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Background: The ratio of benign moles excised for each malignant melanoma diagnosed (number-needed-to-excise (NNE)) is a metric used to express the efficiency of diagnostic accuracy of melanoma. The literature suggests a progressive effort to reduce the NNE, thus raising concerns about missing early melanoma because the NNE does not capture the most significant outcome for melanoma prognosis, which is linked to the Breslow thickness. A lower NNE could reduce health costs related to melanoma diagnosis only if doing so does not increase the proportion of thicker melanomas. Objectives: The diagnostic performance by two tertiary referral centres using the NNE and proportion of thick (Breslow thickness > 1 mm) versus thin (Breslow thickness ≤ 1 mm) excised melanoma (thick/thin ratio: TTR) was compared to determine if a lower NNE is associated with a greater proportion of thicker melanoma. Combining TTR with NNE allows a better estimate of the effectiveness in melanoma diagnosis, assessing both the overall cost for a given pool of excised melanomas and costs due to unnecessary nevi excision at a particular dermatology centre. Methods: Demographic data and Breslow thickness of excised melanoma were extracted from patient histologic records at two referral centres for melanoma (Parma Dermatology Unit and Ravenna and Meldola Skin Cancer Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori. IRCCS (IRST)) on all skin tumours excised between 2002 and 2011 and diagnosed as melanoma or melanocytic nevus. NNE and TTR were calculated and compared among the considered variables. Logistic regression was used to assess the contribution of each variable in predicting a higher TTR. Results: Data from 16,738 excised lesions were analysed. The IRST Unit reported a mean NNE of 4.6, whereas the Parma Unit excised 10.6 nevi for each melanoma. No statistically significant differences existed in the mean (IRST Unit, 0.56 ± 0.89 mm; Parma Unit, 1.07 ± 2.2 mm) and median (range) Breslow thickness (IRST Unit, 0.4 (9) mm; Parma Unit 0.4 (30) mm). The TTR between centres was significantly different (Parma Unit, 24%; IRST Unit, 12%; p < 0.001). Based on logistic regression, the diagnosing centre was the most powerful factor in determining a thickness of >1 mm among diagnosed melanomas (OR = 1.8; 95% CI, 1.2–2.7; p < 0.01), with all other factors being equal. The NNE decreased at both centres from younger-to-older patients, whereas the TTR increased simultaneously; however, the increase in TTR was non-significantly related to NNE reduction after adjusting for confounders (age, gender, and localization). Conclusions: A better diagnostic performance is capable of reducing the NNE and TTR, i.e., unnecessary excisions of melanocytic nevi can be reduced without increasing the risk of overlooking melanomas. The TTR, in addition to the NNE, allows stakeholders to better estimate the effectiveness in melanoma diagnosis because both overall costs for a given pool of excised melanomas and costs due for unnecessary nevi excision at a particular dermatology centre can be compared.

Background Notalgia paresthetica (NP) is a disorder characterized by pruritus localized to the patient's back. Little is known about predictors of severity, duration, side, and localization. Objective To identify factors associated with perceived severity, duration, side, and localization of NP. Methods In a cross-sectional study, disease severity, duration, side, and localization were compared among the considered variables. Multivariate analysis was used to assess each variable contribution in predicting disease severity and its duration. Results Sixty-five patients were recruited. Disease involved more female than male patients (Female/Male: 1.6) and after adjusting for all potential confounders, it was perceived as more severe in females (OR = 7.3, 95% CI = 2–26.3, P < 0.01). NP was reported more frequently on the right side among patients sleeping on the left side and conversely (P < 0.05). A higher disease duration was significantly linked to a higher body mass index (OR = 4.8, 95% CI = 1.3–17.1, P < 0.05). Conclusion Our study linked female gender to worse disease severity, a higher body mass index to longer disease duration, and prevailing sleep position to NP side expression. The sleeping position should be considered a possible target for treating the disease.

Inhibitoren des Tumornekrosefaktor alpha (TNF-α-Hemmer) stellen eine wirksame Therapieoption zur Behandlung schwerer Psoriasis bei Hepatitis-C-Virus (HCV)-positiven Patienten dar. In der Literatur wird vorwiegend über die Kurzzeitbehandlung von Patienten mit chronischer Hepatitis von minimaler bis moderater Aktivität berichtet; bei akzeptablem Sicherheitsprofil. Wir berichten über die ersten beiden Fälle der Entstehung eines hepatozellulärem Karzinoms (HCC) bei HCV-positiven Psoriasis-Patienten mit fortgeschrittener Lebererkrankung während einer Langzeitbehandlung mit Etanercept. Beim ersten Patienten war die HCV-Infektion seit 41 Jahren bekannt; er entwickelte nach 21-monatiger Behandlung mit Etanercept (50 mg/Woche) ein HCC. Der zweite Patient war seit 20 Jahren HCV-positiv, wurde 58 Monate lang mit demselben Therapieschema behandelt und schließlich HCC-diagnostiziert, und obwohl keine Anzeichen einer Leberfunktionsstörung vorlagen. Beide Patienten hatten sich mit einer Zirrhose vorgestellt, die 9 bzw. 5 Jahre zuvor diagnostiziert worden war. Es bleibt zu klären, ob zwischen der Psoriasis-Behandlung mit einem Tnf-α-Hemmer und der Entwicklung des HCC bei den HCV-infizierten Patienten ein Zusammenhang besteht. Weitere Langzeit-Follow-up-Studien und Register von HCV-Patienten mit leichter/moderater Aktivität könnten zur Klärung dieser Frage beitragen.

Industrial workers are exposed to occupational pollutants, which may cause diseases such as cancer, but links to melanoma are not established. The identification of industry-related risk factors for melanoma incidence and mortality might be of importance for workers, health providers, and insurance companies. To assess melanoma incidence and mortality among oil/petroleum, chemical, and electrical industry workers. All studies reporting standardized mortality ratios (SMR) and/or standardized incidence ratios (SIR) of melanoma in workers employed in oil/petroleum, chemical, and electrical industries were included. Random-effect meta-analyses were carried out to summarize SIR and SMR for melanoma among oil/petroleum, chemical, and electrical industry workers. Heterogeneity was assessed using χ and I statistics. Possible source bias and quality were assessed using the Strengthening the Reporting of Observational Studies in Epidemiology checklist and a modified version of the Newcastle-Ottawa scale. Of 1878 citations retrieved, we meta-analyzed 21, 6, and 9 studies for the oil/petroleum, electrical, and chemical industry, respectively. Oil/petroleum industry: summary standardized incidence ratio (SSIR) = 1.23 [95% confidence interval (CI): 1.11-1.36, I = 45%]; summary standardized mortality ratio (SSMR) = 1.02 (95% CI: 0.81-1.28, I = 48%); subgroups: SSIR = 1.16 (95% CI: 1.01-1.32, I = 15%), SSMR = 1.19 (95% CI: 1.00-1.42, I = 20%). Electrical industry: SSIR = 1.00 (95% CI: 0.93-1.11, I = 72%); SSMR = 1.16 (95% CI: 0.74-1.81, I = 11%). Chemical industry: SSIR = 2.08 (95% CI: 0.47-9.24, I = 73%); SSMR = 2.01 (95% CI: 1.09-3.72, I = 33%). Our meta-analysis suggests a slightly increased risk of developing melanoma among oil/petroleum industry workers and an increased melanoma mortality among oil/petroleum and chemical industry workers. No increased risks were found among electrical industry workers.

Background: Cutaneous melanoma is one of the most frequent malignancies of the skin in Caucasian populations. Patients who develop cutaneous melanoma are at increased risk of developing a second primary melanoma. The estimated incidence of multiple primary melanoma (MPM) ranges from 1.2% to 8.2% of cases, with a high preponderance of melanomas occurring metachronously. Objectives: The aim of this study was to describe dermoscopic, microscopic, clinical, and molecular correlations between first and subsequent melanomas in patients with metachronous MPMs. Materials & methods: Twenty-four paired melanomas from 12 MPM patients were evaluated for architectural characteristics based on dermoscopy and confocal microscopy, as well as for mutations in BRAF and NRAS genes by Sanger-based sequencing analysis. Specific scores used for classifying features of dermoscopy (global pattern; 7-point check list; ABCD Stolz score) and confocal microscopy (Segura and Pellacani) were compared with genetic and histological data. Results: Consistency in dermoscopic patterns between the primary and subsequent cutaneous melanomas were observed in about two thirds of cases, whereas concordant features based on confocal microscopy were found in only about two fifths of cases. The majority of patients (7/12; 58%) presented consistent BRAF/NRAS mutation patterns between first and subsequent primary melanomas. A significant association between BRAF mutations and Pellacani score was evident. Conclusions: Similarities between the index melanoma and subsequent cutaneous melanomas were observed with regards to dermoscopic features and, to a much less extent, confocal microscopy findings. Our data further indicate that the Pellacani score may be used to predict BRAF mutations.

Summary Background Photodynamic therapy with 5-methyl-aminolevulinate and photodynamic therapy with trichloroacetic acid 50% are the two techniques utilized in the management of actinic keratosis. This study was planned to compare the efficacy, adverse effects, recurrence and cosmetic outcome of these option therapies in patients with multiple actinic keratosis of the scalp. Methods Thirteen patients with multiple actinic keratosis were treated with one of the two treatments on half of the scalp at baseline, while the other treatment was performed on the other half 15 days apart, randomly. Efficacy, adverse effects, cosmetic outcome and recurrence were recorded at follow-up visit at 1, 3, 6 and 12 months. Results Photodynamic therapy with 5 methyl-aminolevulinate was more effective than trichloroacetic acid although less tolerated by patients as it was more painful. Early adverse effects were almost the same even if trichloroacetic acid leads also to crust formation and to a worse cosmetic outcome characterized by hypopigmentation. Recurrence was lower in the area treated with photodynamic therapy. Conclusion Trichloroacetic acid 50% is less effective than photodynamic therapy with 5 methyl-aminolevulinate in the treatment of multiple actinic keratosis of the scalp although better tolerated by patients. As this technique is less painful and less expensive than photodynamic therapy, we hypothesize and suggest that more sequential treatments could lead to better results.

Summary Background Studies conducted using different tools have invariably observed that physical and mental components of health status are seriously compromised in patients with pemphigus. An improvement in quality of life (QoL) has been commonly observed over the treatment period. Objectives The aim of the study is to verify whether the patients' wellbeing is affected by pemphigus also in absence of cutaneous and mucosal lesions. Materials and methods The clinical records of 203 patients were analysed. A total of 47 patients were without bullae/erosions and reported a score = 0 for both the Patient Global Assessment and the Ikeda index. In order to assess the QoL we used the Skindex-17 and the 12-item General Health Questionnaire (GHQ-12). Results Patients without bullae/erosions had a better QoL when compared with patients with active lesions. This difference, with a reduction of approximately 30% of the Skindex-17 scores in the patients without lesions, was statistically significant, for both the symptoms and the psychosocial scales. The proportion of patients at risk of anxiety/depression (GHQ-positive cases) was 44% lower in patients without lesions compared with patients with lesions. In a multiple linear regression model the presence of bullae/erosions negatively influences QoL with an average increase of Skindex-17 symptoms and psychosocial scale scores of 11·7 and 10·6 points, respectively. Female patients had a statistically significantly worse QoL than males on the symptoms but not on the psychosocial Skindex-17 scales. Conclusions While patients without lesions reported a better QoL than patients with bullae/erosions, their Skindex-17 scores remained elevated. Dermatologists should be aware that a clearing of the skin manifestations does not mean ‘perfect health’ for the patient.

Erosive pustular dermatosis of the scalp (EPDS) is a rare disorder of uncertain aetiology that mainly occurs on the sun-damaged scalps of elderly patients after trauma.Topical corticosteroids (TCS) have been widely used in the treatment of EPDS; anecdotal reports have described successful results with topical tacrolimus [1], calcipotriol [2] and dapsone [3, 4]. Nevertheless, due to the rarity of the disease, a comparison of topical treatments in terms of effectiveness and rate of clearing is lacking. [...]

Glycaemic index (GI) and glycaemic load (GL) are indicators of dietary carbohydrate quantity and quality and have been associated with increased risk of certain cancers and type 2 diabetes. Insulin resistance has been associated with increased melanoma risk. However, GI and GL have not been investigated for melanoma. We present the first study to examine the possible association of GI and GL with melanoma risk. We carried out a population-based, case–control study involving 380 incident cases of cutaneous melanoma and 719 age- and sex-matched controls in a northern Italian region. Dietary GI and GL were computed for each subject using data from a self-administered, semi-quantitative food frequency questionnaire. We computed the odds ratio (OR) for melanoma according to quintiles of distribution of GL and GL among controls. A direct association between melanoma risk and GL emerged in females (OR 2·38; 95 % CI 1·25, 4·52 for the highest v. the lowest quintile of GL score, Pfor trend 0·070) but not in males. The association in females persisted in the multivariable analysis after adjusting for several potential confounders. There was no evidence of an association between GI and melanoma risk. GL might be associated with melanoma risk in females.

The utilization of health-related quality of life (HRQoL) questionnaires in routine clinical practice is hampered by several factors, including their length and thus the time needed to complete and score them. For this reason, growing efforts are devoted both to create short questionnaires and to shorten existing ones. The Skindex-17 is a dermatological HRQoL instrument that was derived from the Skindex-29 using Rasch analysis. It consists of 17 items instead of 29, and answers are given on a three-point scale instead of a five-point scale. The aim of this study was to compare information obtained by the Skindex-29 and the Skindex-17 in a large sample of dermatological outpatients. We compared the Skindex-29 with the Skindex-17 scores in 2,487 patients with several dermatological conditions, using intraclass correlation coefficients. The overall correlation was 0.957 for the symptoms scale and 0.940 for the psychosocial scale. The values were very similar for all diseases. The concordance between the levels of severity of the Skindex subscales in the two instruments was also very high. In conclusion, the Skindex-17 provided very similar information compared with the Skindex-29, with the advantage of being shorter and including some important psychometric properties.

Summary Background. Pemphigus has a strong effect on patients’ quality of life (QOL). Aim. To analyze QOL and psychological well-being within patient groups, subdivided according to their different adjuvant treatments. Methods. All adult patients with pemphigus enrolled in the study were assessed using the Short Form (SF)-36, the Skindex-29, and the General Health Questionnaire (GHQ)-12 for health status, effect of dermatology-specific aspects, and the presence of psychological comorbidity, respectively. The study population was subdivided into the following treatment groups: (i) those who were untreated or were treated only with corticosteroids (CS) at a dose of ≤ 5 mg/day (no adjuvant treatment, NAT); and patients receiving or not receiving CS ≤ 5 mg/day who also received either (ii) azathioprine (AZ), (iii) cyclophosphamide (CY), (iv) mycophenolate mofetil (MM) or (v) rituximab (RTX). Results. In total, 113 patients were recruited. There were no significant differences between the treatment subgroups in either the SF-36 or Skindex-29 results. However, for the GHQ, there were large differences in QOL scores between patients scoring > 4 points (GHQ+) and those scoring

The relationship between quality of life (QoL) and skin lesion improvement due to psoriasis treatment has been recently underlined. Our objective was to study the self-reported disease severity reduction and QoL during spa treatments and identify predictors of psoriasis improvement. Patients were assessed before and after spa treatment with a disease-specific QoL questionnaire (Skindex-17) and self-administered psoriasis area and severity index (SAPASI). Their correlations were tested. Factors predicting a reduction in Skindex-17 or in SAPASI score were evaluated through regression analysis. Significant mean overall reductions in SAPASI (27%) and Skindex-17 scores (psychosocial: 6%; symptoms: 2%) were achieved. However, 51% of patients reporting SAPASI improvement also reported a worsened QoL. Pearson's correlation between the SAPASI and Skindex-17 scores was poor (r=0.26 for SAPASI-symptoms and r=0.40 for SAPASI-psychosocial). Logistic regression analysis identified the age of psoriasis onset before 30 years (OR=3.81, 95% CI 1.22-11.95, p=0.02) and a basal Skindex-17 symptoms value greater than 5 (OR=3.37, 95% CI 1.12-10.08, p=0.03) as predictive of both SAPASI and Skindex-17 score reductions. Age-of-onset-based stratification identifies the subset most likely to respond to spa treatment. Combining the Skindex-17 with SAPASI provides a more comprehensive patient-centered assessment. We recommend this assessment for psoriasis patients undergoing spa treatment.

A 62-year-old Caucasian woman complained of a painful nodular lesion on her right heel that restricted her walking. She had noticed the onset of the itching after approximately 3 weeks of travel in Brazil. She was initially treated by her general practitioner with topical salicylic acid, suspecting a plantar wart. After a week of increased itching and unbearable pain, the patient was referred to our dermatological service. This article is protected by copyright. All rights reserved.

Summary Background In dermatological research and clinical practice it is important to evaluate the burden of the disease. Objective To assess whether the 12-item Short Form of the Medical Outcomes Study (SF-12) could yield a valid description of the health status of a large number of dermatological outpatients. Methods The SF-12 and the 12-item General Health Questionnaire (GHQ-12) were utilized. Questionnaires were self-completed by the outpatients in the waiting rooms. At the end of the visit the dermatologists recorded the diagnosis and the evaluation of the clinical severity. Results Data were complete for 2499 patients. We observed a reduction in the Physical Component Summary score (PCS-12) with increasing age, while the Mental Component Summary score (MCS-12) was stable. PCS-12 and MCS-12 scores were worse in women. Twenty-three per cent of patients were identified as GHQ-12 positive. GHQ-12-positive patients (‘cases’) had lower PCS-12 and MCS-12 scores compared with GHQ-12-negative patients (mean ± SD, PCS-12: 47·9 ± 10·8 vs. 52·2 ± 6·6; MCS-12: 35·2 ± 10·2 vs. 50·9 ± 78·3, respectively). High correlations between the MCS-12 score and the GHQ-12 were documented overall (−0·690, P

Background The assessment of a patient’s disease severity is an essential component in the formulation of treatment strategies. Objectives To compare disease severity assessment by patients and by physicians, and to describe the possible discrepancies between them. Methods For each patient, we obtained the Physician Global Assessment (PhGA) and the Patient Global Assessment (PtGA). Data were completed for 2.578 patients. Sixty-one physicians participated in the study. We calculated the agreement between PtGA and PhGA scores using the weighted kappa statistics; a multinomial logistic regression was performed to assess the risk of disagreement considering both patient and physician variables. Results Differences in the percentages of severity level, identified by patients and by physicians, were always statistically significant (P < 0.05). Overall, the weighted Cohen’s kappa was in the range of 0.09–0.34, depending on the diseases. Gender differences between patients and physicians did not influence the agreement. In the multinomial model female patients (OR = 1.38; 95% CI, 1.07–1.77), patients with higher educational levels (OR = 2.71; 95% CI, 2.12–3.46), and patients with impaired quality of life (OR = 1.56; 95% CI 1.23–1.97) had a higher risk to be underestimated for their disease severity by physicians, independently by physician gender and experience. Conclusions Combining the subjective report with the objective severity assessment of the lesions, dermatologists may reach a better determination of how severity of disease is perceived by their patients and how they feel about the effectiveness of treatment. PtGA and PhGA might be considered in routine clinical assessments and not only for research activities.

There is increasing interest in the management of chronic diseases through patient self-efficacy procedures. Very few studies are available assessing the efficacy of empowerment-based educational interventions for psoriasis patients. To evaluate an educational programme for increasing empowerment, in a spa setting (Comano, Italy). An educational intervention with pre-post test for empowerment evaluation was employed with patients assigned either to a control (balneotherapy) or an experimental group (balneotherapy plus empowerment-based educational interventions) (quasi-experimental). The outcome measures were self-reported scores through validated tools for empowerment, severity of disease and quality of life, assessed before and after a single two-hour empowerment-based educational intervention. A total of 136 patients completed the study (control n. 49; experimental n. 87). The experimental group reported higher levels of empowerment with improved knowledge about the disease as compared to the control group. After the balneotherapy, both groups reported a positive effect on quality of life. Patients' characteristics linked to intervention effectiveness were identified. A single empowerment-based educational intervention has the potential to increase psoriasis patients' empowerment by means of increased knowledge. It is advisable to promote it as a standardized, low-cost practice for motivated patients.

While empowerment is an outcome pursued by advocacy groups and health care providers, no data are yet available about empowerment in patients with psoriasis in the literature. Our aim was to develop a tool for measuring levels of empowerment in psoriatic patients, and to assess its validity and reliability. A cross-sectional study among outpatients with psoriasis was carried out. Principal component analysis was performed to validate the questionnaire and to measure any associations with demographic and clinical data. The 12-item questionnaire (Psoriasis Empowerment Enquiry in the Routine practice, or PEER) showed acceptable consistency and reliability, and three distinct and interpretable factors have been identified: Knowledge, Experience, Skills. Patients older than 44 years and patients with psoriasis for more than one year showed statistically significantly higher levels of empowerment. Neither educational level nor the number of consultations influenced the global empowerment score (GES). A link between GES and prescribed therapy was found, suggesting that patients receiving systemic drugs have better knowledge, more insight and superior skills to manage their psoriasis. We conclude that PEER is an appropriate tool to assess empowerment among patients with psoriasis and may be used to evaluate the efficacy of educational interventions. Further studies are needed to assess its convergent validity and to improve its reliability.

Epidermolysis bullosa is a rare, inherited group of disorders characterized by blistering of the skin following friction or mechanical trauma. The aim of this study was to assess the family burden of epidermolysis bullosa in children aged 0-7 years. A postal survey was conducted. The perceived severity of the disease was evaluated by the caregivers, using the Patient Global Assessment 5-point scale. The caregiver received the Family Strain Questionnaire and the 12-item General Health Questionnaire to assess the probable presence of depression/anxiety. A single-item analysis was also performed for questions related to the burden of disease. Forty-two families were invited to participate. Data from 28 young patients and their caregivers were analysed (response rate 66.7%). The family burden increased with increasing caregiver's perceived disease severity, with increasing patient's body surface involved, and if parents had depression/anxiety, reaching statistical significance in several Family Strain Questionnaire scales. The family burden due to epidermolysis bullosa is very high independent of disease type/subtype.

We report 4 cases of melanoma localized on the sole with some striking histological similarities to the compound nevi. One case showed inguinal lymph node metastases after a diagnosis of compound nevus made 5 years earlier. The other 3 cases were sent to us in consultation as suspected plantar lesions; a diagnosis of melanoma mimicking compound nevus was proposed: the sentinel lymph node technique was accordingly performed and resulted positive. These 4 index cases were compared with 26 cases of ordinary plantar melanoma and with 117 cases of benign compound plantar nevi. Histologically, the similarity of areas of these 4 cases of plantar melanoma to compound plantar nevi (namely Miescher, Clark, or acral lentiginous nevus) is so close that it may prove misleading in the diagnostic pathway. In such cases, an erroneous diagnosis of benign lesion may be made. The correct diagnosis of melanoma can, however, be done by combining the clinical and pathological findings. In fact, this deceptive form of melanoma mimicking a compound nevus is characterized by patients' advanced age (>45 years), large lateral diameters (>10 mm), and significant depth of the lesion (>1 mm). In our 4 cases, such features were combined with one or more of the following histological clues: lentiginous (ie, continuous) proliferation of enlarged and hyperchromatic melanocytes aligned in single units at the dermoepidermal junction; extensive eccrine duct melanocytic infiltration; dermal melanocytes with slight nuclear enlargement, nuclear membrane thickening and folding, and conspicuous central nucleoli; and cellular pleomorphism of the epidermal and dermal component. Moreover, mitotic figures were an inconstant but decisive indication of malignancy. In conclusion, a small group of plantar melanoma has striking similarities with compound nevi. Only the correlation of clinical data (old age of the patient and large size of the lesion) with subtle architectural and cytological alterations (depth of the lesion, lentiginous melanocytic epidermal and eccrine proliferation, and cellular alteration and mitoses) allows a correct diagnosis.

This study aimed to evaluate the prevalence of sunbed use among teenagers and the association between familial behavior and the adoption of UV-protective practices in this age group. We also assessed the impact of an educational program on students’ knowledge about the potential risks of sunbed use. The educational intervention focused on: (i) skin effects of UV radiation, (ii) photoaging and photocarcinogenesis, (iii) risk factors for skin cancer, (iv) indoor sun tanning and misleading concepts such as possible protective effect of sunbed use on skin cancer risk, (v) sun protection and relation with skin phototype, and (vi) early diagnosis of melanoma using the ABCDE check list and the ugly duckling sign. We carried out a survey of 3098 students and found a strong association between parental sunbed use and students’ use of the same (P

Background: A few reports in the literature point out that in special areas of the body, nevi can have peculiar pseudomelanomatous features. In our routine work, we have met few examples of atypical nevi with peculiar features on the scalp of teenagers. To evaluate the frequency and the biological behaviour of these lesions, we have conducted a complete survey on melanocytic lesions on the scalp in a significant group of patients. Materials and methods: Thirty-nine nevi of the scalp were from adolescents (12–18 years), 160 from adults, and 30 from children below the age of 12 years. Results: About 10% of the melanocytic nevi of the scalp of adolescents have atypical cytological and architectural aspects that are different from those seen in Clark’s dysplastic nevus. The most striking features were the presence of large bizarrely shaped nests scattered disorderly along the junction with follicular involvement. Other findings were pagetoid spread of cells above the junction and the discohesive pattern of the melanocytes in the nests. Mild cytological atypia was present but less significant. Such distinctive aspects are not found in nevi of the same site in adults or younger children. The general pattern of these atypical nevi of the scalp of adolescents closely recalls that of the so-called atypical nevi on special sites, i.e. nevi on mammary line, genitalia and body’s folds. Despite the architectural and cytological atypia, clinical follow-up does not show any tendency to recur or proclivity to malignant behaviour. Conclusions: Despite their similarities with melanoma, the nevi with atypical features of the scalp of adolescents are probably an entirely benign entity, at least at the moment of their excision. However, although benign, the relationship of this peculiar group of nevi with melanomas developed in adulthood remains entirely unknown, and the complete excision with conservative margins seems a recommendable procedure.

Tumor necrosis factor-alpha (TNF-α) inhibitors represent an effective treatment for severe psoriasis in hepatitis C virus (HCV) patients. The literature reports mainly on short-term treatment in patients with chronic hepatitis with minimum-to-moderate activity with an acceptable safety profile. We report the first 2 cases of hepatocellular carcinoma (HCC) arising in HCV psoriatic patients with advanced liver disease during long-term treatment with etanercept. Our first patient, known to have had HCV infection for 41 years, developed an HCC after 21 months of therapy with etanercept (50 mg/week). The second patient, HCV+ for 20 years, was treated for 58 months with the same therapy, and despite no signs of liver function impairment was diagnosed with HCC. Both of them presented with cirrhosis, which was diagnosed 9 and 5 years earlier, respectively. It remains to be clarified whether there is any connection between psoriasis treatment with anti-TNF-α agents and the development of HCC in HCV-infected patients. Further long-term, follow-up studies and registries of HCV patients with mild/moderate activity may contribute to clarify this issue.

Milia en plaque (MEP) is an uncommon finding characterized by numerous tiny milia within an erythematous area. Despite its benign and asymptomatic nature, MEP raises cosmetic concerns; moreover, the available treatment modalities for MEP are limited. In view of the few cases described in the literature, no consensus has been reached, with respect to the optimal treatment for MEP, and the choice of therapy should be individualized. We report a case of eyelid milia en plaque successfully treated with a new CO2 fractional laser that is able to ensure superficial ablation of the epidermis remodeling tissue in-depth, with minimal thermal damage and extremely rapid recovery time. The results obtained after only two treatments were good, no scarring or dyschromic changes have been registered. At 1 year, just few recurrent milia were present.