Comparative Analysis of the Cutaneous Microbiome in Psoriasis Patients and Healthy Individuals-Insights into Microbial Dysbiosis: Final Results.

Psoriasis is one of the most frequent chronic inflammatory skin diseases and exerts a significant psychological impact, causing stigmatization, low self-esteem and depression. The pathogenesis of psoriasis is remarkably complex, involving genetic, immune and environmental factors, some of which are still incompletely explored. The cutaneous microbiome has become more and more important in the pathogenesis of inflammatory skin diseases such as acne, rosacea, atopic dermatitis and psoriasis. Dysbiosis of the skin microbiome could be linked to acute flare ups in psoriatic disease, as recent studies suggest. Given this hypothesis, we conducted a study in which we evaluated the cutaneous microbiome of psoriasis patients and healthy individuals. In our study, we collected multiple samples using swab sampling, adhesive tape and punch biopsies. Our results are similar to other studies in which the qualitative and quantitative changes found in the cutaneous microbiome of psoriasis patients are different than healthy individuals. Larger, standardized studies are needed in order to elucidate the microbiome changes in psoriasis patients, clarify their role in the pathogenesis of psoriasis, decipher the interactions between the commensal microorganisms of the same and different niches and between microbiomes and the host and identify new therapeutic strategies.

Host-Microbiome Crosstalk in Chronic Wound Healing.

The pathogenesis of chronic wounds (CW) involves a multifaceted interplay of biochemical, immunological, hematological, and microbiological interactions. Biofilm development is a significant virulence trait which enhances microbial survival and pathogenicity and has various implications on the development and management of CW. Biofilms induce a prolonged suboptimal inflammation in the wound microenvironment, associated with delayed healing. The composition of wound fluid (WF) adds more complexity to the subject, with proven pro-inflammatory properties and an intricate crosstalk among cytokines, chemokines, microRNAs, proteases, growth factors, and ECM components. One approach to achieve information on the mechanisms of disease progression and therapeutic response is the use of multiple high-throughput 'OMIC' modalities (genomic, proteomic, lipidomic, metabolomic assays), facilitating the discovery of potential biomarkers for wound healing, which may represent a breakthrough in this field and a major help in addressing delayed wound healing. In this review article, we aim to summarize the current progress achieved in host-microbiome crosstalk in the spectrum of CW healing and highlight future innovative strategies to boost the host immune response against infections, focusing on the interaction between pathogens and their hosts (for instance, by harnessing microorganisms like probiotics), which may serve as the prospective advancement of vaccines and treatments against infections.

The Contribution of the Skin Microbiome to Psoriasis Pathogenesis and Its Implications for Therapeutic Strategies.

Psoriasis is a common chronic inflammatory skin disease, associated with significant morbidity and a considerable negative impact on the patients' quality of life. The complex pathogenesis of psoriasis is still incompletely understood. Genetic predisposition, environmental factors like smoking, alcohol consumption, psychological stress, consumption of certain drugs, and mechanical trauma, as well as specific immune dysfunctions, contribute to the onset of the disease. Mounting evidence indicate that skin dysbiosis plays a significant role in the development and exacerbation of psoriasis through loss of immune tolerance to commensal skin flora, an altered balance between Tregs and effector cells, and an excessive Th1 and Th17 polarization. While the implications of skin dysbiosis in psoriasis pathogenesis are only starting to be revealed, the progress in the characterization of the skin microbiome changes in psoriasis patients has opened a whole new avenue of research focusing on the modulation of the skin microbiome as an adjuvant treatment for psoriasis and as part of a long-term plan to prevent disease flares. The skin microbiome may also represent a valuable predictive marker of treatment response and may aid in the selection of the optimal personalized treatment. We present the current knowledge on the skin microbiome changes in psoriasis and the results of the studies that investigated the efficacy of the different skin microbiome modulation strategies in the management of psoriasis, and discuss the complex interaction between the host and skin commensal flora.

Recent-Onset Melanoma and the Implications of the Excessive Use of Tanning Devices-Case Report and Review of the Literature.

Introduction: Melanoma, a malignant tumor arising from uncontrolled melanocytic proliferation, commonly found in the skin but capable of affecting extracutaneous sites, ranks fifth among diagnosed oncological entities and is a significant cause of cancer deaths, constituting over 80% of skin cancer mortality. Genetic factors and ultraviolet radiation (UVR) exposure, from both natural and artificial sources, are the primary risk factors. Case Presentation: We reported the case of a 25-year-old female with numerous pigmented nevi and notable changes attributed to extensive indoor tanning sessions. Dermatological examinations and dermoscopic evaluations revealed atypical features in two pigmented nevi, leading to surgical excision. Histopathological and immunohistochemical analyses confirmed a compound nevus in one lesion and superficial spreading melanoma in the other, emphasizing the importance of vigilant follow-up and the correct use of immunohistochemistry. Discussion: Indoor tanning significantly elevates the cutaneous melanoma risk, with initiation before age 35 amplifying the risk by up to 75%, especially in young women. The risk escalates with cumulative sessions, particularly exceeding 480, and individuals undergoing over 30 sessions face a 32% higher risk. UVR induces DNA damage, genetic mutations, and immunosuppression, contributing to oncogenesis. Genetic factors, like the PTCHD2 gene, may influence the tanning dependency. Legislation targeting minors has been enacted globally but only with partial efficacy. Tanning accelerators, though associated with minor side effects, correlate with high-risk behaviors. The case underscores the urgency of addressing indoor tanning risks, emphasizing targeted awareness efforts and legislative improvements. Conclusions: In conclusion, the reported case highlights the increased risk of cutaneous melanoma linked to indoor tanning, particularly among young women and specific sociodemographic groups. Despite legislative measures, challenges persist, suggesting the potential efficacy of online campaigns involving relatable influencers to raise awareness and discourage artificial tanning.

Perspectives on Psoriasiform Adverse Events from Immune Checkpoint Inhibitors: Lessons Learned from Our Practice.

Background: New oncologic therapies, including immune checkpoint inhibitors (ICIs), have revolutionized the survival and prognosis of cancer patients. However, these therapies are often complicated by immune-related adverse effects (irAEs) that may impact quality of life and potentially limit their use. Among these adverse events are psoriasis and psoriatic arthritis that may develop de novo or flare under treatment with ICIs. Given the exceptional immune status of patients receiving ICIs, managing these conditions without interfering with the effect of the oncologic treatment may prove very challenging. Aim: To review the literature data on ICI-induced psoriasis exacerbation or development, to present our own experience, and to discuss the pathogenic mechanisms underlying this association and the optimal therapeutic approach for these patients. Case Reports: We report three cases of ICI-induced de novo psoriasis and two cases of ICI-induced psoriasis exacerbation that required systemic treatment. Oral acitretin treatment successfully controlled psoriasis lesions in three cases and allowed for the continuation of immunotherapy. Literature Review: We performed a medical literature search across several databases (PubMed, Medline, Google Scholar) using the search terms "immune checkpoint inhibitor-induced psoriasis/psoriasiform dermatitis/psoriasis arthritis". We identified and revised 80 relevant publications that reported 1102 patients with psoriasis and/or psoriasis arthritis induced or exacerbated by ICIs. We assessed the type of cancer, the therapeutic agent involved, the clinical form of psoriasis, the presence or absence of psoriatic arthritis, the personal and family history of psoriasis, the age, the gender, the time until onset or exacerbation of skin lesions, the specific treatment recommended, the need for ICI discontinuation, and the patient's outcome. Conclusions: As ICIs represent a fairly novel therapy, the association with several adverse effects is only now unraveling. Psoriasis exacerbation or onset following the initiation of immunotherapy is one such example, as more and more reports and case series are being published. Awareness of the relationship between psoriasis and treatment with ICIs, prompt recognition, and initiation of adequate skin-directed therapies are essential for the avoidance of skin lesions worsening, the need for systemic treatments that may interfere with ICIs' effects, or the discontinuation of the latter. In the absence of generally accepted guidelines, it is advisable to treat patients with severe, widespread psoriasis with drugs that do not impair the effects of immunotherapy and thus do not alter the patient's prognosis.

Ultrasound Enthesitis in Psoriasis Patients with or without Psoriatic Arthritis, a Cross-Sectional Analysis.

Background and objectives: The main objective of the current study was to describe the prevalence of enthesitis at different sites in a group of patients with psoriasis with or without psoriatic arthritis (PsA). Materials and Methods: The study included adult patients with psoriasis who underwent clinical examination, laboratory tests and ultrasound examination of the entheses. The enthesitis ultrasound scores (BUSES, MASEI, GUESS) were evaluated; the presence of OMERACT-defined enthesitis was also recorded for each scan site. Results: The study included 16 (57.1%) patients with PsA and 12 (42.9%) patients with psoriasis, with an increased average body mass index (29.3 kg/m2). Compared to psoriasis patients, PsA patients had a higher prevalence of nail psoriasis (68.8% compared to 33.3%; p = 0.063). There were no significant differences regarding the clinical examination of entheses between patients with psoriasis and patients with PsA (p = 0.459). Ultrasound scores, BUSES, GUESS and MASEI proved to have statistically significant higher median values in PsA patients compared to psoriasis patients. Compared to psoriasis patients, PsA patients had a significantly higher prevalence of OMERACT-defined enthesitis of the quadriceps tendon and inferior patellar ligament (both 81.3% compared to 25.0%, p = 0.003). Clinical examination of the lateral epicondyle and of the superior patellar ligament was consistent with their ultrasound examination (κ = 0.357, p = 0.043, respectively, κ = 0.404, p = 0.008). Conclusions: Clinical enthesitis scores do not differ between psoriasis and PsA patients. All analyzed ultrasound scores are significantly higher in patients with PsA. OMERACT-defined enthesitis has the ability to discriminate sonographic enthesitis between the two subgroups for bilateral quadriceps and inferior patellar tendon enthesitis. Bilateral ultrasound damage of entheses can suggest a PsA diagnosis.

Botulinum Toxin Use for Modulating Neuroimmune Cutaneous Activity in Psoriasis.

Psoriasis is a complex immune-mediated inflammatory disorder that generates enormous interest within the scientific communities worldwide, with new therapeutic targets being constantly identified and tested. Despite the numerous topical and systemic medications available for the treatment of psoriasis, alternative therapies are still needed for the optimal management of some patients who present with localized, resistant lesions. Novel insights into the contribution of cutaneous neurogenic inflammation in the pathogenesis of psoriasis have yielded exciting new potential roles of nerve-targeting treatments, namely botulinum toxin type A (BoNT-A), for the management of this disease. This paper aims to review the existing literature on knowledge regarding the potential role of BoNT-A in psoriasis treatment, with a focus on its ability to interfere with the immunopathogenetic aspects of psoriatic disease. Furthermore, in our paper, we are also including the first report of psoriatic lesions remission following local BoNT-A injections that were administered for treating upper limb spasticity, in a patient that concomitantly suffered from psoriasis and post-stroke spasticity.

Current and Future Approaches in Management of Chronic Spontaneous Urticaria Using Anti-IgE Antibodies.

Chronic spontaneous urticaria (CSU) considerably alters patients' quality of life, often for extended periods, due to pruriginous skin lesions, impaired sleep, unexpected development of angioedema, and failure of conventional treatments in properly controlling signs and symptoms. Recent research focused on the development of new therapeutic agents with higher efficacy. Although the production of specific immunoglobulin E (IgE) antibodies against certain allergens is not a characteristic of the disease, treatment with omalizumab, a monoclonal anti-IgE antibody, proved efficient and safe in patients with moderate to severe chronic spontaneous urticaria uncontrolled by H1-antihistamines. Ligelizumab, a high-affinity monoclonal anti-IgE antibody, may also efficiently relieve symptoms of unresponsive chronic urticaria to standard therapies. This comprehensive review aims to present recently acquired knowledge on managing chronic spontaneous urticaria with new anti-IgE antibodies. We conducted extensive research on the main databases (PubMed, Google Scholar, and Web of Science) with no restrictions on the years covered, using the search terms "anti-IgE antibodies", "omalizumab", "ligelizumab", and "chronic spontaneous urticaria". The inclusion criteria were English written articles, and the exclusion criteria were animal-related studies. ClinicalTrials.gov was also reviewed for recent relevant clinical trials related to CSU treatment. CSU is a challenging disease with a significant effect on patients' quality of life. Current therapies often fail to control signs and symptoms, and additional treatment is needed. New biologic therapies against IgE antibodies and FcεRIα receptors are currently under investigation in advanced clinical trials. We reviewed recently published data on CSU management using these novel treatments. The development of new and improved treatments for CSU will lead to a more personalized therapeutical approach for patients and provide guidance for physicians in better understanding disease mechanisms. However, some agents are still in clinical trials, and more research is needed to establish the safety and efficacy of these treatments.

Allergic Contact Dermatitis to Acrylates: A Case Report.

(Meth)acrylates are a common cause of allergic contact dermatitis (ACD) that can be found in medical (such as pads) and aesthetic (specifically nail cosmetics) products. Prolonged and intimate contact with sanitary pads can predispose individuals to ACD triggered by a variety of allergens. This report presents the case of a young female patient with episodes of nail contact dermatitis followed by a protracted history of intensely symptomatic allergic contact dermatitis affecting the external genital area, precipitated by methacrylates present in menstrual pads.

Pyoderma Gangrenosum: The Impact of Treatment Non-adherence on Disease Progression.

Pyoderma gangrenosum (PG) is a rare, ulcerative, rapidly progressing, destructive, inflammatory cutaneous disease that is both diagnostically and therapeutically challenging. Due to the lack of standardized diagnostic criteria or conclusive guidelines for patient management, clinicians often find themselves without reliable tools for the daily management of PG patients. Additionally, the lack of strict therapeutic compliance in patients with this diagnosis might contribute to a catastrophic evolution of the condition. We report a case of ulcerative PG that is illustrative of the inherent challenges posed by patients frequently changing healthcare providers and treatment regimens, displaying inconsistency and non-adherence. Such behaviors can lead to the loss of disease control, particularly in the context of extensive or rapidly progressing PG, ultimately culminating in the development of mutilating forms of this disease.

Solitary Superficial Angiomyxoma in an Uncommon Location: A Case Report and Literature Review.

Superficial angiomyxoma (SAM) is a rare, benign, and slow-growing soft tissue tumor with a tendency for frequent local recurrence. Most SAMs are solitary and sporadic. However, multiple SAMs, particularly on the external ear or eyelids, may be the initial or only sign of the Carney complex, an autosomal dominant syndrome that impacts various organs, including the heart, breasts, and skin, and is linked to endocrine hyperactivity. To ensure an accurate diagnosis, a comprehensive patient interview, physical examination, and laboratory tests, including endocrine-specific markers and imaging studies, are essential. Due to the high risk of recurrence, especially in large, encapsulated lesions, complete surgical excision is the preferred treatment approach. We present a case of a 24-year-old female with SAM on the shoulder, review the relevant literature, and discuss the pathogenesis and appropriate management of such cases.

Successful Radiotherapy for Metastatic Basal Cell Carcinoma to the Parotid Gland in a Patient With Gorlin-Goltz Syndrome.

Gorlin-Goltz syndrome (GGS), also known as nevoid basal cell carcinoma syndrome (NBCCS), is an autosomal dominant condition characterized by a predisposition to multiple basal cell carcinomas (BCCs) and other neoplasms and is commonly associated with pathogenic variants in the PTCH1 or SUFU tumor suppressor genes. However, the absence of these genetic markers does not preclude the diagnosis due to the variable genetic expression of the syndrome. Diagnosis relies on a set of established major and minor criteria, particularly when genetic testing fails to identify the typical pathogenic variants. The primary clinical manifestation of GGS is the development of multiple BCCs. While these typically exhibit slow growth and remain localized, they can manifest more aggressive behavior in individuals with GGS, including local invasiveness and metastatic potential. Moreover, patients with GGS display heightened sensitivity to ionizing radiation, leading to general contraindications for radiation therapy (RT) due to the risk of inducing additional BCCs. Despite these concerns, we report a case where RT was the only feasible treatment for an inoperable BCC that had metastasized to the parotid gland in a GGS patient. The successful use of RT, which resulted in a cure without adverse effects, illustrates that RT may be a viable option for some GGS patients, reflecting individual variability in radiation sensitivity. This case underscores the importance of personalized treatment plans in managing the complex presentations of GGS, challenging the traditional constraints regarding the use of RT in these patients and suggesting the potential for its reconsideration under specific circumstances.

Mechanisms of Resistance to Rituximab Used for the Treatment of Autoimmune Blistering Diseases.

Autoimmune blistering diseases represent a group of chronic severe, disabling, and potentially fatal disorders of the skin and/or mucous membranes, primarily mediated by pathogenic auto-antibodies. Despite their rarity, these diseases are associated with significant morbidity and mortality and profound negative impact on the patient's quality of life and impose a considerable economic burden. Rituximab, an anti-CD-20 monoclonal antibody, represents the first line of therapy for pemphigus, regardless of severity and a valuable off-label therapeutic alternative for subepidermal autoimmune blistering diseases as it ensures high rates of rapid, long-lasting complete remission. Nevertheless, disease recurrence is the rule, all patients requiring maintenance therapy with rituximab eventually. While innate resistance to rituximab in pemphigus patients is exceptional, acquired resistance is frequent and may develop even in patients with initial complete response to rituximab, representing a real challenge for physicians. We discuss the various resistance mechanisms and their complex interplay, as well as the numerous therapeutic alternatives that may be used to circumvent rituximab resistance. As no therapeutic measure is universally efficient, individualization of rituximab treatment regimen and tailored adjuvant therapies in refractory autoimmune blistering diseases are mandatory.

The Importance of In Vivo Reflectance Confocal Microscopy in a Case of Desmoplastic Melanoma.

Desmoplastic melanoma accounts for 5% of all cases of melanoma, but its diagnosis can be difficult due to its frequent clinical presentation with amelanotic lesions. Histologically, spindled melanocytes surrounded by a collagenous stroma are observed. Compared with other types of melanoma, the desmoplastic types presents greater local aggression, and is more prone to local recurrence, but has a lower risk of lymph node metastasis. Early detection, accurate staging, and proper surgical management are the main factors associated with higher survival rates in melanoma patients. Reflectance confocal microscopy (RCM) has proven to be a valuable imaging tool in the diagnosis of skin neoplasms, being useful for orientating practitioners towards the diagnosis of melanoma and indicating the necessity of performing a diagnostic biopsy. We present the case of 52-year-old woman, who presented to the dermatology department with an irregular, dark-colored plaque in the right deltoid region. Dermoscopy showed asymmetry with an atypical network and some areas of regression. RCM revealed pagetoid cells in the upper epidermis, cell atypia, non-edged papillae, dermal inflammation, and nucleated cells in the dermis, which are highly suggestive of melanoma. A biopsy was also performed. A histopathology exam confirmed the diagnosis of superficially spreading melanoma with a desmoplastic component, and revealed a Breslow index of 0.9 mm, Clark level IV, an absence of mitoses, angiolymphatic invasion and regression, and complete excision. The CT and PET-CT scans were negative. A biopsy of the axillary sentinel lymph node was conducted, with a negative result obtained, establishing the IB stage of the disease. The patient will remain under follow-up to look for a recurrence or a new primary melanoma.

A Current Diagnostic and Therapeutic Challenge: Tinea Capitis.

Tinea capitis is a dermatophyte scalp infection with a marked prevalence among the pediatric population. However, in the last few years, its epidemiology has changed due to increasing population migration worldwide. Host-specific and environmental factors contribute to the pathogenesis of tinea capitis. Clinically, tinea capitis may present as a subtle hair loss accompanied by scalp scaling, alopecia with scaly patches, or alopecia with black dots. A more severe form of tinea capitis is represented by kerion celsi, which clinically presents as a tender plaque covered by pustules and crusts. If left untreated, this dermatophytic infection may resolve with permanent scarring and alopecia. The pathological changes found in tinea capitis are reflected by a spectrum of clinical changes. Zoophilic infections typically prompt an extensive inflammatory reaction, while anthropophilic dermatophytoses often lack inflammation and result in more persistent lesions. Tinea capitis typically requires systemic antifungal therapy. Griseofulvin, terbinafine, itraconazole, and fluconazole are the main antifungal agents used. Currently, the duration of antifungal therapy varies based on the clinical presentation and type of dermatophyte involved. Through the reported cases and literature review, we aim to emphasize the importance of the early recognition of atypical variants of tinea capitis in immunocompetent children for the prompt initiation of systemic antifungal therapy, minimizing the need for prolonged treatment. Additionally, we emphasize the importance of regular laboratory testing during systemic antifungal therapy, particularly liver enzyme tests, to prevent adverse events, especially in cases requiring long-term treatment.

Cutaneous Adverse Reactions Associated with Tattoos and Permanent Makeup Pigments.

Tattooing is the procedure of implanting permanent pigment granules and additives into the dermal layer of the skin, serving various purposes such as decoration, medical identification, or accidental markings. There has been a significant rise in the popularity of decorative tattooing as a form of body art among both teenagers and young adults. Thus, the incidence of tattoos is increasing, with expanding applications such as permanent makeup, scar camouflage, nipple-areola, lips, and eyebrows tattooing, and utilization in oncological radiotherapy such as colon marking. However, there have been reported a broad range of adverse reactions linked to tattooing, encompassing allergic reactions, superficial and deep cutaneous infections, autoimmune disorders induced by the Koebner phenomenon, cutaneous tumors, and others. These reactions exhibit different onset times for symptoms, ranging from immediate manifestations after tattoo application to symptoms emerging several years later. Given the limited information on a tattoo's side effects, this review aims to elucidate the clinical spectrum of cutaneous complications of tattoos in different patients. The analysis will investigate both allergic and nonallergic clinical presentations of tattoo-related side effects, microscopic findings from skin biopsies, and therapeutic outcomes. This exploration is essential to improve our understanding of tattoo-related cutaneous complications and associated differential diagnoses and highlight the significance of patient awareness regarding potential risks before getting a tattoo.

Ultrasound-Guided Botulinum Toxin-A Injections into the Masseter Muscle for Both Medical and Aesthetic Purposes.

With the increasing use of Botulinum toxin type A (BoNT-A) injections in the masseter muscles for both medical and aesthetic purposes, there is a constant need to continually enhance the efficacy of these treatments and reduce the risk of potential adverse events. This review provides an in-depth analysis of the masseter muscle's anatomical structure and essential landmarks and emphasizes the advantages of ultrasound (US) guidance in improving the precision of BoNT-A injections compared to conventional blind methods. The review is supplemented with comprehensive figures, including graphics, clinical images, and ultrasound visuals, to support the discussion. Potential complications such as paradoxical bulging, inadvertent injections into the risorius muscle or parotid gland, facial paralysis, and the risk of bone resorption are examined. Future research should aim at refining injection techniques and assessing the long-term effects of repeated treatments to ensure optimal patient care and safety.

An Eastern County from an European Eastern Country-The Characteristics of Cutaneous Microbiome in Psoriasis Patients-Preliminary Results.

The cutaneous microbiome represents a topic of high interest nowadays. Multiple studies have suggested the importance of the skin microbiome in different dermatological pathologies, highlighting the possible implications of cutaneous microorganisms in either the pathogenesis or prognosis of skin maladies. Psoriasis represents a common inflammatory skin disease, with a high prevalence in the worldwide population. The role of the cutaneous microbiome in psoriasis could explain a number of pathogenic theories and treatment objectives of this incurable skin disease. Our interest in the characteristics of the cutaneous microbiome, especially in psoriatic patients who attended a tertiary dermatological centre in Galati, Romania, is reflected in our current study, of which the preliminary results are discussed in this article. Using three types of skin sampling techniques (swabs, adhesive tape, and punch biopsies), we tried to characterise the microorganisms harboured in the skin of psoriatic patients and healthy individuals. This study was performed using culture-based probes, which were analysed using MALDI-TOF mass spectrometer equipment. Our preliminary results suggested that the greatest diversity was observed in the perilesional areas of psoriatic patients. The lowest cutaneous diversity was obtained from sampling psoriatic plaques. These results are similar to other studies of the cutaneous microbiome in psoriasis. The most frequent microorganisms found in all groups studied were of the Staphylococcus species: Staphylococcus epidermidis, Staphylococcus hominis, and Staphylococcus aureus. Analysing the living environment of each individual from this study, our preliminary results suggested different results from other studies, as higher diversity and heterogenicity was observed in urban environments than in rural living areas. Regarding the differences between sexes, our preliminary results showed higher quantitative and qualitative changes in the skin microbiome of male participants than female participants, opposite to the results found in other studies of the cutaneous microbiome in psoriasis. Given these preliminary results, we can conclude that we have found important differences by studying the cutaneous microbiome of psoriatic patients and healthy control individuals from a population that, to our knowledge, has not been yet studied from this point of view. Our results showed important characteristics of the skin microbiome in an Eastern European population, where cultural and environmental living habits could influence the cutaneous microbiome.

The Curious Case of the Choledochal Cyst-Revisiting the Todani Classification: Case Report and Review of the Literature.

Choledochal cysts (CCs) are rare occurrences presenting as dilatations of biliary structures, which can present as single or multiple dilatations and can appear as both intra- and extrahepatic anomalies. The most widespread classification of CCs is the Todani classification, but there have been numerous reports of cysts that do not fall into any of the types described. We present such a case-a male patient 36 years of age who underwent preoperative CT, MRCP, and ERCP, which mistakenly indicated a type II Todani CC, and intraoperatively was found to be located at the confluence of the hepatic ducts and encompassed the origin of the common bile duct. Complete resection of the cyst and the proximal segment of the common bile duct was performed, and reconstruction was carried out by Roux-en-Y double-tutorized hepaticojejunostomy. Considering the risk of malignant transformation, the frequent preoperative misdiagnosis, as well as the technically challenging surgery required in such cases, we advocate for a revision of the classification and raise awareness of the need for guidelines regarding the proper short-term and long-term management of this disease to ensure adequate quality of life and disease-free survival for patients.

Antimicrobial Biomaterials for Chronic Wound Care.

Chronic wounds encompass a myriad of lesions, including venous and arterial leg ulcers, diabetic foot ulcers (DFUs), pressure ulcers, non-healing surgical wounds and others. Despite the etiological differences, chronic wounds share several features at a molecular level. The wound bed is a convenient environment for microbial adherence, colonization and infection, with the initiation of a complex host-microbiome interplay. Chronic wound infections with mono- or poly-microbial biofilms are frequent and their management is challenging due to tolerance and resistance to antimicrobial therapy (systemic antibiotic or antifungal therapy or antiseptic topicals) and to the host's immune defense mechanisms. The ideal dressing should maintain moisture, allow water and gas permeability, absorb wound exudates, protect against bacteria and other infectious agents, be biocompatible, be non-allergenic, be non-toxic and biodegradable, be easy to use and remove and, last but not least, it should be cost-efficient. Although many wound dressings possess intrinsic antimicrobial properties acting as a barrier to pathogen invasion, adding anti-infectious targeted agents to the wound dressing may increase their efficiency. Antimicrobial biomaterials may represent a potential substitute for systemic treatment of chronic wound infections. In this review, we aim to describe the available types of antimicrobial biomaterials for chronic wound care and discuss the host response and the spectrum of pathophysiologic changes resulting from the contact between biomaterials and host tissues.