% in the psoriatic population and 15.16% in the control population (p = 0.0001; adjusted odds ratio 1.96). MetS was associated with a greater degree of psoriasis severity, and the prevalence and risk of diabetes tended to be higher in psoriatic patients than in the control group.In the Italian population, the prevalence of MetS and associated comorbidities is elevated in patients with psoriasis compared with non-psoriatic subjects, as has been demonstrated in other countries. Our findings reinforce the importance of considering the implications of metabolic comorbidities in treating patients with psoriasis.

Fatal calciphylaxis (CPX) occurred in two 71-year-old females both requiring haemodialysis for end-stage renal disease. Case 2 also had an associated follicular lymphoplasmocytoid lymphoma. Although laboratory tests disclosed normal coagulation parameters, this woman had a striking cutaneous histological picture of vessel thrombosis and finally died of disseminated intravascular coagulation. CPX is a rare but potentially life-threatening complication of renal failure. The clinical picture is primarily characterized by livedoid purpura with subsequent cutaneous ischaemia and painful ulcerations. Cutaneous ischaemic phenomena are sustained by a progressive process of vascular calcification and thrombosis involving small to medium size arteries of the dermis and subcutis. Although not yet clearly explained, the pathogenetic role of a predisposing hypercoagulability state is currently the most frequently considered hypothesis.

Background: Metalloproteinases (MMPs) are thought to be involved in the process of destruction of basement membranes and stromal invasion by neoplastic epithelial cells. Aims: In order to investigate the role of MMPs in cutaneous oncogenesis we studied the expression of MMP-2 and MMP-9 in 34 cases of epidermal preinvasive neoplastic lesions and invasive carcinomas. We also studied their relationship with the expression of tissue inhibitors of MMPs and with proliferative activity and p53 expression in neoplastic epithelial cells. Results: MMP-9 was found to be focally expressed by neoplastic epithelial cells at the infiltrative edges in microinvasive carcinomas and in dyskeratotic foci in Bowen’s disease and widely invasive carcinomas. Gradation of Mib-1 positivity and p53 expression was found with increasing abnormality in the spectrum of malignancy. Conclusions: Our results seem to suggest the involvement of MMPs in microinvasive carcinomas, which show also low proliferative activity and p53 expression, whether other factors seem to be more important in widely invasive carcinomas.

A case of acquired reactive perforating collagenosis in a 70-year old man with a long standing digitate parapsoriasis is reported. Multiple asymptomatic cutaneous hyperpigmented papules with a central adherent keratotic plug developed simultaneously with widespread purpuric eruption following a single i.m. diclofenac injection. Histologic examination of a keratotic lesion revealed an epidermal crater with centrally degenerated collagen and elastic fibre extrusion. This case is interesting for the lack of pruritus, the transepithelial elimination of both collagen and elastic fibres and the association with parapsoriasis. The etiologic role of diclofenac is discussed. The term acquired perforating dermatosis may be more suitable for this case.

Background In the literature no specific dermoscopic criteria have been described for the diagnosis of Bowen's disease (BD). Objective/aim To assess the morphological findings of BD seen under dermoscopic observation. Methods Clinical and dermoscopic images of 14 patients affected by BD with various amount of pigmentation were obtained by means of Heine Dermaphot. Dermoscopic images were analysed by experienced observers applying the modified pattern analysis. Results The most frequently occurring dermoscopic features were found to be: multicomponent pattern (100%); atypical vascular structures (86.6%); absence of pigmented network (64.3%) or presence of pseudo-network (35.7%); irregular diffuse pigmentation or blotches of pigment (64.2%); irregularly distributed dots and globules (64.2%); focal/multifocal hypopigmentation (78.5%), scaly surface (64.2%) and haemorrages (26.6%). Conclusions Dermoscopically, BD is mainly characterized by a multicomponent global pattern associated with a prominent vascular pattern (mainly dotted vessels) and a scaly surface. Although no specific dermoscopic criteria can be given for BD, epiluminescence can be a valuable aid in the diagnosis of such a mimicker lesion.

In this article, we provide a detailed depiction of capillary changes at the nailfold and labial mucosa in a patient with hereditary benign telangiectasia. To the best of our knowledge, no such extensive capillaroscopic documentation of this entity has been made previously.

Background: Conventional antipsoriatic therapies are often administered until remission, with treatment resumed in the case of relapse, in order to reduce the likelihood of cumulative, dose-dependent toxicities. Biological agents have been safely used in continuous therapy. Objective: To assess the use of etanercept for psoriasis in clinical practice in Italy. Methods: This was an observational study carried out in 13 dermatological centres across Italy in patients with plaque psoriasis (with a Psoriasis Area and Severity Index [PASI] score ≥10) treated with etanercept. The study comprised a treatment and subsequent discontinuation period. Patients were eligible if they had plaque psoriasis and had begun treatment with etanercept between 1 September 2007 and 1 April 2008. Patients were evaluable for the duration of discontinuation analysis if they achieved a PASI reduction ≥50% (PASI50) and a PASI score

The main aim of the present study was to determine the prevalence of subclinical entheseal involvement at lower limbs by ultrasound (US) in patients with psoriasis. The secondary aim was to determine the interobserver reliability of the Glasgow Ultrasound Enthesitis Scoring System (GUESS) and power Doppler (PD) technique in the assessment of enthesopathy.The study was conducted on 45 patients with psoriasis and 45 healthy sex- and age-matched controls. All patients with no clinical evidence of arthritis or enthesitis underwent an US examination. All US findings were identified according to GUESS. The interobserver reliability was calculated in 15 patients with psoriasis.A total of 450 entheses in 45 patients with psoriasis were evaluated by US. In 148 of 450 (32.9%) entheses, grayscale US found signs indicative of enthesopathy. In 4/450 (0.9%) entheses PD signal was detected. In the healthy population, US found signs of enthesopathy in 38 of 450 (8.4%) entheses and no PD signal was detected. The GUESS score was significantly higher in patients with psoriasis than in healthy controls (P0.0001). Both concordance correlation coefficient and unweighted κ values for US findings showed an excellent agreement (0.906 and 0.890, respectively).Our results indicate that both grayscale US and PD findings indicative of enthesopathy were more frequent in patients with psoriasis. The US ability to detect signs of subclinical enthesopathy should be the object of longitudinal investigations to define its value in predicting the clinical onset of psoriatic arthritis.

Background Excision of large tumours, particularly of the limbs, can be challenging because of problems related to wound repair. This is especially true of the lower legs, where skin is often tight and difficult to mobilize. Closure by flap, which would represent the first choice for defects usually between 12–15 mm to 38–40 mm diameter, is at risk of developing complications, such as end-flap necrosis or dehiscence due to skin tension. For larger defects, usually more than 40 to 45 mm diameter, grafting still remains the only realistic option in the majority of cases, with all the various problems associated with this procedure, such as lengthy healing times and the risk of developing leg ulcers, above all in elderly patients with impaired blood circulation. Second intention healing implies extraordinarily long healing times with often unacceptable delays in normal ambulation and activity. Objective To find an alternative to the usual repair techniques and to try to reduce the risk of complications. Conclusions We developed a relatively simple but effective technique for the closure of large wounds resulting from the excision of tumours. Our technique consists of two longitudinal, parallel, transposition flaps obtained from two opposite sides of the wound, with major axes orientated in the cephalic-caudal direction. The two flaps are then rotated around two fulcra placed at two extremes of the wound by approximately 90°. This relatively simple technique has never caused any of the ordinarily associated problems in terms of necrosis or ulcer development. In addition, dehiscence of sutures never occurred, given the fact that suture tension is minimal. Quick healing has resulted in the majority of cases, avoiding all the problems associated with grafting or other traditional flap techniques.

Introduction : Acute generalized exanthematous pustulosis (AGEP) is a clinical reaction pattern that is principally drug induced and is characterized by acute, extensive formation of nonfollicular sterile pustules on an erythematous and edematous substrate. Hydroxychloroquine (HHCQ), an antimalarial drug widely used to treat rheumatic and dermatologic diseases, has been described as an uncommon cause of AGEP. Objectives : This article reports 3 cases of HCQ-induced AGEP and reviews similar cases in the published literature. Case summaries : The first case involved a 36-year-old woman with a 10-year history of rheumatoid arthritis and Sjogren's syndrome who had begun a 25-day course of HCQ 100 mg BID due to lack of response to a corticosteroid, with a skin reaction developing 21 days into the new treatment. In the second case, a 70-year-old man with poorly controlled rheumatoid arthritis had begun a course of oral HCQ 100 mg BID 20 days before development of AGEP. The final case involved a 79-year-old woman with polymyalgia rheumatica who had been receiving HCQ 100 mg BID as a steroid-sparing agent for 22 days, with rash developing 20 days after the initiation of HCQ. Sixteen cases of HCQ-induced AGEP were identified in the literature, including some that may have been reported under a different name but were consistent with a clinical diagnosis of AGEP.The US Food and Drug Administration has mandated a change to the labeling for HCQ to include AGEP among potential adverse dermatologic reactions to the drug. Conclusions: This article reports 3 cases of AGEP related to administration of HCQ. HCQ-induced AGEP is a rare but severe, extensive, and acute reaction. No specific therapy is available, and correct diagnosis generally leads to spontaneous resolution once the causative drug has been withdrawn.

Pegylated liposomal doxorubicin (Peg-Doxo) is a promising drug for advanced/recalcitrant primary cutaneous T-cell lymphomas (CTCLs). This prospective phase II trial enrolled 19 patients. We observed overall and complete response rates of 84.2% and 42.1% (with no significant differences between stage I-IIA and IIB-IV patients), and 11% grade III/IV toxicity. After a maximum 46 month-follow-up, median overall (OS), event-free (EFS) and progression-free (PFS) survival were 34, 18 and 19 months. OS, EFS and PFS rates at 46 months were 44%, 30% and 37% respectively. Peg-Doxo seems to be an active and safe principle that should be used in plurirelapsed, early stage-MF and in combination with other chemotherapeutic agents in advanced and aggressive CTCLs.

Objectives Combined high-dose Interferon-alpha and psoralen plus ultraviolet A irradiation (PUVA) have been reported to be effective in the treatment of early mycosis fungoides (MF); however, our study is the first controlled prospective study in the literature exploring the activity and tolerability of the combination with low dosages and evaluating further clinical outcome of early-MF patients. Methods We carried out a multicentric prospective Phase II clinical study on 89 patients with early-stage IA to IIA MF treated for 14 months with low-dose IFN-alpha2b (6-18 MU/wk) and PUVA. Treatment success was analysed in terms of freedom from treatment failure. Results and conclusions Complete remission (CR) was achieved in 84% and an overall response rate in 98% of cases: six-month CR was associated with a non-confluent skin infiltrate at histology (P = 0.044) and 14-month CR with high epidermal CD1a+ dendritic-cell density (P = 0.030). The combination protocol was successfully tolerated and the most common reason of 'failure' was related to relapse and not to toxicity. Sustained remissions were achieved in 20% of patients. High CD8+ lymphoid T-cell density was associated with a lower relapse rate (P = 0.002). We think that our combination therapy can be considered an alternative approach compared with other modalities. Good immunological host surveillance in the skin lesions seems to be an optimal basis for the therapeutic success.

Background Dermoscopy provides additional criteria for the diagnosis of skin lesions. Objective To investigate the dermoscopic aspect of clear cell acanthoma (CCA). Methods Six consecutive cases of CCAs were observed under conventional dermoscopy (Case 1–4) or videodermoscopy (Case 5–6). Results Common dermoscopic findings were: (i) squamous surface with translucid collarette; (ii) dilated capillary loops, mainly perpendicularly orientated to the skin surface, as dotted, pinpoint-like structures, regularly distributed in a reticular array over the surface. Conclusions The vascular psoriasis-like dermoscopic findings seem to be a clue for CCA and provide evidence of an inflammatory process for CCA formation.

Background: Videocapillaroscopy (VCP) is a method to study the morphology and dynamics of microcirculation, but information about capillaroscopic features of the psoriatic plaque is limited. Objective: To investigate the distribution, morphology and density of capillaries in lesional and perilesional skin of the psoriatic plaque. Methods: VCP of a well-delimited plaque of the trunk, arms or legs in 15 consecutive patients with untreated, chronic plaque psoriasis was performed. Results: In the lesional skin, capillaries were tortuous and dilated, homogeneously appearing as ‘bushy’. In the perilesional skin, capillary loops seemed to be on a parallel course with respect to the skin surface, with their apex directed towards the marginal zone. The number of capillary loops per area unit was statistically increased in perilesional compared to lesional skin. Conclusion: According to the morphology, distribution and density of capillary loops, two different angiogenetic patterns were found in lesional and perilesional skin.

Objective: To study the validity and feasibility of transferring images of cutaneous biopsy specimens via e-mail to remote physicians active in dermatopathology for teleconsultation. Design: Twenty skin specimens previously diagnosed at the Department of Dermatology, University of Graz, Austria, were subsequently sent for teleconsultation using the store-and-forward method. For each case, 3 or 4 images at different magnifications were sent by e-mail to 16 colleagues (11 dermatopathologists and 5 pathologists) in 15 centers in 6 different countries. Six weeks later each observer received the hematoxylin-eosin-stained specimens to render a conventional diagnosis. Setting: Dermatopathology and pathology units within institutional and private settings. Material: Twenty small skin biopsy specimens of cutaneous diseases were selected randomly from a study set of 80. Main Outcome Measure: Concordance between telepathologic diagnoses and conventional histopathologic diagnoses of 20 skin specimens. Results: On average, 78% of the telediagnoses were correct (range, 60%-95%), whereas 8510 of the conventional diagnoses were correct (range, 60%-95%). A perfect diagnostic concordance was obtained in 7 (35%) of 20 cases, and a significant difference was identified in only 1 case. Conclusions: Results suggest that telepathology performed by physicians active in dermatopathology may serve as a reliable technique for the diagnosis of cutaneous diseases when experts in dermatopathology are not available locally. Furthermore, teledermatopathology is attractive because it provides an opportunity to obtain timely consultation on difficult cases. RI Soyer, H. Peter/E-6000-2010

Adult-onset Still's disease (AOSD) is a rare disorder of unknown aetiology, characterised by high spiking fever, an evanescent, erythematous, maculopapular rash, arthralgia or arthritis, lymphadenopathy, hepatosplenomegaly, sore throat and serositis. It is associated with marked leukocytosis, high erythrocyte sedimentation rate, increased level of serum ferritin and negative rheumatoid factor and antinuclear antibody tests. Here we report a patient in whom an urticaria-like rash was an uncommon presenting clinical feature of AOSD. To our knowledge, this association has only been reported once before.

Accelerated nodulosis (AN) is a potential complication of methotrexate (MTX) therapy for rheumatoid arthritis (RA). We report on a 62-year old man affected by seropositive RA who developed AN after five months of MTX treatment. MTX-dose reduction was followed by rapid regression of the skin nodules. The Authors describe the typical features of AN and discuss on the pathogenetic mechanisms.

Background There is an increasing evidence supporting power Doppler (PD) ultrasound as a sensitive imaging technique for the assessment of disease activity and therapy monitoring in patients with chronic arthritis, including psoriatic arthritis (PsA). The recent availability of probes with Doppler frequency higher than 10 MHz allows the detection of even minimal blood flow changes of superficial targets such as nail and skin (1). Objectives To investigate the role of PD ultrasound for the assessment of blood flow changes induced by anti-TNFα therapy at five target areas (joint, tendon, enthesis, skin and nail) in patients with PsA. Methods Sixteenpatients with diagnosis of PsA (receiving different anti-TNFα: 9 adalimumab, 4 etanercept and 3 infliximab),and clinical involvement of multiple targets (joint, tendon, enthesis, skin, nail) were enrolled. Before the PD ultrasound assessment all patients underwent a clinicalexamination aimed to detect tenderness and/or swellingat joints, tendons, and entheses level. Moreover, HAQ modified for spondyloarthritis (-S), PASI and NAPSI were assessed. At baseline, all clinically involved targets were scannedand those showing the highest expression of PD signal, one for each target area, were selected to be scanned at follow-up visit 8 weeks after. For each target a semi-quantitative PD scoring (0 to 3) was used. Clinical and PD assessments were performed on the same day both at baseline and at follow-up visit. Results A total of 60 targets (16 joints, 9 tendons, 11 enthesis, 16 psoriatic plaques and 8 psoriatic nails) were assessed. A significant improvement of the clinical scores was found at follow-up with respect to the baseline: HAQ-S [mean ± SD: 0.88±0.20 vs 0.47±0.12 respectively (p=0.0001)]; PASI [mean ± SD: 17.5±5.3 vs 8.0±2.7 respectively (p=0.0001)] and NAPSI [mean ± SD: 2.2±2.6 vs 0.8±1.0 respectively (p=0.35)]. PD ultrasound findings at baseline and follow-up were: joint [median; range: 2.5; 1-3 vs 1; 0-2, respectively (p=0.0001)], tendon [median; range: 2; 0-3 vs 0; 0-1, respectively (p=0.04)]; enthesis [median; range: 1.5; 0-2 vs 0 0-2, respectively (p=0.04)], skin [median; range: 3; 2-3 vs 0.5; 0-2, respectively (p=0.0001)] and nail [median: range: 0; 0-1 vs 0; 0-1, respectively (p=0.3657)]. There was no significant correlation between HAQ-S and PD ultrasound findings (p=0.51)at baseline and at follow-up (p=0.93), respectively.The mean time (± SD) spent on baseline ultrasound examinations was: 10.5 (± 2.0) minutes and no more than 7 (± 1.5) minutes for follow-up assessment. Conclusions PD ultrasound provides a useful and feasible method for short-term multi-target monitoring of anti-TNFα therapy effect in patients with PsA. Ongoing investigation including a wider cohort of patients, more centres and testing the reproducibility will provide further information regarding the advantages and limitations of this multi-target approach in patients with PsA. References Gutierrez M, De Angelis R, Bernardini ML, et al. Clinical, power Doppler sonography and histological assessment of the psoriatic plaque: short-term monitoring in patients treated with etanercept. Br J Dermatol 2011;164:33-37. Disclosure of Interest None Declared