Onychoscopic characteristics of Trichophyton rubrum and Trichophyton interdigitalis fungal infections: A multicentric study.

BACKGROUND: Trichophyton rubrum and Trichophyton mentagrophytes variant interdigitalis are the most frequent etiologic agents of onychomycosis. Diagnosis of certainty requires mycological examination, which often results unfeasible. OBJECTIVES: The aim of our study is to describe pathogen specific dermoscopic features, allowing a differential diagnosis without the need for cultural examination, in order to prescribe the most appropriate treatment anyway. PATIENTS AND METHODS: We conducted an observational retrospective study on 54 patients with a culture proven diagnosis of distal subungual onychomycosis of the toenail, caused by Trichophyton rubrum or Trichophyton mentagrophytes variant interdigitalis. Using a videodermatoscope we collected data on nail colour (white, yellow, orange, brown, dark) and on dermoscopic patterns (aurora, spikes, jagged, ruin, linear edge, dots, striae). RESULTS: Fifty-four patients, with a total of 72 nails, were eligible for this study. Analysing the association between discoloration of the nail plate and type of infection (T. rubrum or T. interdigitalis), no correlation turned out to be statistically significant. Instead, significant associations between spikes and T. rubrum infection and striae and infection from T. interdigitalis were identified. Finally, a 100% specificity was identified for white colour and ruin pattern for T. rubrum infection, and brown colour, jagged border and aurora pattern for T. interdigitalis. CONCLUSIONS: Trying to find relationships between specific pathogens and dermoscopic patterns, we found out an association between spikes and striae and T. rubrum and T. interdigitalis respectively. Further larger studies are however necessary to evaluate our preliminary findings.

Ultrasound Features of Onychopapilloma at High-Frequency and Ultra-High Frequency.

OBJECTIVE: This study aimed to identify the sonographic features of pathologically confirmed onychopapilloma cases. METHODS: High-frequency up to 24 MHz and ultra-high frequency-ultrasound up to 71 MHz examinations were performed and correlated with their clinical and pathologic presentations. RESULTS: Twenty-two cases met the criteria. Clinical presentations revealed longitudinal erythronychia in 63.3% of cases. The ultrasound examinations identified a hypoechoic band in the nail bed (86.3%), nail plate abnormalities including upward displacement (68.2%) and thickening (68.1%), focal hyperechoic focal spots on the nail plate (50%) and irregularities of the ventral plate (33.3%). Color Doppler imaging showed no hypervascularity of the nail bed in all studies. These findings correlate with histological characteristics of onychopapilloma, including nail bed acanthosis, papillomatosis, and layered hyperkeratosis. Recurrence occurred in two cases after surgery, with tumors showing proximal extension in the matrix region on ultrasound not evident during clinical examination. CONCLUSION: High-frequency and ultra-high-frequency can provide anatomical information in onychopapilloma that could enhance understanding and management.

Tinea capitis in newborns: Report of a case and review of the literature with a focus on treatment modalities.

Tinea capitis is a common disease in children but rare in newborns younger than 1 month of age. Only 29 cases of tinea capitis in newborns have been described in indexed literature from 1990 until now. While antifungal agents can be used topically and systemically, systemic antifungal therapy is generally accepted as the treatment of choice for tinea capitis due to limited penetration of topical agents into the hair follicle. However, there is a lack of data on the use of systemic antifungal agents in newborns, and there are reports of successful treatment of tinea capitis in newborns using only topical therapy. In this paper, we present a case of tinea capitis in a 29-day-old female baby and review the previous 29 reported cases.

Elongated linear vessels simulating branching vessels and diffuse structureless orange areas as prominent dermoscopic features of diffuse flat facial and extrafacial granuloma faciale: A case series.

Dermoscopy can be an important help for the diagnosis of skin cancers and inflammatory cutaneous diseases. The list of the dermoscopic features reported in granuloma faciale is wide and includes vascular and non-vascular features. We report here three cases of diffuse flat facial and extrafacial granuloma faciale that exhibited elongated linear vessels simulating branching vessels and diffuse structureless orange areas. The differential diagnosis between flat-type granuloma faciale, basal cell carcinoma and cutaneous sarcoidosis can be extremely difficult, making histology mandatory before any treatment.

Adverse events in patients treated with Jak-inhibitors for alopecia areata: A systematic review.

Recently, the impressive efficacy of JAK-inhibitors (JAK-I) in alopecia areata (AA) has been described in several studies; however, to date, there is limited information on the safety of JAK-I in AA patients. For this reason, on 18 August 2022, a systematic review was performed to collect the premarketing and postmarketing data on the safety of JAK-I in patients treated for AA, evaluating for each molecule the reported adverse events (AEs) in indexed literature and their frequency. The keywords 'alopecia areata' AND 'Jak-inhibitors OR Janus-kinase Inhibitors' were searched on PubMed, Embase and Cochrane databases. Of 407 studies retrieved, 28 papers met the requirements and were used in our review, including five RCTs and 23 case series; overall, 1719 patients were included, and the safety of 6 JAK-I was assessed (baricitinib, brepocitinib, deuruxolitinib, ritlecitinib, ruxolitinib and tofacitinib). Systemic JAK-I were well-tolerated, most of the AEs were mild, and the withdrawal rate for AEs was very low and inferior to placebo in controlled studies (1.6% vs. 2.2%). Laboratory abnormalities represented 40.1% of AEs associated with oral JAK-I, which mostly included the rise in cholesterol, transaminase, triglycerides, creatine phosphokinase (CPK) and sporadic cases of neutro/lymphocytopenia. The remaining AEs involved the respiratory tract (20.8%), the skin (17.2%), the urogenital (3.8%), or the gastroenterological (3.4%) tract. Increased rates of infections involved not only the upper (19.0%) and lower (0.3%) respiratory tract, but also the urogenital system (3.6%) and the skin (4.6%). Isolated cases of grade 3 to 4 AEs have been reported, including myocardial infarction, hypertensive urgencies, cellulitis, rhabdomyolysis, neutropenia and high elevation of creatinine kinase. No fatal outcomes were reported. AEs reported with topical formulation included scalp irritation and folliculitis. The main limit of this review is the lack of data related to postmarketing surveillance, which should be maintained on a long-term basis.

Treatment of retronychia: A systematic review and suggested treatment algorithm.

Retronychia is an inflammatory disorder typical of the great toes characterized by arrested nail growth, ingrowth of the nail plate into the proximal nail fold and paronychia. There is no standardized treatment for retronychia, and its management should be weighed based on the severity stage, treatment modality, and clinical outcome. In this paper, a systematic review of the literature was performed to assess all published data regarding the treatment of retronychia. A total of 231 patients from 24 studies were included in the analysis. Conservative management was adopted in mild-intermediate forms, consisting of medical (topical or intralesional high-potency corticosteroids) and podiatric treatment (taping, clipping back the onycholytic plate, orthosis), leading to a global cure rate of 41.2%, with no reported side effects. Non-conservative management, that is, chemical or surgical avulsion of the nail plate, proved resolutive in 71.2% of cases. Surgical avulsion of the nail plate produced the highest cure rate (78.2%), but was burdened by 9.6% of long-term sequelae, mainly nail dystrophies. A decision-making algorithm was designed to give clinicians treatment indications based on the severity stage of retronychia, treatment invasiveness, and possible clinical outcomes.

Therapeutic approach with squaric acid dibutylester for steroid resistant-alopecia areata incognita: A pilot study of a single center.

Topical immunotherapy is widely used in the treatment of alopecia areata (AA). Alopecia areata incognita (AAI) is a relatively common disorder, predominantly affecting females, characterized by widespread hair thinning in the absence of typical alopecic patches. AAI can have a chronic relapsing course and in some cases can be resistant to current standard treatments. Topical immunotherapy has been used in the management of AA with encouraging results, but to date there are no literature studies reporting the efficacy of topical immunotherapy with squaric acid dibutylester (SADBE) in AAI. The aim of our study is to evaluate the efficacy and tolerance of topical immunotherapy with SADBE in AAI not responding to conventional steroid therapy. A total of 12 patients were enrolled in our Hair Disease Outpatient Service, with a proved histological diagnosis of AAI, and resistant to classical steroid therapy. Each patient underwent global photography, pull test, and trichoscopy at beginning and during the follow-ups. The efficacy of topical immunotherapy with SADBE was assessed by evaluating the changes of clinical and trichoscopic signs. Complete regrowth was achieved in 66.7% of cases (8/12), three patients remained unchanged on clinical evaluation but showed subclinical improvement on trichoscopy, whereas one patient progressed and worsened both on clinical and trichoscopic examination. All patients reported scalp diffuse mild erythema and itching the day after the application of SADBE, which were well tolerated. Three patients developed reactive cervical lymphoadenomegaly. No other side effects were observed. Topical immunotherapy with SADBE is widely used in the management of patchy AA and can be considered an effective alternative in resistant AAI, providing visible clinical and trichoscopic improvement in the majority of cases. Further studies are warranted to confirm and validate our findings.

Digital Myxoid Cysts: Correlation of Initial and Long-Term Response to Steroid Injections.

BACKGROUND: Digital mucous cysts (DMCs) are benign myxoid pseudocysts that develop on the distal interphalangeal joint's lateral or dorsal aspects. Management consists either of a surgical approach, conservative therapy, or simple follow-up. OBJECTIVE: To correlate the initial and long-term response with clinical and ultrasound parameters in DMCs treated with intralesional steroids as first-line therapy. METHODS: A single-center prospective open-label study recruited 15 patients affected by DMCs, who had been treated with a cycle of up to 3 steroid injections at a 6 to 9 week time interval. RESULTS: At the first follow-up visit, 53.3% of patients were cleared of DMCs, achieving a complete response, whereas 46.7% experienced a >30% decrease in their DMC volume, and were considered partial responders. After 1 year of follow-up, the cure rate decreased to 40%, and the recrudescence rate was 27.3%. Clinical and sonographic characteristics that positively correlated with a maintained complete response at follow-up were as follows: young age, absence of osteophytes, low volume, complete clearance at T1, and short disease duration (p < .05). CONCLUSION: Intralesional steroid therapy is an easy approach for DMC, with minimal side effects; identifying predictive hallmarks is useful to offer a straightforward surgical treatment to patients who have nonresponder characteristics.

Homogeneous blue lumps of the nipple-areola complex in pubertal girls.

Retroareolar cysts are benign breast lesions caused by the obstruction and consequent dilatation of Montgomery tubercles. Herein, we report two cases of premenarchal girls who developed retroareolar cysts. Their course and differential diagnosis are discussed.

Head and neck dermatitis, a subtype of atopic dermatitis induced by Malassezia spp: Clinical aspects and treatment outcomes in adolescent and adult patients.

BACKGROUND AND OBJECTIVES: Head and neck dermatitis (HND) is a clinical variant of atopic dermatitis (AD), presenting in adolescence or adulthood and characterized by involvement of the head, neck, and superior part of the trunk. The role of Malassezia spp has been advocated in the pathogenesis of HND, and antifungal agents represent the treatment of choice. METHODS: A retrospective single-center study was performed to define the clinical features and treatment response of HND among adolescent and adult patients. RESULTS: Thirty-one patients were identified, 17 with "adolescent-onset" and 14 with "adult-onset" HND. Adolescent-onset HND positively correlated with a past history of AD and presented with exclusive head and neck involvement (P < .05). Adult-onset HND was associated with concomitant widespread atopic eczema, involving the flexural areas of the upper and lower limbs, trunk, nipples, or hands (P < .05). A positive response to itraconazole in combination with topical treatments was observed in both groups. CONCLUSIONS: This study delineates two HND clinical phenotypes: adolescent vs adult onset. Different characteristics were observed in terms of relationship to AD and eczema localization. A history of AD in childhood and presentation with exclusive involvement of head and neck regions was observed predominantly in the adolescent-onset form, while adult-onset HND often occurred in association with diffuse dermatitis and a past history of AD was less frequent than in the adolescent group. The study is limited by the single-center retrospective nature, which may lead to diagnostic and selection biases, and the small cohort of patients.

Bei CALME (childhood asymmetry labium majus enlargement): die Ruhe bewahren und nachverfolgen.

CALME steht für childhood asymmetry labium majus enlargement und bezeichnet eine physiologische, nichtneoplastische Schwellung des Weichteilgewebes der Labia majora. CALME wird durch die Vergrößerung einer oder mehrerer normaler vulvärer Gewebeanteile verursacht und weist keine äußere Kapsel auf. Vereinzelte Berichte in der Literatur haben das Augenmerk auf diese gutartige Veränderung gelenkt und die Notwendigkeit betont, invasive Eingriffe mit möglichen Dauerfolgen zu vermeiden. Die Ätiopathogenese von CALME ist nach wie vor umstritten, wobei die Hypothese einer hormonell bedingten stromalen Hyperplasie der großen Schamlippen gegenüber der Annahme eines gutartigen neoplastischen Prozesses favorisiert wird. Dieser Artikel zielt darauf ab, einen detaillierten Überblick über die klinischen, histologischen und apparativen Befunde bei CALME zu geben und einen abgestuften Algorithmus zur Herangehensweise und zum Management von genito-inguinalen Geschwülsten bei pädiatrischen Patienten zu erstellen.

Keep CALME (childhood asymmetry labium majus enlargement) and follow up.

CALME is the abbreviation of "childhood asymmetry labium majus enlargement" and denotes a physiological, non-neoplastic swelling of labium majus soft tissues. It is caused by the expansion of one or more normal vulvar tissue components and is devoid of a peripheral capsule. A few reports in the literature have raised awareness of this benign condition and stressed the need to avoid invasive procedures with possible permanent sequelae. The etiopathogenesis of CALME is still debated, although the hypothesis of a hormone-driven major labia stromal hyperplasia is favored over the assumption of a benign neoplastic process. This article aims to provide a detailed review of the clinical, histological, and instrumental findings of CALME and provide a step-based algorithm to approach and manage genito-inguinal masses in pediatric patients.

Intralesional steroid treatment for the intermediate stage of retronychia: A pilot study.

Retronychia describes the proximal ingrowing of the nail plate. In the early stage, topical steroids are the gold standard therapy, while in the late stage surgical treatment is mandatory. We identified an intermediate severity stage of retronychia, where the topical treatment alone is ineffective and surgery is avoidable. Intralesional steroids turn the best treatment in these patients. A pilot study consisting of a 3-month treatment period and 9-month follow-up time was designed to evaluate the treatment outcome to intralesional steroid injections in patients affected by the intermediate-stage of toenail retronychia. The complete recovery of retronychia-associated nail abnormalities was observed in 27/28 recruited patients at the end of the treatment phase. Paronychia, nail plate discoloration, proximal nail fold (PNF) elevation, and discharge were reduced (P < .01) after one steroid administration, while nail regrowth became significant after two sessions. No significant difference in terms of clinical outcome was found, while pain VAS score and intra-operative pain evaluated with Wong-Baker faces scale were higher in the female group (P < .01). Limitation Lack of control group of patients. Despite its temporary effect, the intralesional triamcinolone injection is an effective, cheap, and safe treatment especially for the intermediate stage of retronychia.

Ultrasound features of the subungual glomus tumor and squamous cell carcinomas.

BACKGROUND: Nail tumors often pose a significant challenge for the clinician, as they are burdened by a high delay in diagnosis and paucity of clinical signs in the early stage. In most cases, the onset of pain or nail plate dystrophy leads to imaging investigations such as plain radiography, magnetic resonance imaging, and ultrasonography (US) when surgery is pending. MATERIAL AND METHODS: A 2-year monocentric study evaluated the histologically confirmed cases of subungual glomus tumor (GT) and squamous cell carcinoma (SCC) with a pre-surgical US assessment, and reviewed their sonography features. A total of 7 digital GTs and 6 SCCs of the nail were collected. RESULTS: GT and SCC are easily distinguishable on US. Compared to SCC, GT was positively associated with an ovoid shape, well-defined borders, bone cup-scalloping without cortical erosion, and a rich intralesional vascular pattern (P < 0.05). Vice versa, SCC was significantly correlated with irregular shape, ill-circumscribed margins, an infiltrative growth pattern with peripheral hypoechoic foci, posterior acoustic shadow, cortical erosion, and a highly vascular multipolar peripheral pattern (P < 0.05). CONCLUSION: The rapid assessment of GT and SCC sonographic features may contribute to reduce diagnostic delay, expedite management, and decrease the risk of surgical relapse.

Dermoscopy of subungual red comets associated with tuberous sclerosis complex.

We report here our experience on the use of dermoscopy for the detection of subungual red comets, which are sometimes present in the nails of patients affected by tuberous sclerosis complex. Dermoscopy allowed us to visualize, with better resolution than the naked eye, very tortuous capillaries surrounded by a whitish halo and close parallel binary tortuous capillaries. In some cases, subungual red comets are associated with the presence of periungual or subungual fibromas, but their exact pathogenesis remains unknown.

Sonographic features of vaccination granulomas in children with delayed-type hypersensitivity to aluminum.

In this article, we report the sonographic features of vaccination granulomas in three children sensitized to aluminum. Although the recognition of the vaccination granuloma relies on the clinical examination, misdiagnosis is frequent, leading to distressful procedures or prolonged antibiotic administration. In all our cases, sonography revealed a teardrop-shaped echogenic central structure, suggesting the deposition of aluminum crystals along the route of administration with consequent subcutaneous degenerative changes, and a surrounding hypoechoic cap, which reflects the changeable inflammatory reaction and the granuloma formation.

Multiple perianal ulcers due to suppositories.

We report a case of long-standing inexplicable perianal ulcers. After exclusion of an inflammatory, infectious or neoplastic origin, a thorough personal history revealed that for many years the patient had been using analgesic suppositories containing indomethacin, caffeine, and prochlorperazine dimaleate, four to five times a week, for migraine. On stopping the suppositories, there was complete healing within 12 weeks. We hypothesize that vasoconstriction and vascular damage were the pathogenetic mechanisms behind the perianal ulcers.

Post-traumatic erosive dermatosis of the scalp: A hypergranulated variant.

Erosive pustular dermatosis of the scalp is a slowly progressive chronic inflammatory disease that predominantly affects elderly male patients with marked actinic damage. The clinical evolution consists firstly of keratotic and erosive plaques surmounted by yellow-brown crusts and non-follicular pustules; later, the active crusting lesions regress in number and the scarring process causes diffuse cutaneous thinning and loss of hair follicles. However, manifestations may be atypical, leading to frequent misdiagnosis. We present a case series of post-traumatic erosive pustular dermatosis on the scalp of 4 elderly patients. The characterising feature was the presence of erosion consisting of abundant hypergranulation tissue, with an almost total lack of crusts and pustules. Dermoscopy showed a unique pattern of stretched and dilated linear, telangiectatic and polymorphous on-focus vessels, milky-red areas and white scarring areas. This clinical entity is rarely reported in the literature. The majority of reported cases were located on the legs.