Analysis of serological treatment response to doxycycline versus benzathine penicillin in syphilis infections, a retrospective single-center study.

Doxycilicine is the second-line treatment of choice for infectious syphilis when treatment with penicillin G is not feasible. To date, difficulties in the penicillin supply chain make it necessary to evaluate and resort to antibiotic therapies which are currently considered a second-line choice. Moreover, systematic studies comparing the two treatments in affected patients are still few, and many do not consider late and indeterminate latent infections. The objective of this study was to assess the differences in the serological response of the treatment of syphilis infections with benzathine penicillin compared with doxycycline. We built an in-house database with all patients diagnosed with syphilis infection from January 2010 to January 2020 in the STD Centre of the S.Orsola-Malpighi Polyclinic of the University of Bologna, located in the North-east of Italy. We recorded all the principal independent (demographic, social status, reinfection rare, HIV infections, comorbidities, sexual behaviors, and initial TPHA values) and dependent variables (RPR values). We then extrapolated all patients treated with doxycycline (100 mg of doxycycline twice daily for 14 days for infections diagnosed within the first year and a 28 days course for infections older than 1 year or undetermined) and matched in 1:1 ratio numbers with a homogeneous group of patients treated with penicillin G (2.4 million units in a single dose intramuscularly for infections diagnosed within the first year and a cycle consisting in of 2.4 million units administered in a single dose per week for 3 weeks for infections older than 1 year or undetermined) We then analyzed the serological trends and outcomes in the primary, secondary and early latent groups versus late latent and undetermined infections. We retrieved 41 patients for each group with homogeneous initial characteristics. At the end of the 24-month observation period, a slight difference in a valid RPR reduction rate emerged, with a greater success rate emerged in patients receiving penicillin than those with doxycycline (26 vs. 22, p 0.615). Indeed, patients with latent or indeterminate syphilis treated with doxycycline appear to have a higher rate of serofast than those treated with penicillin. Linear regression analysis showed no strong correlation between the analyzed independent variables and the observed outcomes. Doxycycline had a slightly lower, though not statistically different, success rate when compared with penicillin in treating primary syphilis, but appeared to have a reduced success rate in attaining resolution in late and undetermined syphilis infection.

Management of malignant cutaneous wounds in oncologic patients.

PURPOSE: Neoplastic wounds may develop as a result of primary tumor growth in the skin, due to metastasis, or due to skin invasion by tumors emerging from deeper levels. Malignant wounds may present as a crater-like ulcer, or as raised nodules with a cauliflower-like appearance. They are associated with malodor, necrosis, pain, bleeding, and secondary infection. The aim of our study is to better characterize fungating wounds and their management. METHODS: We retrospectively reviewed the database of the Wound Care Unit of the University of Bologna in order to identify individuals affected by neoplastic wound, between January 2019 and February 2021. RESULTS: We identified 9 females and 2 males with a mean age of 63 years; all were referred by the Oncology Unit. Management differed depending on the characteristics of the patients and the ulcers. Complete healing of the wound, following the parallel complete remission of the lymphoproliferative neoplasia, was observed in one individual. Among the others, one died because of breast cancer, while cutaneous lesions in 2 individuals deteriorated after 1 year of follow-up. Remission/relapse of the ulcer following the treatment course administered for the lymphoma were observed in one patient. CONCLUSIONS: Treatment of malignant fungating wounds is challenging. Considering the neoplastic nature of the wounds, complete healing or improvement cannot be expected with the application of classically prescribed dressing for wounds. A mostly palliative treatment, focusing on maintaining the patient's quality of life, is a reasonable choice.

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.

Short anagen syndrome: A case series and algorithm for diagnosis.

BACKGROUND: The short anagen syndrome (SAS) is a rare idiopathic pediatric disorder characterized by the short duration of the anagen phase. SAS mainly affects Caucasian children. Parents complain of their child's inability to grow long hair. Topical minoxidil may be an effective treatment for SAS; however, a slow spontaneous improvement is typical. OBJECTIVE: Our aim was to collect data on out cases of SAS and create an algorithm to facilitate diagnosis of SAS. METHODS: A retrospective review of 25 patients with SAS was performed within the Dermatology Department of the University of Bologna. We collected data regarding symptoms, pull test, hair card test, trichoscopy, trichogram, treatments, including biotin and minoxidil, and clinical outcome. RESULTS: Characteristic findings included parental reporting that the hair had not required a haircut, hair card test showing hairs with conical-shaped tips, and hair shafts of different diameters, with more 10%-20% of hair shafts less than 60 µm thick on trichoscopy. Trichogram revealed an increased percentage of telogen hair with normal hair shafts and tapering ends. The mean anagen-to-telogen ratio was 66:34 (normal ratio 90:10). CONCLUSION: We developed an algorithm to facilitate the diagnosis of this rare hair disease using clinical examination and invasive and non-invasive testing to differentiate SAS from other forms of pediatric alopecia. In conclusion, the collected data of the therapy showed that biotin alone or in combination with topical minoxidil is an effective treatment for SAS.

Tinea corporis incognito due to Microsporum Gypseum: Report of eight cases in children.

Microsporum gypseum is a geophilic saprophyte for which soil is the natural habitat. Tinea corporis caused by Microsporum gypseum is rare and usually occurs after direct contact with the soil or healthy carrier animals. We present a case series of eight children with tinea corporis caused by M gypseum, with unusual clinic presentations mimicking dermatitis.

Oral supplementation in female telogen effluvium: a clinical and instrumental objective evidence of efficacy and tolerability of new oral cosmetic treatment.

BACKGROUND: Telogen effluvium and androgenetic alopecia (AGA) represent the most common non scarring hair diseases. In addition to medical treatments such as finasteride and minoxidil, recommendations for telogen effluvium or AGA include oral supplementation, that can be prescribed in association or before starting medical therapies. The objective of our study was to evaluate the tolerability, efficacy and the compliance of the patient of a treatment with oral supplementation in patients affected by telogen effluvium eventually associated with grade I/II of AGA according to the Ludwig Scale. METHODS: We enrolled a total of 20 female patients affected by telogen effluvium, in 7 cases associated with grade I/II of AGA according to the Ludwig scale. Patients were asked to take a supplement containing sulfurated aminoacids (L-cystine, L-methionine, liposomal glutathione) and trace elements (zinc, copper, iron, selenium) with ubidecarenone and vitamin B5. All patients underwent the dermatological examination, photography and trichoscopy, at the first visit, after 3 months and after 6 months. RESULTS: At the end of the study, clinical healing was assessed in 14 patients while 6 patients showed good improvement. 4 patients rated moderate satisfaction; 16 patients were very satisfied of the results. Trichoscopy showed important improvement in 17 patients and only 3 patients showed a moderate improvement in the hair density and diameter. All patients tolerated very well the treatment, and none of patients needed to discontinue the assumption of the tablets. CONCLUSIONS: The results of our study demonstrate the ability of a new tablet supplement with sulfurate amino acids and trace elements ingredients to effectively and safely improve the hair growth and hair loss in patients with telogen effluvium associated with mild to moderate AGA. The supplement was found to be excellently tolerated from all the patients, safe, and easily incorporated into daily routines.

Tufted hairs: A bouquet of flowers in different hair diseases.

Tufted hairs, an unusual hair follicle dysplasia, are characterized by several hair shafts grouped together, emerging from a single hair follicle-like "doll's hair". This clinical picture is considered characteristic of folliculitis decalvans (FD). However, the emergence of grouped hair shafts from a single follicle can also be observed in other hair disorders, even if not as a distinctive diagnostic sign. This paper aims to collect and analyze all clinical and trichoscopic features of different hair diseases with tufted hairs to find distinctive features, helping the clinician with the diagnosis.

Review of the literature on the efficacy and safety of a new cosmetic topical treatment containing Pistacia lentiscus and hyaluronic acid for the treatment of nail plate damages.

OBJECTIVES: The objective of our study is the review of the literature on the efficacy and safety of a novel water-soluble nail strengthened (WSNS) containing hyaluronic acid and Pistacia lentiscus used for the improvement of nail plate diseases. MATERIALS AND METHODS: We conducted literature research on PubMed/MEDLINE to identify all the studies reporting the use of hyaluronic acid and P. lentiscus in the improvements of nail alterations. RESULTS: We found two reports and two posters published in the literature, accounting for 96 patients treated with WSNS containing P. lentiscus and hyaluronic acid. The 83 patients were affected by brittle nails and 13 patients by onychomycosis. CONCLUSIONS: This review demonstrates that the daily application of this new product containing P. lentiscus and hyaluronic acid can be used as a cosmetic adjuvant for improving common nail diseases such as nail fragility and onychomycosis, with significant results on nail quality and appearance. Patients did not report any adverse events and its ease of application and cosmetic qualities contribute to the great compliance to treatment.

Use of Apremilast® in the psoriasis treatment: a real-life multicenter Italian experience.

BACKGROUND: Apremilast® (Amgen, Thousand Oaks, CA, USA) is the first small molecule approved for the treatment of moderate-to-severe psoriasis in adult patients; however, real-life data are still limited. We investigated the effectiveness and safety of this drug in a multicenter real-world setting. METHODS: We retrospectively reviewed data from all psoriatic patients who received at least one dose of Apremilast® (Amgen) and collected demographic data and medical history at baseline and periodically for 36 months. RESULTS: A total of 111 patients entered in the study. The mean drug survival duration was 21.8±10.6 months; however, it was significantly shorter when comorbidities were ≥3 and if biologic drugs were previously administered. ΔPASI90 was achieved in 29% of patients and ΔPASI50 in 68% at T4; the rate of ΔPASI improvement increased progressively at T12, T24, T36 in patients who continued to receive Apremilast® (Amgen). At the end of the study 50 patients discontinued the treatment because of adverse events (19.8%), primary failure (19%) or secondary failure (6.3%). CONCLUSIONS: Apremilast® (Amgen) proved to be an effective, safe, and manageable drug, showing effectiveness also in difficult-to-treat patients with psoriasis, with a favorable tolerability profile and a potentially valid weight loss effect. We believe that treating patients with few comorbidities who are naive to biological therapy may result in higher response rates and longer mean drug survival.

Angiokeratoma Circumscriptum Naeviforme Presenting as a Dark Warty Plaque on the Leg.

Dear Editor, A 45-year-old man presented with a large, dark, keratotic, warty, and friable plaque on the distal posterior aspect of the left leg (Figure 1, a). The patient reported that the lesion was not present at birth but had appeared approximately at the age of three as an erythematous patch that progressively grew over the time. During adolescence, the surface of the lesion became rough and warty and was easily traumatized due to its location, resulting in recurrent bleeding episodes over a period of years. For this reason, the patient requested lesion removal. The patient did not report any other significant comorbidity, and physical examination revealed no other abnormalities. A shaving biopsy of the lesion was performed, and histopathology highlighted ectatic vascular spaces with some luminal red blood cell beneath a papillomatous and hyperkeratotic epidermis (Figure 1, b). Based on clinical and histopathological features, a diagnosis of angiokeratoma circumscriptum naeviforme (ACN) was established. ACN is one of the five disorders belonging to the group of angiokeratomas (AKs) that also include AK of Mibelli, AK of Fordyce, solitary or multiple AK, and AK corporis diffusum. Among these variants, ACN is the rarest and is seldom studied (1). AKs are benign vascular anomalies of the superficial vascular plexus that appear as dark red papules and plaques arranged either discretely or in clusters. ACN lesions are typically situated unilaterally on the lower limbs, especially on the legs and feet, but can occasionally occur elsewhere. Lesions are generally noted in early childhood. The early lesions are flat and reddish in color, while older lesions become increasingly studded and acquire a verrucous or warty surface. There is no tendency of spontaneous improvement, and minor traumas can easily cause beading and infection (2). While the plaques were linear in disposition in most of the cases reported in the literature, a peculiar feature of our case was the isolated, round, and giant appearance of the plaque. Even though ACN is not typically associated with other abnormalities, coexistence with other vascular malformations has been reported in some cases, including AK of Fordyce, Cobb syndrome, Klippel-Trenaunay syndrome, nevus flammeus, infantile hemangioma, and traumatic arteriovenous fistula (3). From a histological point of view, ACN appears as dilated dermal papillary capillaries drained by dilated venules. The overlying epidermis shows a variable degree of acanthosis, papillomatosis, and compact hyperkeratosis. Typically, the deep dermis and hypodermis are not involved, helping distinguish them from verrucous hemangioma (4). Lichen simplex chronicus, verrucous carcinoma, and verrucous melanoma must also be considered in the differential diagnosis (5). Recurrent bleeding or cosmetic reasons are common indications for treatment. Surgical excision represents the most effective option. Other possibilities include diathermy, electrocautery, cryosurgery, or laser (6). In our case, there was no macroscopic residual disease after the shaving biopsy. A collagen dressing was applied, and the wound underwent second intention healing in three weeks. There was no evidence of local recurrence after 18 months. References: Das A, Mondal AK, Saha A, Chowdhury SN, Gharami RC. Angiokeratoma circumscriptum neviforme: An entity, few and far between. Indian Dermatol Online J. 2014;5:472-4. Mittal R, Aggarwal A, Srivastava G. Angiokeratoma circumscriptum: a case report and review of the literature. Int J Dermatol. 2005;44:1031-4. Wankhade V, Singh R, Sadhwani V, Kodate P, Disawal A. Angiokeratoma circumscriptum naeviforme with soft tissue hypertrophy and deep venous malformation: A variant of Klippel-Trenaunay syndrome? Indian Dermatol Online J. 2014;5(Suppl 2):S109-S112. Oppermann K, Boff AL, Bonamigo RR. Verrucous hemangioma and histopathological differential diagnosis with angiokeratoma circumscriptum neviforme. An Bras Dermatol. 2018;93:712-5. Goldman L, Gibson SH, Richfield DF. Thrombotic angiokeratoma circumscriptum simulating melanoma. Arch Dermatol. 1981;117:138-9. del Pozo J, Fonseca E. Angiokeratoma circumscriptum naeviforme: successful treatment with carbon-dioxide laser vaporization. Dermatol Surg. 2005;31:232-6.

Trichodynia and telogen effluvium in COVID-19 patients: Results of an international expert opinion survey on diagnosis and management.

BACKGROUND: The cutaneous manifestations of COVID-19 may be useful disease markers and prognostic indicators. Recently, postinfectious telogen effluvium and trichodynia have also been reported. OBJECTIVE: To evaluate the presence of trichodynia and telogen effluvium in patients with COVID-19 and describe their characteristics in relation to the other signs and symptoms of the disease. METHODS: Patients with a history of COVID-19 presenting to the clinics of a group of hair experts because of telogen effluvium and/or scalp symptoms were questioned about their hair signs and symptoms in relation to the severity of COVID-19 and associated symptoms. RESULTS: Data from 128 patients were collected. Telogen effluvium was observed in 66.3% of the patients and trichodynia in 58.4%. Trichodynia was associated with telogen effluvium in 42.4% of the cases and anosmia and ageusia in 66.1% and 44.1% of the cases, respectively. In majority (62.5%) of the patients, the hair signs and symptoms started within the first month after COVID-19 diagnosis, and in 47.8% of the patients, these started after 12 weeks or more. LIMITATIONS: The recruitment of patients in specialized hair clinics, lack of a control group, and lack of recording of patient comorbidities. CONCLUSION: The severity of postviral telogen effluvium observed in patients with a history of COVID-19 infection may be influenced by COVID-19 severity. We identified early-onset (<4 weeks) and late-onset (>12 weeks) telogen effluvium.

Atypical Presentation of Congenital Triangular Alopecia: A Case Series in Italy.

BACKGROUND: Congenital triangular alopecia (CTA) is a benign, asymptomatic, nonprogressive, localized and noncicatricial type of alopecia that is usually first noted during infancy or childhood. The pattern of hair loss is traditionally described as triangular, oval or lancet shaped with apex toward the vertex. OBJECTIVE: We present a case series of CTA located in unusual sites. PATIENTS AND METHODS: We performed trichoscopy in 78 patients with CTA. From this group, we selected 10 individuals (4 males and 6 females) whose disease was not localized on the typical scalp area. RESULTS: The alopecic area was located on the occipital region in 5 patients, the parietal region in 4 patients, at the vertex in 1. With trichoscopy, vellus hairs were detected in all patients, and evidence of empty follicles was noticed only in 3 patients. CONCLUSIONS: In contrast with the preconceived notion that all CTAs are frontotemporal, our case series points out that this disease could be localized in other scalp sites.