Dermoscopic evaluation of melanocytic nevi changes after photo-epilation techniques: a prospective study.

BACKGROUND: The clinical and dermoscopic changes of melanocytic nevi under the effects of photo-epilation are poorly known. OBJECTIVE: Prospective study on clinical and dermatoscopic effects of photoe-pilation on melanocytic nevi. METHODS: Eighteen patients exposed to photo-epilation gave consent to a follow-up programme from 2008 to 2017 at the Videodermatoscopic Office of the Dermatology Clinic of Cagliari (Italy), with clinical and dermoscopic assessment. RESULTS: A mean 2-year follow-up was recorded for 73 lesions. The most frequent clinical change was nevi colour, clearer than basal pictures, sometimes with increased pigmentation at the periphery, or residual islands of pigmentation, with vanishing borders. Acute burn with crusting was noted in few cases. Only one case showed progressive growth. Corresponding dermoscopic findings were bleaching of nevi, followed by pigment network disruption, appearance of white structureless areas and grey-blue globules. Complete regression occurred in 32.8% of the lesions. The growing nevus was characterized by peripheral globules. Excision for histopathological examination showed a compound nevus with mild atypia. CONCLUSIONS: Although malignant modifications of nevi after photo-epilation have not been described, the clinical and dermoscopic changes we observed suggest to extend the follow for more than 24 months, as the potential long-term adverse effects of photo-epilation on melanocytic nevi are unknown.

Bullous morphoea: a retrospective study.

Bullous morphoea is a rare variant of localized scleroderma whose pathogenesis has been widely discussed. We retrospectively reviewed the records of all histopathologically confirmed cases of morphoea followed from 2005 to 2015 at the Dermatology Clinic and Pathology Institute of the University of Cagliari, Sardinia, Italy. Among 137 patients with morphoea, 2 cases of the bullous variant were identified, which were successfully treated with methotrexate. Thus, the bullous form comprised 1.4% of all cases of morphoea, which is much lower than the 7.5% previously reported. In one of the cases, histopathological examination revealed a peculiar 'stretching' pattern of basal keratinocytes attached to the epidermal roof of the bulla, together with increased lymphatic vessels, which were either collapsed or dilated, stressing the role of lymphatics and possibly of excessive skin trauma and friction in the development of bullous lesions.

STAT4 expression and activation is increased during mitosis in vitro and in vivo in skin- and mucosa-derived cell types: implications in neoplastic and inflammatory skin diseases.

BACKGROUND: The signal transducer and activator of transcription-4 (STAT4/Stat4) is a transcription factor known to convey signals from interleukin-12, interleukin-23, and interferon-alpha/beta to the nucleus, resulting in activation of dendritic cells, T-helper cell differentiation and production of interferon-gamma. OBJECTIVE: To demonstrate a novel role for STAT4 in cell mitosis. RESULTS: Phosphoserine STAT4 (pSerSTAT4) is increased in cells undergoing mitosis and is distributed throughout the cytoplasm during this stage of the cell cycle, whilst phosphotyrosine STAT4 (pTyrSTAT4) is confined to the chromosomal compartment. This distinct pattern of pSerSTAT4 during mitosis is seen in vitro in human keratinocytes and in other cell types. This is also present in vivo in cells undergoing mitosis in normal skin, psoriasis and squamous cell carcinoma. Inhibition of STAT4 phosphorylation by lisofylline and depletion of STAT4 by RNA interference results in a delay in progression of mitosis and leads to a reduction in cells completing cytokinesis. CONCLUSION: Our data demonstrate that STAT4 plays a role in enabling the normal and timely division of cells undergoing mitosis.

Differences in clinicopathological features and distribution of risk factors in Italian melanoma patients.

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

Granulomatous reactions after injections of multiple aesthetic micro-implants in temporal combinations: a complication of filler addiction.

BACKGROUND: Granulomatous reaction is a well-known complication following soft filler procedures. However, the diagnosis of filler-induced granulomas may be challenging because of the occasional reluctance of patients to report the previously performed aesthetic procedure. OBJECTIVE: To describe a new clinical situation in which some patients, in the quest for physical perfection, become addicted to multiple sequential cosmetic injections, increasing the risk of adverse reactions. METHODS: We describe three women who developed diffuse facial nodular tumefaction after multiple procedures of filler injections into their face that occurred at different times in the previous years. RESULTS: Histopathology showed a granulomatous reaction including different combined substances that were identified with different types of micro-implants in the same biopsy. CONCLUSIONS: Excessive demand of multiple cosmetic injections may increase the frequency of skin granulomatous reactions and can be included in the spectrum of similar addictive dysmorphophobic behaviours. Histopathology is the best mean to achieve the diagnosis.

Diffuse dermal angiomatosis: a clinical mimicker of vasculitis associated with calciphylaxis and monoclonal gammopathy.

Diffuse dermal angiomatosis is a form of cutaneous reactive angiomatosis characterized clinically by painful erythematous or violaceous lesions with ulcers that may mimic cutaneous vasculitis/vasculopathy. Histologically it shows a benign, diffuse proliferation of endothelial cells with tiny blood vessels in the papillary and reticular dermis. Herein, we report four patients with diffuse dermal angiomatosis in the setting of calciphylaxis and monoclonal gammopathy and review the cases previously published in the literature. Comorbidities and management will also be discussed.

Thalidomide-induced granuloma annulare.

Granuloma annulare (GA) is an acquired, usually self-limiting, asymptomatic granulomatous skin disease with well recognized clinical and histological features that occurs in children and adults generally before the age of 30. Five clinical types are described including the localized, generalized, subcutaneous, perforating, and patch forms. The possible role of immune dysregulation has been pointed out in the pathogenesis of GA, as it has been reported in association with several diseases and conditions like diabetes, thyroid diseases, malignancies, tuberculosis, human immunodeficiency, Epstein Barr and hepatitis C virus infection. Drug-induced GA is a rare presentation, that can appear similar or identical to idiopathic GA. We present a 75-year-old Caucasian man with a violaceous ring-like firm, papular eruption, localized on the dorsal aspect of both hands, with histological features of GA, which subsequently resolved with the discontinuation of thalidomide he had started 1 month earlier for the treatment of a multiple myeloma. The lesions appeared with renewed intensity after resuming a therapy cycle. Jones's algorithm for the diagnosis of adverse drug reactions (ADR) showed a certain association, thus the final diagnosis of thalidomide-induced GA was made.

Cutaneous adverse drug reactions to allopurinol: 10 year observational survey of the dermatology department--Cagliari University (Italy).

BACKGROUND: Allopurinol is extensively prescribed for conditions associated with urate excess, despite being responsible for severe cutaneous adverse drug reactions (ADR). OBJECTIVE: A cross-sectional survey of allopurinol cases observed at the main Dermatology Department with inpatients facilities in southern Sardinia. (approx 560,836 inhabitants). MATERIAL AND METHODS: Data collection of all consecutive patients referred for ADR between 2001 and 2010. Causality assessment followed the WHO Collaborating Centre for Drug Monitoring criteria; illness severity score was adopted for toxic epidermal necrolysis (SCORTEN). RESULTS: Allopurinol was the culprit drug in 84 of 780 cutaneous ADR cases (10.7%; 8.4 cases/year). Mean age was 74 years, 58% of the patients were female, 95% of patients required hospitalization. Clinical forms were maculo-papular eruptions (34 cases), Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (31 cases), vasculitis (six cases), Drug Rash Eosinophilia and Systemic Symptoms (DRESS) (three cases), Acute Generalized Exanthematous Pustolosis (AGEP) (three cases), Pityriasis rosea-like eruption (three cases), lichenoid dermatitis (two cases), fixed drug eruption (one case), erythroderma (one case). The indication for allopurinol prescription was asymptomatic hyper-uricemia in 95% of the patients. Twelve patients were under allopurinol dosage adjustment according to creatinine clearance. Final causality assessment was definite for 12% of the cases and probable for the remaining 88%. Full recovery was achieved in 88% of subjects; ten SJS/TEN patients died (12% overall mortality; 32% mortality of the SJS/TEN cases). CONCLUSION: Considering the populations size of Southern Sardinia, is plausible that 1.5/100,000 Sardinian will be affected by allopurinol related ADR per year. Advanced age, and inappropriate allopurinol prescription were the main conditions affecting morbidity and mortality.

[A case report of eccrine porocarcinoma]. / Porocarcinoma eccrino: caso clinic.

Eccrine porocarcinoma (EPC) is a rare malignant skin appendage tumour deriving from the intraepithelial ductal parts of the sweat glands. First described by Pinkus e Mehregan nel 1963 as an epidermotropic eccrine carcinoma, it is rarely reported in medical literature and represents 0.005-0.01% of all skin tumors. We report a case of a 88-year-old Caucasian female presented to our Clinic with an asymptomatic, red-brown , irregularly shaped firm nodule on the left thigh aroused 15 years earlier. The lesion has been excised and histopathological examination showed an "eccrine porocarcinoma aroused on eccrine poroma". Review of the literature on this rare condition and possible therapeutic strategies are also discussed.

Rare emerging malignant skin tumours.

As clinical skills improve and innovative diagnostic techniques become available in the field of dermatology and dermatopathology, new types or additional variants of malignant skin tumors are described. This article reviews the current nomenclature, clinico-pathological features, differential diagnosis, prognostic and therapeutic implications of some new dermato(patho)logical rare emerging skin tumors, including epithelial tumors (squamous cell carcinoma with mucinous metaplasia), adnexal tumors (endocrine mucin-producing sweat gland carcinoma), soft tissue tumors of vascular differentiation (pseudolymphomatous cutaneous angiosarcoma, pseudomyogenic hemangioendothelioma), hematopoietic tumors (blastic plasmacytoid dendritic cell neoplasm) and mixed epithelial/melanocytic tumor (squamomelanocytic tumor).

Local immune response in the skin of the external auditory meatus: an immunohistochemical study.

Cerumen plays an important role in the protection of the external auditory meatus against several kinds of damage. Its hydrophobic properties, due to the high concentration of lipids, shelter the canal from physical damages, while other components probably protect against certain microbial strains. Nevertheless there has been considerable dispute in the literature with regard to the antibacterial activity of cerumen. Because of the importance of the role of immunoglobulins (Ig) in local defense mechanisms, we attempted to study, by immunohistochemical methods, the presence and localization of the cells necessary to activate an Ig-mediated immune response and the epithelial expression of immunoglobulin A (IgA), immunoglobulin M (IgM), and immunoglobulin G (IgG) in order to obtain information about a local immune response in those areas of the skin that take part in cerumen production. Our findings indicate that in the human skin of the external auditory canal the cells necessary to activate an antibody-mediated immune response were localized in the different layers of the epidermis and/or in the dermis surrounding the sebaceous and ceruminous glands and the piliary follicle, while an intense immunoreactivity for IgA and IgG was observed in the epithelial layers of the skin. The results suggest that the external auditory canal is protected from the insults of pathogens by an antibody-mediated local immune response, because all the effector components of an active local immune system are present.

[Primary retroperitoneal tumors. Our experience]. / I tumori retroperitoneali primitivi. Nostra esperienza.

Primary retroperitoneal tumors are rare (0.05-0.2% of all tumors), often malignant and characterized by a poor and non-specific symptomatology and by a late diagnosis. Complete resection is possible in only a few patients, while recurrence is very common. The records of 29 adult patients who underwent operative treatment at Surgical Oncology Institute-University of Cagliari between November 1973 and June 1992 were reviewed; 9 were males, 20 females, median age 46.4 years (range 12-82). There were 4 benign tumors (13.8%) and 25 malignant (86.2%). Fibrosarcoma (9 cases, 31%) and liposarcoma (3 cases, 10.3%) were the most frequent histologic types. There were also two fibroleiomyomas, leiomyosarcomas, malignant fibrous histiocytomas and neuroblastomas, one case of fibroma, neurofibroma, rhabdomyosarcoma and schwannoma. Five sarcoma were not otherwise specified. Abdominal mass (25 cases, 86.2%), flank or abdominal pain (15 cases, 51.7%) and weight loss (8 cases, 27.6%) were most common symptoms; change in bowel habit and constipation (6 cases, 20.7%), fever (5 cases, 17.2%), urinary disorders (4 cases, 13.8%) nausea and vomiting (2 cases, 6.7%) were less common. Diagnosis was made by ultrasonography, computed tomography and traditional radiographic studies. median interval between first symptoms and diagnosis was 11 months. Complete surgical resection was possible in only 13 cases (46.4%): 10 of the 25 malignant tumors (40%) and 3 of the 4 benign tumors (75%).(ABSTRACT TRUNCATED AT 250 WORDS)

[A serious complication due to liquid silicone injection in the legs for cosmetic purpose]. / Effetto collaterale da iniezione di silicone liquido nelle gambe per uso estetico.

Liquid injectable silicone has been used to increase volume in determined cutaneous districts, particularly in aesthetical reconstructive surgery. Although considered biologically inert for a long time this substance produced various complications as granulomatous foreign body reaction (siliconomas), secondary limphedema, tissue destruction and lethal embolism. A 35-year-old Caucasian woman came to our department with erithema and edema on the right leg, fever and chills. A thorough examination of the patient's history revealed injection of liquid silicone 7 years before for cosmetic volume increase of both legs. A closer observation revealed a small fistulous element from which came out white-yellow puruloid material. Antibiotic therapy and drainage of the abscess were undertaken. Within few days of treatment erithema and swelling essentially improved and the patient was discharged. After two months she came back to our department due to the same disease on her left leg that we treated with the therapy previously used. We highlight the long time, 7 years, elapsed between liquid silicone injection and onset of cutaneous symptoms.

The usefulness of c-Kit in the immunohistochemical assessment of melanocytic lesions.

C-Kit (CD117), the receptor for the stem cell factor, a growth factor for melanocyte migration and proliferation, has shown differential immunostaining in various benign and malignant melanocytic lesions. The purpose of this study is to compare c-Kit immunostaining in benign nevi and in primary and metastatic malignant melanomas, to determine whether c-Kit can aid in the differential diagnosis of these lesions. c-Kit immunostaining was performed in 60 cases of pigmented lesions, including 39 benign nevi (5 blue nevi, 5 intradermal nevi, 3 junctional nevi, 15 cases of primary compound nevus, 11 cases of Spitz nevus), 18 cases of primary malignant melanoma and 3 cases of metastatic melanoma. The vast majority of nevi and melanomas examined in this study were positive for c-Kit, with minimal differences between benign and malignant lesions. C-Kit cytoplasmatic immunoreactivity in the intraepidermal proliferating nevus cells, was detected in benign pigmented lesions as well as in malignant melanoma, increasing with the age of patients (P=0.007) in both groups. The patient's age at presentation appeared to be the variable able to cluster benign and malignant pigmented lesions. The percentage of c-Kit positive intraepidermal nevus cells was better associated with age despite other variables (P=0.014). The intensity and percentage of c-Kit positivity in the proliferating nevus cells in the dermis was significantly increased in malignant melanocytic lesions (P=0.015 and P=0.008) compared to benign lesions (compound melanocytic nevi, Spitz nevi, intradermal nevi, blue nevi). Immunostaning for c-Kit in metastatic melanomas was negative. Interestingly in two cases of melanoma occurring on a pre-existent nevus, the melanoma tumor cells showed strong cytoplasmatic and membranous positivity for c-kit, in contrast with the absence of any immunoreactivity in pre-existent intradermal nevus cells. C-Kit does not appear to be a strong immunohistochemical marker for distinguishing melanoma from melanocytic nevi, if we consider c-Kit expression in intraepidermal proliferating cells. The c-Kit expression in proliferating melanocytes in the dermis could help in the differential diagnosis between a superficial spreading melanoma (with dermis invasion) and a compound nevus or an intradermal nevus. Finally, c-Kit could be a good diagnostic tool for distinguishing benign compound nevi from malignant melanocytic lesions with dermis invasion and to differentiate metastatic melanoma from primary melanoma.

Platysma myocutaneous flap for reconstruction of skin defects in the head and neck.

The platysma myocutaneous flap (PMF) is a common reconstructive option for defects in the head and neck region. Its applications have expanded from the reconstruction of intraoral defects to include laryngo-pharyngeal, lip, and cheek defects. The platysma flap can be superiorly, posteriorly, or inferiorly-based. The superiorly-based flap has a robust arterial blood supply but less efficient venous drainage, whereas the opposite is the case with the posteriorly-based flap. We present our results of using a superiorly based PMF flap for reconstruction of defects in the parotid, auricular/mastoid, and cheek regions after resection for squamous cell carcinoma. Of 11 patients, eight had no postoperative complications. The remaining three developed venous congestion of their flaps, in two of whom it led to secondary epidermolysis and limited skin loss. The venous congestion resolved with conservative management, and all flaps remained viable. The PMF flap is an alternative to more complex reconstructive options for skin defects of the auricular, parotid, and cheek regions, and gives a satisfactory cosmetic result.