Brodalumab: A new way to inhibit IL-17 in psoriasis.

Psoriasis is a chronic inflammatory disease that affects 2% to 4% of the population; about 20% of the patients present a moderate-to-severe form. The IL-23/Th17/IL-17 molecular axis is considered crucial in the pathogenesis of psoriasis and IL-17 is fundamental in the maintenance of the immune and inflammatory alterations causing psoriasis. Expression of IL-17A, IL-17F, and IL-17C is strongly increased in psoriatic plaques. Effective therapy leads to restoration of the expression of a wide range of genes (including effector cytokines and chemokines downstream of IL-17) to near normal levels. Brodalumab is the first biologic drug targeting specifically the subunit A of the IL-17 receptor (IL-17RA) and thus inhibiting not only IL-17A but also other members of the IL-17 family. Brodalumab is very effective and safe in treating moderate-to severe psoriasis.

Pancreatic panniculitis: the "bright" side of the moon in solid cancer patients.

BACKGROUND: Pancreatic panniculitis is a rare complication of pancreas disorders occurring in 0.3-3% of patients, most often accompanied by the pancreatic acinar carcinoma. It presents multiple, painful, deep, ill-defined, red-brown, migratory nodules and plaques of hard elastic consistency; often ulcerated and typically located on the lower proximal and distal extremities. The pathogenesis is not fully understood, but it is thought to result from lipolysis and fat necrosis with secondary tissue inflammation induced by pancreatic enzymes. Histopathology shows subcutaneous lobular fat necrosis with anuclear adipocytes (called ghost cells) surrounded by a mixed inflammatory infiltrate. Focal calcification may also be seen. The treatment is directed to the underlying disorder, which may result in regression of skin lesions. CASE PRESENTATION: We present two cases of pancreatic panniculitis with similar clinical, laboratory, and histopathological features associated with different internal malignancy. The first case, after extensive investigations showed the presence of a pancreatic carcinoma with multiple liver metastases and a poor prognosis. The second one instead is the first case in literature where painful subcutaneous nodules of the legs were the early manifestation of a neuroendocrine carcinoma of the adrenal gland. CONCLUSIONS: Although subcutaneous fat necrosis usually occurs late in the course of a malignancy, recognition of the association with pancreatic panniculitis may prevent a long delay in the diagnosis and management of the occult neoplasm. It should be primarily considered when panniculitis is widespread and persistent, and frequent relapses or tendency to ulcerate of the nodules are regarded as red flags.

Comparison of clinical and sonographic scores in hidradenitis suppurativa and proposal of a novel ultrasound scoring system.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic, inflammatory disease that presents with nodules, abscesses and fistulae affecting the apocrine gland-bearing skin. Since few years, ultrasonography is used to better characterize HS skin lesions but comparison between clinical and sonographic scores has been made only in small series of patients. To assess concordance between clinical and sonographic scores in a larger cohort of HS patients. METHODS: We conducted a retrospective observational study on 140 HS patients comparing two clinical score systems, Hurley and HS-Physical Global Assessment (PGA), with two ultrasonographic scores, sonographic score of hidradenitis suppurativa (SOS-HS) and ultrasonographic HS-PGA, a novel ultrasound scoring system set up by our group. We used the weighted Cohen's Kappa statistic (k) to evaluate the agreement. RESULTS: Agreement between Hurley staging and SOS-HS was found in 61.4% of patients (weighted kappa 0.477), while agreement between clinical and ultrasonography HS-PGA scores was found in 35% of patients (weighted kappa 0.278), both findings suggesting a substantial disagreement. CONCLUSIONS: Our study demonstrated a relevant disagreement between clinical and ultrasonography scores. Ultrasonography discovered non-clinically evident HS lesions, notably fistulae. Taken together, the above findings may support the view, previously suggested in expert panel reports, on the higher sensitivity of ultrasonography compared to clinics in HS.

Immunohistochemical expression and prognostic role of CD10, CD271 and Nestin in primary and recurrent cutaneous melanoma.

BACKGROUND: CD10, CD271 and Nestin, which are proteins associated with tumor-initiating properties and/or progression potential, have not been specifically studied on malignant melanoma (MM) with cutaneous recurrences. METHODS: We evaluated the expression of CD10, CD271 and Nestin in 27 tumor samples from 16 patients. These tumor samples corresponded to 6 primary melanomas which developed 11 ITM and 10 primary melanomas without recurrences at 10-year follow-up from specimens obtained from surgical excisions of patients referred to the Unit of Dermatology, Department of Medical-Surgical and Transplant Physiopathology, University of Milan, between 2006 and 2016. RESULTS: We demonstrated a higher expression of CD271 and Nestin in primary tumors which recurred than control population, Nestin was expressed with significantly higher percentages in primary tumors than recurrences, and CD10 expression was statistically significant correlated with disease-free survival: cases with a lower score recurred lately than cases with higher scores. CONCLUSIONS: Our preliminary results suggested that CD271 and Nestin can be considered early biomarkers for the development of ITM, Nesting can be useful in differentiating primary MM from cutaneous recurrences and CD10 is associated with a rapid disease progression and may be considered a potential prognostic marker.

Cutaneous tricholemmal carcinoma: a 15-year single center experience.

BACKGROUND: Clear cell morphology has been described in several cutaneous neoplasms either as a specific feature of some entities either as a morphological variant in the spectrum, and these two entities are frequently considered together in the differential diagnosis. METHODS: We reviewed our series of cases occurred in our laboratory in order to further quantify the number of cases showing morphological features of tricholemmal differentiation and to investigate other clinical or histological difference. We retrieved 91 cases and, for each of them, all the clinical data regarding age, sex, clinical features, and clinical suspicious were collected, when available. RESULTS: The revision of the specimens concluded with a final diagnosis of tricholemmal carcinoma in 15 cases (17%), all the other cases were thus considered as squamous cell carcinoma with clear cell features. No statistically significant correlations were observed with the demografic or clinicopatholagical parameters such as age, sex or dimensions, but morphological revision highlighted a potentially greater "vertical" growth frequently not matched by a concomitant radial one in tricholemmal carcinoma than in squamous tumors. CONCLUSIONS: The debate upon the diagnostic distinction of these tumors is still ongoing with authors proposing the tricholemmal carcinoma as a variant of a squamous cell carcinoma rather than a distinct entity. Further studies are needed to confirm our data and to evaluate the reproducibility of this feature.

Hidradenitis suppurativa/acne inversa: a prospective bacteriological study and review of the literature.

BACKGROUND: Hidradenitis suppurativa is a chronic inflammatory disease of the hair follicle that usually involves specific anatomic areas which are partially occluded, have a higher density of eccrine and apocrine sweat glands and a higher pH. These characteristics could promote the superinfection of certain group of bacteria. We aimed to describe the bacteria that can be isolated from hidradenitis lesions and to establish a correlation between bacteriological results and clinical data. METHODS: We prospectively enrolled forty-six patients presenting purulent or seropurulent discharge. Sixty samples were performed using swabs, which were deeply introduced in the lesions. RESULTS: Fifty-two percent of cultures resulted positive and fifteen bacterial species were isolated. The more prevalent species were Proteus mirabilis and Staphylococcus aureus. Samples from advanced cases were more likely to yield a positive bacterial growth. CONCLUSIONS: In our study the rate of positive cultures increased in more severe stages of the disease, thus bacterial superinfection of established lesions may contribute to maintain chronic inflammation. We could not find statistically significant correlation with the sampled anatomic area or specific group of bacteria. Larger prospective studies should be performed.

Nestin Expression in Spitzoid Lesions: An Immunohistochemical Characterization With Clinical and Dermoscopic Correlations.

Spindle or epithelioid melanocytic (Spitz) nevi usually affect children or adolescents and growth in the face or the lower extremities. Histologically, they may show cytoarchitectural atypia and mitotic figures that could represent diagnostic pitfalls with malignant melanoma. Atypical spitzoid tumors (AST) indicate lesions that microscopically show intermediate characteristics between benign nevi and malignant melanoma. Nestin expression has been evaluated in benign nevi and malignant melanoma, but no studies on its role in Spitz lesion have been elaborated so far. Our results indicate that Nestin could allow to discriminate between AST and malignant spiztoid melanoma; the typical dermoscopic pattern is also associated with benign nevi in contrast to the atypical pattern that accumunates AST and malignant spitzoid melanoma.

Multidisciplinary approach for hidradenitis suppurativa patients.

Hidradenitis suppurativa or acne inversa is an inflammatory, chronic disease of the hair follicles located in specific areas of the skin surface (axillae, submammary, inguinal and intergluteal folds, pubis, genitalia and buttocks). The diagnosis and the management of this disease are usually made by the dermatologist. However, the frequent association of hidradenitis suppurativa or acne inversa with important systemic comorbidities needs the cooperation with a number of specialists. In particular, the cooperation with rheumatologists, gastroenterologists, endocrinologists, microbiologists/infectivologists, psychologists/psychiatrics and plastic surgeons is often helpful or necessary.

What is this very big skin lesion?

This clinical image shows the importance of the early diagnosis and treatment of any suspicious skin lesion.

Desmoid tumor of the abdominal wall A case report and literature review.

BACKGROUND: Desmoid tumor is a rare soft tissues neoplasia characterized by local invasiveness and by a tendency towards local recurrence although not towards metastasization. DISCUSSION: Etiology is not clear. Desmoid tumors originate from the monoclonal proliferation of one mesenchymal cell and develop in the context of fascial, muscular and aponeurotic tissue. They are free of capsule and do not usually metastatize, although they do present a high risk of local recurrence CONCLUSION: In the absence of a systematic data collection and of a clear distinction, in the existing databases, between primitive and recurrent lesions and between lesions of different sites, there are no standard guidelines for a correct management of desmoids. KEY WORDS: Aggressive fibromatos Desmoid tumor, Soft tissue neoplasia.

Cutaneous metastases of internal malignancies: an experience from a single institution.

BACKGROUND: Cutaneous metastases represent 2% of all skin tumours. Their recognition can be challenging, as they may present with different clinical features, with consequent frequent delay and failure in diagnosis. OBJECTIVES: To review our series of cutaneous metastatic lesions, analyse their frequency according to patient gender, histotype, localization of the primary tumour, and site of cutaneous metastasis, and correlate this data with clinicopathological parameters. MATERIALS & METHODS: We conducted a retrospective review of all cases of cutaneous metastases from visceral neoplasms diagnosed in our dermatopathology department from July 2003 to February 2017. We registered clinical, histological, and immunohistochemical data. Additional immunohistochemical staining panels were elaborated to confirm or identify the origin of the primary tumour, or at least to specify the histological subtype. RESULTS: We identified 45 histological diagnoses of cutaneous and mucocutaneous metastases. The primary tumour that was most likely to metastasize to the skin was breast cancer. Most cases of breast (89%) and lung cancer (86%) metastasized to the trunk. Of the lesions, 57.5% were nodules and 32.5% were plaques, more frequently multiple (64.4%). In 58% of cases, a metastasis was clinically suspected. Histological examination most frequently revealed an adenocarcinoma, sometimes suggestive of the site of origin. CONCLUSIONS: Cutaneous metastases should be primarily considered when discrete firm painless nodules emerge rapidly. Clinicians should carefully consider infiltrated lesions of the chest in women since scleroderma and erysipelas-like presentation can be a clue for undiagnosed breast cancer.

Onychomycosis caused by Trichosporon mucoides.

A case of onychomycosis caused by Trichosporon mucoides in a man with diabetes is presented. The infection was characterized by a brown-black pigmentation of the nail plates and subungual hyperkeratosis of the first three toes of both feet. Onychogryphosis was also visible on the third left toe. Direct microscopic examinations revealed wide and septate hyphae and spores. Three cultures on Sabouraud-gentamicin-chloramphenicol 2 agar and chromID Candida agar produced white, creamy, and smooth colonies that were judged to be morphologically typical of T. mucoides. Microscopic examinations of the colonies showed arthroconidia and blastoconidia. The urease test was positive. A sugar assimilation test on yeast nitrogen base agar showed assimilation of galactitol, sorbitol, and arabinitol. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) confirmed the diagnosis of T. mucoides infection. The patient was treated with topical urea and oral itraconazole. Three months later, a mild improvement was observed. The patient was subsequently lost to follow-up.

Nasal polyps: a predisposing factor for cutaneous leishmaniasis of the lips?

OBJECTIVES: Cutaneous leishmaniasis (CL) of the lips is rare. This study was conducted to investigate findings in patients with this condition. METHODS: From 2007 to date, we observed 10 patients (nine males and one female), with a median age of 45.2 years (range: 8-77 years), with CL of the lips. RESULTS: Six of the 10 patients suffered from nasal polyps, three from bronchial asthma, and one from chronic obstructive pulmonary disease (COPD). Three of the patients with nasal polyps also had asthma. Three patients had none of nasal polyps, asthma, or COPD. In all patients with nasal polyps, diagnosis was confirmed by anterior rhinoscopy and nasal endoscopy. CONCLUSIONS: It is possible that, in patients with nasal polyps, asthma, and COPD, the need to breathe through the mouth rather than the nose facilitates the sting by sandflies. Subjects with nasal polyps living in areas endemic for CL should be warned about the risk for being stung by sandflies on the lips, in addition to other uncovered areas.