Detection of demodex mites in papulopustular rosacea using microscopic examination and polymerase chain reaction: a comparative case-control study.

Demodex mite proliferation is frequently involved in the pathogenesis of rosacea. The gold standard for Demodex identification is microscopic examination on a standardized skin surface biopsy. However, this method of sampling can be distressing and painful, especially when performed on hairy sites. In this case-control study, we compared the sensitivity of PCR and microscopic examination in diagnosing a Demodex infestation. Moreover, we investigated the possible correlations between the presence of Demodex mites and clinical characteristics. In total, 20 patients affected by papulopustular rosacea and 10 controls were included. At both microscopic examination and PCR, patients with rosacea presented a greater prevalence of positive samples than controls at the scalp and at the face. Microscopy had sensitivity of 50% at the face and of 46.7% at the scalp. PCR had sensitivity of 93.75% at the face and of 86.7% at the scalp. The positivity of PCR was associated to a higher frequency of facial papules and pustules. Patients with positivity at the face had a more frequent positivity at the scalp. The scalp could represent a reservoir for the Demodex mites, and should be investigated by sensitive and painless methods. PCR performed on painlessly collected samples should be further investigated.

Presence of Demodex spp. on the face and scalp in patients affected by papulopustular rosacea of face.

BACKGROUND: The increased proliferation of Demodex mites in the pilosebaceous unit can be the cause of rosacea flare-ups on the face. Signs and symptoms of the scalp (e.g., itching, dandruff) have sometimes been reported in patients with papulopustular rosacea of face; they may be due to a proliferation of Demodex mites on the scalp. METHODS: To study the Demodex mites count, a standardized skin surface biopsy was performed on the cheek and on the scalp. Microscopic examination and molecular identification of Demodex were performed. Pearson's χ2 Test or Fisher's Exact Test were used to test for any association between categorical variables and outcome. RESULTS: Patients affected by papulopustular rosacea had a greater frequency of Demodex-positive standardized skin surface biopsy than controls at the scalp (35.0% vs. 0%, P=0.033), at the face and/or at the scalp (50% vs. 10%, P=0.032). Demodex positive patients with a Demodex-positive face sample were more frequently found to have a Demodex-positive scalp sample (P=0.035). The predominant species was found to be Demodex folliculorum (92.6% of samples); the species Demodex brevis was identified only in 7.4% of samples. CONCLUSIONS: Demodex folliculorum is more frequently found on the scalp and face of patients with rosacea than controls, even though it is not statistically associated with scalp symptoms. The scalp may be a reservoir area for Demodex mites which could migrate on the face again after an acaricidal treatment.

A deep learning approach to direct immunofluorescence pattern recognition in autoimmune bullous diseases.

BACKGROUND: Artificial intelligence (AI) is reshaping healthcare, using machine and deep learning (DL) to enhance disease management. Dermatology has seen improved diagnostics, particularly in skin cancer detection, through the integration of AI. However, the potential of AI in automating immunofluorescence imaging for autoimmune bullous skin diseases (AIBDs) remains untapped. While direct immunofluorescence (DIF) supports diagnosis, its manual interpretation can hinder efficiency. The use of DL to classify DIF patterns automatically, including the intercellular (ICP) and linear pattern (LP), holds promise for improving the diagnosis of AIBDs. OBJECTIVES: To develop AI algorithms for automated classification of AIBD DIF patterns, such as ICP and LP, in order to enhance diagnostic accuracy, streamline disease management and improve patient outcomes through DL-driven immunofluorescence interpretation. METHODS: We collected immunofluorescence images from skin biopsies of patients suspected of having an AIBD between January 2022 and January 2024. Skin tissue was obtained via a 5-mm punch biopsy, prepared for DIF. Experienced dermatologists classified the images as ICP, LP or negative. To evaluate our DL approach, we divided the images into training (n = 436) and test sets (n = 93). We employed transfer learning with pretrained deep neural networks and conducted fivefold cross-validation to assess model performance. Our dataset's class imbalance was addressed using weighted loss and data augmentation strategies. The models were trained for 50 epochs using Pytorch, achieving an image size of 224 × 224 pixels for both convolutional neural networks (CNNs) and the Swin Transformer. RESULTS: Our study compared six CNNs and the Swin Transformer for AIBD image classification, with the Swin Transformer achieving the highest average validation accuracy (98.5%). On a separate test set, the best model attained an accuracy of 94.6%, demonstrating 95.3% sensitivity and 97.5% specificity across AIBD classes. Visualization with Grad-CAM (class activation mapping) highlighted the model's reliance on characteristic patterns for accurate classification. CONCLUSIONS: The study highlighted the accuracy of CNNs in identifying DIF features. This approach aids automated analysis and reporting, offering reproducibility, speed, data handling and cost-efficiency. Integrating DL into skin immunofluorescence promises precise diagnostics and streamlined reporting in this branch of dermatology.

Artificial intelligence (AI) is transforming healthcare through machine and deep learning (computer systems that can learn and adapt, and make complex decisions, without receiving explicit instructions), improving disease management in dermatology, particularly in detecting skin cancer. However, AI's potential in automating immunofluorescence imaging in autoimmune bullous (blistering) skin diseases (AIBDs) remains largely untapped. Manual interpretation of direct immunofluorescence (DIF ­ a type of microscopy) can reduce efficiency. However, using deep learning to automatically classify DIF patterns (for example, the 'intercellular pattern' (ICP) and the 'linear pattern' (LP)) holds promise in helping with the diagnosis of AIBDs. This study aimed to develop AI algorithms for the automated classification of AIBD DIF patterns, such as ICP and LP, to improve diagnostic accuracy and streamline disease management. Immunofluorescence images were collected from skin biopsies of patients with a suspected AIBD between January 2022 and January 2024. Dermatologists classified the images into three categories: ICP, LP and negative. The dataset was divided into training (436 images) and test sets (93 images). A transfer learning framework (where what has been learned previously in one setting is used to improve performance in another) was used to make up for the limited amount of training data, to explore different models for the AIBD classification task. Our results revealed that a model called the 'Swin Transformer' achieved an average accuracy of 99% in diagnosing different AIBDs. The best model attained 95% accuracy on the test set and was reliable in identifying and ruling out different AIBDs. Visualization with Grad-CAM (a technique used in deep learning) highlighted the model's use of characteristic patterns to classify the diseases accurately. Overall, integrating deep learning in skin immunofluorescence promises to improve diagnostics and streamline reporting in dermatology, which could improve consistency, speed and cost-efficiency.

The impact of occlusive vs non-occlusive application of methyl aminolevulinate on the efficacy and tolerability of daylight photodynamic therapy for actinic keratosis.

BACKGROUND: Conventional photodynamic therapy (c-PDT) is an effective treatment for actinic keratoses (AKs) and nonmelanoma skin cancer which exploits the photosensitizing properties of methyl aminolaevulinate (MAL). Daylight photodynamic therapy (DL-PDT) is an alternative to c-PDT which does not require the application of MAL in occlusion and that is better tolerated by patients. The impact of occlusion on the efficacy of DL-PD has not been investigated by previous studies. OBJECTIVE: To compare the efficacy and tolerability of occlusive and non-occlusive DL-PDT. METHODS: We conducted a prospective intraindividual left/right comparison study. AKs of the face or scalp were marked in two symmetrical treatment areas. The two target areas were randomly assigned to DL-PDT with occlusive and non-occlusive application of MAL. The efficacy and cosmetic outcome were determined by a "blinded" investigator. RESULTS: Lesions in occluded areas showed a better response in the clearance rate of the lesions (65.5% vs 35.0 %, p < 0.001 %), and cosmetic outcome (P < 0.001). There was no difference in phototoxicity or pain between occluded and non-occluded areas. CONCLUSION: The occlusive application of MAL improves the efficacy of DL-PDT in clearing AKs and does not increase the incidence of side effects.

Diffuse Melanosis Cutis as the First Sign of Recurrence of Low-Risk Melanoma: Case Report and Systematic Review.

INTRODUCTION: Diffuse Melanosis Cutis (DMC) is a rare and late complication of metastatic malignant melanoma (MM) characterized by progressive pigmentation of skin and sometimes mucous membranes. The distinctive feature is the widespread and progressive deposition of melanin precursors in the dermis. OBJECTIVES: The purpose of this review is to define the clinical and demographic features of DMC and to promote a deeper insight into the clinical manifestation, histological findings, and pathophysiology behind DMC. METHODS: We have conducted a systematic review of the literature on published DMC in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. We also reported a case of DMC secondary to low-risk melanoma. RESULTS: Overall, including our case report, we reported 53 articles described 62 DMC patients. Breslow level of primary melanoma was reported having a mean value of 3.3 mm. The mean survival rate from onset of DMC resulted being 4.36 months. CONCLUSIONS: Among the most widely accepted etiopathogenetic hypotheses are deposition of melanic precursors in the dermis following tumor lysis, melanocyte proliferation induced by neoplastic growth factors, and the presence of diffuse dermal micro-metastases of MM. However, unanimous consensus on the proposed etiopathogenetic models of DMC is still lacking.

Has the Use of the Mask Exacerbated Rosacea During the Pandemic?

INTRODUCTION: During the COVID-19 pandemic, personal protective equipment, particularly face masks, became an essential requirement to engage in various activities. Several articles reported an increase of recurrences of dermatologic facial diseases (ie, acne, rosacea) related to mask use. OBJECTIVES: To evaluate the number of recurrences of rosacea related to face mask use. METHODS: This prospective study was conducted on adult patients with a pre-pandemic diagnosis of mild and moderate papulopustular rosacea. All patients had previously achieved either partial or complete remission after a 4-month treatment with topical ivermectin in 2019. We collected data in two different phases characterized by different intensity of mask use during the pandemic and post-pandemic period. We collected data through clinical assessment of the disease, questionnaires on personal habits and standardized skin surface biopsy to study the Demodex mites count. RESULTS: We enrolled a total of 30 patients. In the pandemic period, 5/30 patients had a relapse of mild papulopustular rosacea; the Demodex sample resulted positive in 4/5 relapsed patients. In the post-pandemic period, 4/30 patients reported a relapse of mild rosacea (3 patients) and moderate papulopustular rosacea (1 patient). At the Demodex exam, 1/4 relapsed patients resulted positive. CONCLUSIONS: We did not find a significant increase in relapses of papulopustular rosacea during the pandemic. An appropriate anti-parasitic treatment may reduce the number of recurrences due to mask use.

Improvement in quality of life and sexual function in patients affected by vulvar lichen sclerosus treated with combined autologous platelet-rich plasma and fat grafting.

BACKGROUND: Vulvar lichen sclerosus (LS) severely impairs patients' quality of life. OBJECTIVES: To evaluate the impact of a combined application of autologous platelet-rich plasma (PRP) and fat grafting as treatment for vulvar LS on patient quality of life. MATERIALS & METHODS: We reviewed the clinical charts of 72 patients affected by LS, who underwent regenerative surgery. The patients' quality of life was assessed using: the Dermatology Life Quality Index (DLQI), the Skindex-29, the Female Sexual Function Index (FSFI) and the patient-administered - Clinical Scoring System (CSS). RESULTS: After reconstructive surgery, all scores improved: Skindex-29 (-31.8 [IQR: 42.1, -21.8] points; p<0.001), FSFI (7.6 [IQR: 2.7, 14.7)] points; p<0.001), Patient-administered CSS (-24 [IQR: -30, -15] points; p<0.001), DLQI (-9 [IQR: -17, -7] points; p<0.001), Physician-administered CSS (-5 [IQR: -7, -5] points; p<0.001), and IGA (median ΔIGA: -4, IQR: -4, -3; p<0.001). CONCLUSION: Combined treatment with PRP and fat grafting proved to be effective in improving the quality of life of patients with vulvar LS.

Autoimmune bullous dermatoses in cancer patients treated by immunotherapy: a literature review and Italian multicentric experience.

Cutaneous immune-related adverse events are frequently associated with immune checkpoint inhibitors (ICIs) administration in cancer patients. In fact, these monoclonal antibodies bind the cytotoxic T-lymphocyte antigen-4 and programmed cell death-1/ligand 1 leading to a non-specific activation of the immune system against both tumoral cells and self-antigens. The skin is the most frequently affected organ system appearing involved especially by inflammatory manifestations such as maculopapular, lichenoid, psoriatic, and eczematous eruptions. Although less common, ICI-induced autoimmune blistering diseases have also been reported, with an estimated overall incidence of less than 5%. Bullous pemphigoid-like eruption is the predominant phenotype, while lichen planus pemphigoides, pemphigus vulgaris, and mucous membrane pemphigoid have been described anecdotally. Overall, they have a wide range of clinical presentations and often overlap with each other leading to a delayed diagnosis. Achieving adequate control of skin toxicity in these cases often requires immunosuppressive systemic therapies and/or interruption of ICI treatment, presenting a therapeutic challenge in the context of cancer management. In this study, we present a case series from Italy based on a multicenter, retrospective, observational study, which included 45 patients treated with ICIs who developed ICI-induced bullous pemphigoid. In addition, we performed a comprehensive review to identify the cases reported in the literature on ICI-induced autoimmune bullous diseases. Several theories seeking their underlying pathogenesis have been reported and this work aims to better understand what is known so far on this issue.

Usefulness of Dermoscopy in Eruptive Syringomas in an Elderly Woman.

Introduction: Eruptive syringomas (ES) are a rare variant of syringomas, benign adnexal tumors of eccrine sweat glands' ducts. They mostly affect young-to middle-aged women, but rarely they may also occur in the elderly, requiring generally no specific treatment. Case Presentation: We present the case of a 76-year-old woman with sudden onset of ES. Clinical examination evidenced brown-to-orange papules and plaques on the anterior neck, corresponding dermatoscopically to orange-brownish structureless areas, with barely hinted peripheral incomplete network, superimposed on areas of light pink. Histology showed dermal proliferation of epithelial cells forming cords and ductules, confirming the clinical-dermoscopic suspect of ES. The lesions remained stable at 12-month follow-up without treatment. Discussion: This case highlights the role of dermoscopy to help differentiate ES from other clinically similar but more serious entities, such as histiocytosis, mastocytosis, and lichen planus, and to schedule the required confirmatory biopsy in due time without haste.

Acne fulminans and its multiple associated factors: a systematic review.

Acne fulminans (AF) is a severe form of acne that presents with an outburst of haemorrhagic pustules and ulcerations, which may or may not be associated with systemic symptoms and laboratory abnormalities. In the latest classification, four variants of AF are considered, but this does not include AF associated with systemic therapies and inherited genetic syndromes. To systematically review disease features and evaluate differences among AF. Related articles were searched using the terms "acne fulminans", "acne conglobata with septicaemia", "acute febrile ulcerative acne" and "pseudo acne fulminans". We searched Medline and Google Scholar from inception to 1977 to identify case reports, case series, commentaries and reviews reporting new AF cases. A total of 98 articles met our inclusion criteria. AF induced by higher levels of androgens more frequently presented nodules and cysts than erosions, crusted and haemorrhagic lesions and necrosis. In contrast, patients affected by AF without any apparent cause (referred to here as "miscellaneous AF") more frequently presented with ulcerations and erosions, and patients with AF associated with systemic treatment showed a similar frequency of lesions. Notably, AF in patients with high levels of androgens and AF induced by antibiotics rarely showed comedones. In addition, aseptic osteolytic lesions were more common in miscellaneous AF than other AF. AF may present with differences in clinical and laboratory features and associated systemic illnesses, which should be evaluated for the planning of a personalized therapeutic scheme. We propose a classification of AF, according to its association with certain factors.

Dermatoskopisch kontrollierte, schmalere Resektionsränder bei Basalzellkarzinomen an Kopf und Hals: Retrospektive Fallkontrollstudie.

Hintergrund: Unbehandelt kann das Basalzellkarzinom (BCC) erhebliche Gewebezerstörungen verursachen. Die komplette chirurgische Exzision ist die Behandlung der Wahl. Allerdings stellt es besonders im Gesichts- und Halsbereich eine Herausforderung dar, den Tumor vollständig zu entfernen und möglichst viel gesundes Gewebe zu erhalten. Material und Methoden: Bereits exzidierte kleine BCC (≤ 1 cm) von Kopf oder Hals wurden retrospektiv analysiert. Verglichen wurde die histologisch kontrolliert angemessene Breite des Resektionsrandes nach präoperativer dermatoskopischer Untersuchung (Fälle) im Vergleich zur rein klinischen Untersuchung (Kontrollen), sowie die Rezidivrate. Ergebnisse: Bei 281 BCC: 6 % (8/139) der Fälle und 8 % (12/142) der Kontrollen zeigten inadäquate basale Resektionsränder; 4 % (5/139) der Fälle und 20 % (29/142) der Kontrollen zeigten inadäquate laterale Resektionsränder (P < 0.001). Laterale Resektionsränder von 3 mm waren in 0 % (15/66) der Fälle, jedoch in 15 % (10/66) der Kontrollen inadäquat (P >0.005); laterale Resektionsränder von 1-2 mm waren in 7 % (5/73) der Fälle und in 25 % (19/76) der Kontrollen inadäquat (P < 0.01). Rezidive traten in den Fällen mit 3 mm Resektionsrand in 1,5 % auf, in den Fällen mit 1-2 mm Resektionsrand bei 0 %, und bei den Kontrollen bei 7,7 %. Schlussfolgerung: Für BCC im Kopf- und Halsbereich erscheint ein Resektionsrand von 3 mm angemessen, sofern das BCC klein, dermatoskopisch gut definiert und wenig aggressiv ist. Hier zeigten sich operative Heilungsraten von 100 % mit 1,5 % Rezidiven. Resektionsränder von 1-2 mm sollten nur für BCC in sehr schwierig zu behandelnden Bereichen in Betracht gezogen werden, da die Heilungsrate hier nur bei 93 % lag.

Dermatoscopically narrowed surgical margins for head and neck basal cell carcinoma: A retrospective case-control study.

BACKGROUND: Basal cell carcinoma (BCC) can cause extensive tissue damage if untreated. Complete surgical excision is the treatment of choice, but especially in the head-and neck area, defining both radical and healthy skin sparing surgical margins is complex. MATERIALS AND METHODS: Excised, small (≤ 1 cm), BCCs of the head and neck were retrospectively analyzed, comparing histological properness of surgical margins after clinical-dermatoscopical preoperative evaluation (cases), vs. clinical evaluation only (controls) and recurrences. RESULTS: Of 281 BCCs: 6 % (8/139) of cases and 8 % (12/142) of controls had unproper deep margins; 4 % (5/139) of cases, 20 % (29/142) of controls had unproper lateral margins (P < 0.001). Surgical 3 mm lateral margins were unproper in 0 % (15/66) of cases, 15 % (10/66) of controls (P > 0.005); surgical 1-2 mm lateral margins were unproper in 7 % (5/73) of cases, 25 % (19/76) of controls (P < 0.01). Of cases excised at 3 mm, 1-2 mm, and controls, 1.5 %, 0 %, and 7.7 % recurred, respectively. CONCLUSIONS: BCC excision at 3 mm may be appropriate in the head and neck for small, dermatoscopically well-defined and non-aggressive BCCs, attaining surgical cure rates of 100 % and 1.5 % recurrences. Excision at 1-2 mm should be reserved only for BCCs in very difficult-to-treat areas, as the surgical cure rate was only 93 %.

Dimethyl fumarate as a safe and effective therapy for recalcitrant psoriasis in comorbid patients.

Psoriasis is a chronic condition for which multiple therapies are currently available. In particular, in cases of moderate- severe psoriasis, traditional systemic drugs or the new biological drugs can be administered. However, the treatment of patients who require systemic therapy and have multiple comorbidities can be particularly complex. Some treatment options may be in fact contraindicated or may lose effectiveness over time, reducing the options available to the dermatologists. In such circumstances, dimethyl fumarate may represent a safe and effective choice, also in patients who have already attempted biological therapies. In this regard, we report the case of a patient with moderate-severe psoriasis treated over time with various therapies (including topicals, phototherapy, traditional and biological drugs) that were discontinued due to ineffectiveness or incompatibility caused by the occurrence of concomitant diseases, who finally achieved clinical remission with dimethyl fumarate.

Paraneoplastic Wong-Type Dermatomyositis Associated with Gynecological Malignancy.

Although dermatomyositis is known to be a possible paraneoplastic syndrome, often in the setting of gynecological cancers, Wong-type dermatomyositis-a rare variant of dermatomyositis-has not been clearly associated with internal malignancies to date. There is only one report from Japan of a woman who developed Wong-type dermatomyositis together with the recurrence of uterine cancer. We report the case of a Caucasian patient who presented with infrequent Wong-type dermatomyositis with positive anti-TIF1γ antibodies; screening for internal malignancies revealed fallopian tube carcinoma.

Anti-laminin 332 antibody detection using biochip immunofluorescence microscopy in a real-life cohort of Italian patients with mucous membrane pemphigoid

Background: Mucous membrane pemphigoid (MMP) with anti-laminin 332 autoantibodies may be associated with malignancies, however, current serological assays have considerable limitations. At present, no commercial test for anti-laminin 332 antibodies is available, restricting the diagnosis to specialized laboratories worldwide. Biochip immunofluorescence microscopy has shown promising results in selected cohorts of laminin 332-MMP patients. Objectives: To detect anti-laminin 332 antibodies by biochip immunofluorescence microscopy in a real-life cohort of MMP patients and compare the results with those from traditional immunoblotting. Materials & Methods: Sera were obtained from 31 patients with MMP, 28 with bullous pemphigoid, five with pemphigus vulgaris, five with paraneoplastic pemphigus, five with linear IgA bullous dermatosis, and 10 controls, and analysed by biochip immunofluorescence using human cells expressing laminin 332. Immunoblotting was performed using purified laminin 332. Results: MMP involved the oral mucosa in 65%, ocular mucosa in 9%, oral and ocular mucosae extensively in 13% as well as other mucosae in 13% of patients. Concomitant cutaneous involvement was reported in 35% of patients. Three MMP patients had an underlying malignancy. Anti-laminin 332 antibodies were detected in 2/31 (6%) cases by both methods. Based on immunoblotting, both laminin 332-positive sera reacted with α3 chain (in one case also with ß3 chain). Both patients with anti-laminin 332 antibodies had extensive mucosal involvement and only one had cancer. Anti-laminin 332 antibodies were not detected in control groups. Conclusion: Biochip immunofluorescence is an appropriate technique to detect anti-laminin 332 antibodies which should be tested in patients with MMP.