Gender differences in adult atopic dermatitis and clinical implication: Results from a nationwide multicentre study.

BACKGROUND: Atopic dermatitis (AD) is a common inflammatory skin disease that affects both children and adults. However, limited research has been conducted on gender differences in AD. OBJECTIVES: This study aimed to assess gender differences in adult AD patients, focusing on demographic and clinical features, comorbidities and treatment approaches. METHODS: In this multicentre, observational, cross-sectional study, we enrolled 686 adult patients with AD (357 males and 329 females). For each patient, we collected demographic data (age and sex), anthropometric measurements (weight, height, hip circumference, waist circumference and waist-to-hip ratio), clinical information (onset age, disease duration, severity, itching intensity, impact on quality of life) and noted comorbidities (metabolic, atopic and other). We recorded past and current topical and systemic treatments. We analysed all collected data using statistical techniques appropriate for both quantitative and qualitative variables. Multiple correspondence analysis (MCA) was employed to evaluate the relationships among all clinical characteristics of the patients. RESULTS: We found no differences in age at onset, disease duration, severity and quality of life impact between males and females. Males exhibited higher rates of hypertriglyceridaemia and hypertension. No significant gender differences were observed in atopic or other comorbidities. Treatment approaches were overlapping, except for greater methotrexate use in males. MCA revealed distinct patterns based on gender, disease severity, age of onset, treatment and quality of life. Adult males with AD had severe disease, extensive treatments and poorer quality of life, while adult females had milder disease, fewer treatments and moderate quality of life impact. CONCLUSIONS: Our study reveals that gender differences in adult AD patients are largely due to inherent population variations rather than disease-related disparities. However, it highlights potential undertreatment of females with moderate AD and quality of life impact, emphasizing the need for equitable AD treatment. JAK inhibitors may offer a solution for gender-based therapeutic parity.

The Pacman Flap and Its Modifications for Reconstruction of Skin Cancer Surgical Wounds on the Scalp and Other Body Areas: A Review of 23 Cases.

BACKGROUND: The Pacman flap is a modified V-Y advancement flap that showed to be versatile in repairing surgical and non-surgical wounds. Indeed, this flap has been used in any anatomical localization, except for the scalp, where its use has not been reported. Moreover, the versatility of the Pacman flap can be enhanced by applying simple modifications to its original design. MATERIALS AND METHODS: A case-series of 23 patients whose surgical breaches were repaired using standard or modified Pacman flap were included in this retrospective study. RESULTS: Most patients were male (65.2%) with a median age of 75.7 years. Squamous cell carcinoma was the tumor most commonly removed (60.9%), while scalp and face were the most frequent localizations (30.4%). Although 18 flaps were sculpted in the traditional Pacman shape, 5 were modified to fit the defect and localization. Complications occurred in 30% of flaps, but all of them were minor except for 1 extended necrosis. CONCLUSIONS: The Pacman flap can be used to repair surgical wounds localized in any body area, including the scalp. Three modifications can enhance the versatility of the flap and offer new repair options to dermatologic surgeons.

The Pacman Flap and Its Modifications for Reconstruction of Skin Cancer Surgical Wounds on the Scalp and Other Body Areas: A Review of 23 Cases. / [Artículo tradudico] El colgajo Pacman y sus modificaciones para la reconstrucción de heridas quirúrgicas oncológicas en el cuero cabelludo y otras áreas corporales: Revisión de 23 casos.

BACKGROUND: The Pacman flap is a modified V-Y advancement flap that showed to be versatile in repairing surgical and non-surgical wounds. Indeed, this flap has been used in any anatomical localization, except for the scalp, where its use has not been reported. Moreover, the versatility of the Pacman flap can be enhanced by applying simple modifications to its original design. MATERIALS AND METHODS: A case-series of 23 patients whose surgical breaches were repaired using standard or modified Pacman flap were included in this retrospective study. RESULTS: Most patients were male (65.2%) with a median age of 75.7 years. Squamous cell carcinoma was the tumor most commonly removed (60.9%), while scalp and face were the most frequent localizations (30.4%). Although 18 flaps were sculpted in the traditional Pacman shape, 5 were modified to fit the defect and localization. Complications occurred in 30% of flaps, but all of them were minor except for 1 extended necrosis. CONCLUSIONS: The Pacman flap can be used to repair surgical wounds localized in any body area, including the scalp. Three modifications can enhance the versatility of the flap and offer new repair options to dermatologic surgeons.

Dupilumab therapy of atopic dermatitis of the elderly: a multicentre, real-life study.

BACKGROUND: Treatment of moderate-to-severe atopic dermatitis (AD) in the elderly may be challenging, due to side-effects of traditional anti-inflammatory drugs and to comorbidities often found in this age group. Furthermore, efficacy and safety of innovative drugs such as dupilumab are not yet well known. OBJECTIVES: A multicentre retrospective, observational, real-life study on the efficacy and safety of dupilumab was conducted in a group of patients aged ≥65 years and affected by severe AD. Their main clinical features were also examined. METHODS: Data of elderly patients with severe (EASI ≥24) AD treated with dupilumab at label dosage for 16 weeks were retrospectively collected. Treatment outcome was assessed by comparing objective (EASI) and subjective (P-NRS, S-NRS and DLQI) scores at baseline and after 16 weeks of treatment. RESULTS: Two hundred and seventy-six patients were enrolled in the study. They represented 11.37% of all patients with severe AD. Flexural eczema was the most frequent clinical phenotype, followed by prurigo nodularis. The coexistence of more than one phenotype was found in 63/276 (22.82%) subjects. Data on the 16-week treatment with dupilumab were available for 253 (91.67%) patients. Efficacy of dupilumab was demonstrated by a significant reduction of all the scores. No statistically significant difference regarding efficacy was found in elderly patients when compared to the group of our AD patients aged 18-64 years, treated with dupilumab over the same period. Furthermore, only 18 (6.52%) patients discontinued the drug due to inefficacy. Sixty-one (22.51%) patients reported adverse events, conjunctivitis and flushing being the most frequent. One (0.36%) patient only discontinued dupilumab due to an adverse event. CONCLUSIONS: Therapy with dupilumab led to a significant improvement of AD over a 16-week treatment period, with a good safety profile. Therefore, dupilumab could be considered as an efficacious and safe treatment for AD also in the elderly.

HIDRAdisk: validation of an innovative visual tool to assess the burden of hidradenitis suppurativa.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, relapsing, inflammatory skin disease characterized by painful inflamed nodules, recurrent abscesses and fistulas located in apocrine gland-bearing body sites. The negative impact of HS on patient's quality of life (QoL) has been reported to be greater than other dermatologic conditions as psoriasis and atopic eczema, and its improvement is an important goal in disease management. Nowadays, there are no specific validated QoL instruments available for HS and generic dermatologic questionnaires are used. OBJECTIVE: The objective of this study was to demonstrate the validity, reliability and responsiveness of HIDRAdisk, a new innovative tool designed for rapid assessment of HS burden and, at the same time, an intuitive graphic visualization of the measurement outcome. METHODS: A multicentre, longitudinal, observational study was conducted to validate the HIDRAdisk compared with other validated questionnaires [Skindex-16, Dermatology Life Quality Index (DLQI), Work Productivity and Activity Impairment-General Health (WPAI:GH)] and to evaluate its correlation with disease severity in Italian patients with any degree of HS severity, as measured by Hurley stage and HS Physician Global Assessment (HS-PGA). RESULTS: A total of 140 patients (59% women; mean age 34.9 ± 11.0 years) were enrolled in 27 dermatologic centres. HIDRAdisk showed a strong correlation with Skindex-16 and DLQI, and a good one with WPAI:GH (correlation coefficient: 0.7568, 0.6651 and 0.5947, respectively) and a statistically significant correlation with both Hurley stage and HS-PGA. Very good internal consistency (Cronbach coefficient >0.80; intraclass correlation coefficient >0.6), with correlation between the 10 items, good test-retest reliability (Spearman correlation coefficient, 0.8331; P < 0.0001) and responsiveness to changes were demonstrated. CONCLUSION: Our study shows that HIDRAdisk, a short and innovative visual HS QoL instrument, has been psychometrically validated in Italian language and it may help improve the management of HS once implemented in routine clinical practice.

Psoriasis and migraine.

BACKGROUND: Psoriasis and migraine share several pathogenetic mechanisms due to systemic inflammation, which increase the risk of developing cardiovascular disease. OBJECTIVE: Our aim was to investigate the prevalence of migraine with (MA) and without aura (MO) in the psoriatic population, investigating a possible new comorbidity of the psoriatic disease. METHODS: We referred 68 psoriatic patients to a nine questions survey formulated on the basis of the International Headache Society (IHS) diagnostic criteria for migraine. Then, in the case of MA, the mean monthly number of migraine crises was assessed. Data of psoriatic patients were then compared with those of a psoriasis-free control group composed of 235 migraine patients (with and without aura). RESULTS: A clinical diagnosis of migraine was performed in 32 psoriasis patients with a great prevalence in women (F: 87.50% - M: 12.5%). Moreover, we found a much higher prevalence (62.5%) of MA, with the remaining 37.5% diagnosed with MO. Comparing the prevalence of MA between psoriasis + migraine patients and the control group we observed a statistical significative difference (P < 0.0001); furthermore, the number of MA crises was significantly higher (P < 0.0001) in patients with psoriasis with respect to the MA control group. CONCLUSIONS: We showed a significant association between psoriasis and migraine, especially MA, probably due to common pathogenetic mechanisms, but further studies are needed to assess their interplay in developing cardiovascular diseases.

Thermal alterations in patients with inflammatory diseases: a comparison between psoriatic and rheumatoid arthritis.

Functional infrared imaging (fIRI) is used to provide information on circulation, thermal properties and thermoregulatory function of the cutaneous tissue in several clinical settings. This study aims to evaluate the application of fIRI in rheumatoid arthritis (RA) assessment, evaluating the thermoregulatory alterations due to joint inflammation in RA patients both in basal conditions and after a mild functional (isometric) exercise, using the same protocol we projected in our recent work on psoriatic arthritis (PsA); fIRI outcomes were compared with those provided by power-Doppler ultrasonography. Ten patients with RA and 11 healthy controls were enrolled in the study. The cutaneous temperature dynamics of 20 regions of interest located on the dominant hand were recorded by means of high-resolution thermal imaging at baseline and after a functional exercise. RA patients showed lower thermal parameters compared to healthy controls, suggesting that the RA-related inflammatory state alters the normal thermal properties of the skin overlying inflamed joints. These results are different from PsA data observed in the previous study. fIRI applied to the study of the response to a functional stimulus may represent an innovative, non-invasive, and operator-independent method for the assessment of early RA.

Polyglandular autoimmune syndrome type III with a prevalence of cutaneous features.

Polyglandular autoimmune syndrome (PAS) is the name given to a group of autoimmune disorders of the endocrine glands. PAS type III (PAS III) comprises several autoimmune diseases (autoimmune thyroiditis, immune-mediated diabetes mellitus, pernicious anaemia, vitiligo, alopecia areata and many others) and is subdivided into four subcategories. We report the case of a 52-year-old woman with autoimmune thyroiditis, vitiligo, alopecia areata, psoriasis and lichen sclerosus, suggesting a clinical diagnosis of PAS IIIC with a singular prevalence of cutaneous features.

Joint functional impairment and thermal alterations in patients with Psoriatic Arthritis: A thermal imaging study.

BACKGROUND: Functional infrared imaging (fIRI) is used to provide information on circulation, thermal properties and thermoregulatory function of the cutaneous tissue in several clinical settings. OBJECTIVES: This study aims to evaluate the application of fIRI in Psoriatic Arthritis (PsA) assessment, evaluating the thermoregulatory alterations due to joint inflammation in PsA patients both in basal conditions and after a mild functional (isometric) exercise; fIRI outcomes were compared with those provided by Power Doppler Ultrasonography (PWD-US). METHODS: 10 patients with PsA and 11 healthy controls were enrolled in the study. The cutaneous temperature dynamics of 20 regions of interest located on the dominant hand were recorded by means of high-resolution thermal imaging at baseline and after a functional exercise. RESULTS: Higher temperature values and faster temperature variations characterized the PsA group compared to healthy controls, confirming that the PsA-related inflammatory state alters the normal thermal proprieties of the skin overlying inflamed joints. fIRI outcomes correlated with the PWD-US findings. CONCLUSIONS: fIRI applied to the study of the response to a functional stimulus may represent an innovative, non-invasive, and operator-independent method for the assessment of peripheral PsA.

Mole modifications following controlled ovarian stimulation for assisted reproduction technologies.

BACKGROUND: The role of estrogens on moles biology remains undefined although estrogenic receptors have been found on melanocytes. It has been postulated that supraphysiological estrogen levels could promote the progression of moles to melanoma. Women undergoing controlled ovarian stimulation (COS) for assisted reproductive technologies (ART) are exposed to high levels of estrogens, produced by the ovary in response to exogenous gonadotropin administration. The aim of this study is to assess whether COS for ART may have an impact on mole structure and/or characteristics. METHODS: Women undergoing to ART for various infertility conditions were included in the study. Personal and clinical data were collected. Dermatoscopic features and scores (total dermoscopy score--TDS) were statistically compared before COS and after a 6-month follow-up period. Statistical correlation was performed between estradiol, FSH blood levels and relative variation in moles dimensions. RESULTS: A total of 46 patients were included in the study. One hundred and seventy-five melanocytic lesions from 31 patients were evaluated at both time points. Although statistically significant differences were found in mole dimension and TDS between the two time points, these differences had no relevance in the clinical setting not suggesting the need for mole excision. Moreover, the only statistically significant correlation with estradiol blood concentration on hCG administration day was found with one-axis dimensional variation. CONCLUSIONS: To our knowledge this is the first work to evaluate the effect of COS on moles. The obtained results do not support a causal relation between the supraphysiological hormone levels stimulation and worsening of clinical and dermoscopical features of moles. Further study is needed to clarify whether estrogens plays a role in melanoma.

PSOCUBE, a multidimensional assessment of psoriasis patients as a both clinically/practically sustainable and evidence-based algorithm.

BACKGROUND: There is increasing awareness of the clinical relevance of psoriasis comorbidities and of the importance of timely and effective screening for such comorbidities in the management of psoriatic patients. Previous works have focused on assessing evidence for prevalence of comorbidities and on the best available evidence for sensitivity in diagnosing suspected comorbidities. No algorithms are available, which have been tested on large numbers of physicians concerning the acceptance of such algorithms both by practicing clinical dermatologists and by their consulting specialists from other fields. OBJECTIVE: To propose a multidimensional assessment algorithm for psoriasis comorbidities which may prove at the same time enough sensitive and practically sustainable in daily clinical practice. METHODS: After an exhaustive literature search, we performed a Delphi procedure involving 50 dedicated dermatological centres to obtain a standardized assessment algorithm, which would meet requirements of sustainability and acceptability both from the point of view of Evidence-Based Medicine as well as from the point of view of practical and clinical feasibility: to meet both requirements, results from the Delphi procedure were elaborated and modified by a restricted panel of experts. RESULTS: The procedure has yielded PSOCUBE, a three-dimensional table comprising 14 clinical examination and history taking items, 32 screening laboratory and instrumental exams and 11 clinimetric scores. CONCLUSION: PSOCUBE, a simple algorithm, may be employed by practising dermatologists to perform standardized assessment procedures on psoriatic patients raising the chances of early recognition of patients at risk for comorbidities, thus fostering more effective prevention; PSOCUBE may therefore contribute to reduce the overall impact of this chronic, widespread disease.

The impact of psoriasis on work-related problems: a multicenter cross-sectional survey.

BACKGROUND: Psoriasis can have cumulative physical and psychosocial effects preventing sufferers from achieving their full-life potential. Few studies have addressed the impact of psoriasis on work-related characteristics. OBJECTIVE: To evaluate the impact of psoriasis on education prospects and work limitations in patients with moderate-to-severe psoriasis. METHODS: This study was conducted in 29 dermatology centres across Italy. Information was collected by questionnaire during office visits. RESULTS: A total of 787 patients (64% male, aged 50 years) completed the questionnaire. At the time of the survey, mean Psoriasis Area and Severity Index (PASI) score and disease duration were 10 and 19 years respectively. Current smokers had higher PASI scores compared to non-smokers (10.8 vs. 9.4, P = 0.02). Plaque psoriasis was the most frequently described (91.2%). Fifty-five percent of patients had limited expectations of career progression. Similarly, in 42% of cases, psoriasis reduced the prospects of improvement in employment status and 35% of patients reported having reduced earning potential. Approximately 60% of patients reported that psoriasis localized to their hands or feet caused work limitations, whilst in about 25%, it caused them to quit their job. Approximately 37% of patients reported having lost between 3-10 work days in the past 3 months due to clinical assessment or treatment. Logistic regression revealed that gender, low standard of education, number of localizations, shame, anger and self-esteem were predictors significantly associated with limitations in work. CONCLUSIONS: Moderate-to-severe psoriasis has a profound negative impact on the employment capacity of patients in Italy. Psoriasis also contributes to days lost from work, affects job opportunity, career prospects and revenue potential.

Cutaneous signs of classical dermatomyositis.

Idiopathic immune myopathies (IIM) are an heterogeneous group of autoimmune muscle disorders characterized by progressive muscle involvement. Dermatomyositis (DM) is the most common form of IIM. It is a multisystem disorder characterized by symmetric proximal, extensor, inflammatory myopathy, vascular involvement and a characteristic cutaneous eruption. Six types of DM have been identified: idiopathic, juvenile (JDM), cancer-related other autoimmune diseases-related, iatrogenic DM and amyopathic DM. Cutaneous manifestations of DM are the most important aspect of this disease and can precede from several months to years muscle or systemic involvement. Three groups of signs have been described: pathognomonic, highly characteristic and compatible. Although differences exist among the different clinical presentation of skin lesions, they share common histological findings including the presence of interface dermatitis with epidermal atrophy, basement membrane degeneration, vacuolar alteration of basal keratinocytes, and dermal changes consisting of interstitial mucin deposition and a sparse lymphocytic infiltrate. DM is a serious disease; the correct evaluation of any skin lesion suggesting an early diagnosis is of utmost importance. Skin signs may, also, represent a marker of treatment efficacy even though systemic symptoms worsening may not always be followed by more severe skin lesions.

Hair disorders associated with autoimmune connective tissue diseases.

Hair disorders are frequently observed in various systemic diseases, including autoimmune connective tissue diseases (CTDs), with predilection of lupus erythematosus (LE), followed by dermatomyositis (DM) and scleroderma. Hair disorders in CTDs may manifest as various clinical patterns, such as telogen hair loss, diffuse thinning or fragility of hair, and scarring alopecia. Less common hair disorders include anagen effluvium, alopecia areata, and trichomegaly. Some drugs used to treat CTDs may cause hair loss in a drug-related manner or hyperthrichosis. In the assessment of common hair loss patterns, such as telogen effluvium, the possible association with CTDs must be borne in mind and should not be overlooked. Alopecia appears to be a significant sign in the course of LE and especially systemic LE. In DM, the involvement of the scalp is common, and is often characterized by a diffuse, violaceous, scaly, non-scarring and symptomatic hair loss. Linear scleroderma en coup de sabre is an uncommon localized form of morphea with involvement of the paramedian forehead and frontal scalp, where it is associated with cicatricial alopecia. The most important variant of scarring alopecia in the context of CTDs is that associated with discoid lupus erythematosus (DLE). In the diagnostic work-up of DLE-related cicatrical alopecia, histopathological and immunopathological studies are useful, and a relevant role has been attributed to dermatoscopy (trichoscopy) over the last years. Hair loss has been reported in several other CTDs, including mixed and undifferentiated CTDs, and primary Sjögren's syndrome, although it is likely to be underestimated in such diseases.

Cancer risk in dermatomyositis: a systematic review of the literature.

The association between idiopathic inflammatory myopathy (IIM) and cancer has been extensively studied in adults. Many epidemiological studies demonstrated this association, which appears stronger for dermatomyositis (DM) than for polymyositis (PM). The first case suggesting an association between cancer and DM was reported in 1916. At present the reported incidence of cancer association with DM varies widely, from less than 7% to over 30%. Many early evidences came from case reports, but this association was later confirmed in case-control as well as in population-based studies. Ovarian cancer or breast cancer in females and lung cancer in males are the main malignancies associated with DM. Given the frequency of the association of dermatomyositis with cancer, for cost-effectiveness reasons it might be important to develop simple and appropriate diagnostic tests for identification of patients with DM, who may be at higher risk of developing a malignancy. Clinicians should plan follow-up schedules to optimize both cancer detection and treatment, and thus to improve patient survival. Many different clinical and serological signs have been suggested as possible predictive factors for malignancy in dermatomyositis: age, increased erythrocyte sedimentation rate (ESR), presence of cutaneous leukocytoclastic vasculitis, cutaneous rash and skin lesions as cutaneous necrosis and periungueal erythemas, neoplastic markers or dysphagia. The results of the different studies are quite discordant. Therefore, we conducted a systematic review of the scientific literature to evaluate the level of the risk of cancer in patients with dermatomyositis and to explore whether certain patient characteristics may be linked to different levels of cancer risk.