Dermoscopic patterns of intradermal naevi.

BACKGROUND: Intradermal naevi represent a benign histopathological variant of common melanocytic naevi. Studies describing dermoscopic criteria of dermal naevi are very limited. OBJECTIVES: To identify dermoscopic features of dermal naevi in order to facilitate differential diagnosis from malignant lesions. METHODS: A 15-year retrospective study was performed to evaluate the dermoscopic characteristics of 202 dermal naevi, histopathologically diagnosed through the analysis of digital dermoscopic images performed with polarised light dermoscopy. For each lesion, vascular pattern, pigment pattern and other dermoscopic clues were evaluated. RESULTS: 147 Unna naevi and 55 Miescher naevi were included in the study. Brown pigment (37.1%) was the pigment pattern most frequently observed in both Unna and Miescher naevi, followed by cobblestone pattern (30.6%) in Unna naevi and white areas (23.6%) and dotted/globule pattern (20%) in Miescher naevi. As regards the vascular patterns, the polymorphic one was the most frequently observed (34.6%). The combination between comma-shaped and arborising vessels was the most common among all naevi. CONCLUSIONS: Our study describes the dermoscopic features of dermal naevi that may help to differentiate them from malignant lesions such as basal cell carcinoma, amelanotic melanoma and Spitz naevi.

Unusual Dermoscopic Patterns of Seborrheic Keratosis.

BACKGROUND: Seborrheic keratoses (SKs) may sometimes mimic benign and malignant skin tumors, and a biopsy can be necessary in order to rule out malignancy. METHODS: From the database of our pigmented lesion clinic, we evaluated the dermoscopic features of difficult-to-diagnose SKs that were biopsied between January 2010 and December 2014. RESULTS: SKs represented 3.8% of all excised lesions (161/ 4,182). Specifically, 91 (56.5%) were excised to rule out melanoma, 63 (39.1%) to rule out squamous cell carcinoma and 7 (4.4%) to rule out basal cell carcinoma. The following 10 global dermoscopic patterns were identified: multicomponent (32; 19.9%); reticular (24; 14.9%), characterized by an irregular pigment network; bowenoid (21; 13.0%); hairpin (19; 11.8%); keratoacanthoma-like (16; 9.9%); blue-nevus-like (15; 9.3%); lichenoid (6; 3.7%); hyperkeratotic (6; 3.7%); clonal (5; 3.1%); spitzoid (5; 3.1%). Furthermore, 12 SKs (7.5%) were not included in any of such patterns (not classified). CONCLUSION: Our results are in line with previous studies highlighting the dermoscopic variability of SKs. Although excised SKs may be classified into 1 of 10 repetitive dermoscopic patterns, a biopsy remains mandatory for those that cannot be clearly differentiated from common skin malignancies.

Vismodegib-Induced Alopecia: Trichoscopic and Confocal Microscopy Evaluation.

INTRODUCTION: Vismodegib is the first-in-class inhibitor of the sonic hedgehog pathway useful in the treatment of locally advanced or metastatic basal cell carcinoma (BCC) that is not amenable to surgery and radiation therapy. Common adverse events of vismodegib, probably mechanism related, include alopecia (58%) as a reversible side effect. CASE PRESENTATION: We report 2 cases of patients receiving vismodegib for the treatment of locally advanced BCCs that developed alopecia during treatment and describe clinical, dermoscopic, and reflectance confocal microscopy (RCM) features of this adverse event. CONCLUSION: Alopecia is one of the most distressing adverse events leading to vismodegib discontinuations. To our knowledge, these are the first descriptions of RCM dermoscopy in vismodegib-induced alopecia. Trichoscopy and confocal microscopy are essential to monitoring vismodegib hair loss and the response to the treatment.

Low-Dose Vismodegib as Maintenance Therapy After Locally Advanced Basal Cell Carcinoma Complete Remission: High Efficacy with Minimal Toxicity.

INTRODUCTION: Locally advanced basal cell carcinoma (laBCC) has always represented an uncommon, difficult-to-treat form of skin cancer, but approval of the Hedgehog inhibitor (HHI) vismodegib has provided an effective, well-tolerated therapy. While this drug has been shown to be a safe and effective during treatment, to date the effect of its prolonged use at a low dose after complete remission (CR) of laBCC has not been described. The aim of this study was to report our experience regarding the long-term efficacy of low-dose vismodegib as maintenance therapy in patients with CR of the disease during a 1-year follow-up period. METHODS: An observational retrospective study was conducted at the Non-Melanoma Skin Cancer Unit of the University of Federico II (Naples). Patients who reported complete regression of their advanced BCC after vismodegib treatment were included in the study and subsequently separated into two groups. One group of patients continued with the "drug holiday" regimen consisting of a once-weekly maintenance dosage of 150 mg vismodegib for 1 year after CR of their BCC; the second group comprised patients who decided not to take a maintenance dosage following complete regression of their BCC. RESULTS: A total of 42 patients (35 males, 7 females) with a median age of 75.2 years and complete regression of their advanced BCC after treatment with vismodegib were included in the study. Of these, 27 (64%) patients continued with the "drug holiday" regimen, receiving a once-weekly maintenance dosage of 150 mg vismodegib for 1 year after CR of their BCC, and 15 (36%) patients decided not to take the maintenance dosage. Patients who continued to receive the low-dose vismodegib treatment did not present any BCC recurrence during 1-year follow-up period, while those who discontinued vismodegib treatment reported a BCC recurrence rate of 26.6% (4/15 patients) during the 1-year follow-up period. CONCLUSIONS: Our retrospective analysis focused on the use of a novel therapeutic scheme based on prolonged use of vismodegib after CR of the laBCC. The results demonstrate that the maintenance dose of vismodegib described herein effectively eliminated skin tumor recurrence and reduced the severity of common adverse events, thus increasing patient compliance.

Real-Life Effectiveness of Vismodegib in Patients with Metastatic and Advanced Basal Cell Carcinoma: Characterization of Adverse Events and Assessment of Health-Related Quality of Life using the Dermatology Life Quality Index (DLQI) Test.

INTRODUCTION: Non-melanoma skin cancer (NMSC) is the most common type of human tumor, with an estimated five million new cases each year. NMSC has been described as having a major impact on the health-related quality of life of the patient. Vismodegib is a hedgehog pathway inhibitor therapy for patients who are affected by locally advanced basal cell carcinoma (laBCC) and metastatic basal cell carcinoma and are ineligible for surgery and/or radiotherapy. The objective of this study was to assess treatment-emergent adverse events reported by patients with advanced BCC who were undergoing hedgehog pathway inhibitor therapy with vismodegib, and to quantify their health-related quality of life using the Dermatology Life Quality Index (DLQI) questionnaire. METHODS: Patients with advanced and/or multiple basal cell carcinomas treated with vismodegib at the Non-Melanoma Skin Cancer Unit of the University of Naples Federico II (Italy) were consecutively enrolled. Each patient was evaluated every month until the end of the treatment cycle to assess adverse events related to the drug and the patient's quality of life. RESULTS: 48 patients (35 males and 13 females) with advanced BCC were included in the study. Muscle spasms, alopecia, and dysgeusia were the most frequently reported adverse events. 41 patients completed the DLQI questionnaire at the baseline visit and after 6 months of treatment. The average reported DLQI score decreased from a mean value of 5.7 at the baseline visit to 0.4 after 6 months of treatment. CONCLUSION: This is the first study to demonstrate a significant change in patient health-related quality of life from baseline to 6 months after hedgehog pathway inhibitor therapy initiation using the DLQI test. Interestingly, patients with BCC in visible areas such as the face or neck presented an overall DLQI score that was higher than that of patients with BCC located on the trunk and legs at the baseline visit, but the DLQI scores of these two groups were almost the same after 6 months of vismodegib therapy.

Melanoma frequency among symmetrical Spitzoid-looking lesions: a retrospective study.

BACKGROUND: Many efforts have been spent attempting to define clinical, histopathological and molecular markers for differential diagnosis of Spitz nevus and melanoma. Dermoscopy has been widely used but it may be not always sufficient. METHODS: A retrospective study was performed evaluating Spitzoid-looking lesions showing symmetry at clinical and dermoscopic examination in patients ≥12 years attending our Clinic from 2004 to 2014. Demographic, clinical and dermoscopic data were assessed for each lesion in order to highlight the most common characteristics which could help the differential diagnosis between Spitz nevus and melanoma when clinical or dermoscopic asymmetry is lacking. RESULTS: A total of 760 lesions were excised. 690/760 (90.8%), were identified as typical Spitz nevi, whereas 70/760 lesions (9.2%) consisted of malignant melanocytic lesions. Our study showed that almost 9.2% of clinically and dermoscopically symmetric Spitzoid lesions revealed to be malignant melanocytic lesion. For symmetric Spitzoid looking lesions female sex, clinical palpability, the presence of an inverse network at dermoscopic examination and the involvement of lower limbs were observed as the main factors, which were linked to a higher possibility of being malignant lesions. CONCLUSIONS: In order to avoid missing diagnoses for malignant melanocytic lesions, this study remarked the importance of preventive excision for all Spitzoid-looking lesions in patients ≥12 years, even if they show symmetry at both clinical and dermoscopic level.

Petechia of the Penis: Sexual Habits or Adverse Drug Reaction?

To the best of our knowledge, we report the first case of recurring small red macules (petechia), exclusively localized on the gland secondary to fellatio in an adult man, who is on therapy with acetylsalicylic acid. No previous studies have been ever conducted on the possible onset of penis petechia after oral sex. Petechia are nonspecific cutaneous lesions appearing as circumscribed sub-epithelial hemorrhages, or appearing as small dark red or purplish spots as a result of capillaries rupture.

Long-Term Efficacy of Vismodegib After its Withdrawal and Patients' Health-Related Quality of Life Using the Dermatology Life Quality Index (DLQI).

INTRODUCTION: Although non-melanoma skin cancers (NMSCs) are associated with a very low mortality risk, they have been reported to have a major impact on patients' health-related quality of life (HRQoL). Vismodegib is a therapy for patients who are affected by locally advanced basal cell carcinoma (BCC) or metastatic BCC who are ineligible for surgery and/or radiotherapy. The aim of the present clinical study was to assess the long-term efficacy of vismodegib after its withdrawal by evaluating the recurrence rate of advanced BCC, assessing also patients' HRQoL after 3 and 6 months from drug withdrawal. METHODS: A retrospective study was performed to analyze patients with advanced and/or multiple BCCs that had been treated with vismodegib (150 mg daily) at the Non-Melanoma Skin Cancer Unit of the University of Naples Federico II (Italy) and had obtained a complete regression in 6 months. At the end of the 6-month treatment cycle, patients that reported total remission of the skin tumor were visited monthly in order to assess their therapeutic response. Moreover, to assess the specific impact of vismodegib on HRQoL, DLQI was administered before vismodegib treatment (baseline), at the end of the therapy cycle (6 months), as well as after 3 and 6 months from vismodegib discontinuation. RESULTS: Thirty-five patients (27 male, 8 female), with a complete regression of their advanced BCC after vismodegib treatment, were included in the study. The duration of treatment for all patients was 6 months as set by study inclusion criteria. A BCC recurrence rate of 31% (11/35) was reported after a 6-month follow-up. The average reported Dermatology Life Quality Index (DLQI) score increased from a value of 0 at the end of the 6-month vismodegib treatment to a mean value of 2.4 after 3 months from drug withdrawal and 3.6 after 6 months from treatment discontinuation. CONCLUSION: The results of this exploratory analysis of vismodegib withdrawal are consistent with a substantial link between treatment response and patients' HRQoL. Furthermore, 11 out of 35 (31%) patients that reported a complete remission of the disease after 6 months of vismodegib treatment reported BCC recurrence. These data highlight the importance of continuous follow-up and perhaps different regimens of treatment, such as an alternate dose regimen to maintain disease control and reduce the adverse events as previously described in the literature.

Difficult to diagnose small cutaneous melanoma metastases mimicking angiomas: utility of dermoscopy.

BACKGROUND: Metastases from melanoma can be found in any organ, while the reported incidence of skin metastases varies between 2 and 20%. Cutaneous melanoma metastases (CMM) can be heterogeneous at clinical examination, and they can simulate other benign and malignant lesions, thus generating major diagnostic troubles for the dermatologist. Dermoscopy is a useful tool that may increase the physician's diagnostic accuracy to this purpose. MATERIALS AND METHODS: Herein, we describe the case of two patients having lesions that can easily be confused with other benign or malignant lesions for their clinical and dermoscopic similarities and for the variability of presentation of skin metastases. The description of the dermoscopy patterns of melanoma metastases may be useful to recognize early metastases, when clinically not suspected, facilitating an early removal and histopathological confirmation. RESULTS: Diagnoses of melanoma metastases and angiomas were confirmed by histological examination. Melanoma metastases show at dermoscopic examination the angioma-like pattern. The ability to detect CMM between other lesions was good taking into consideration that, without the patient's history and with just the dermoscopy image, it could be very difficult to distinguish CMM from other benign or malignant skin lesions. CONCLUSIONS: The present study confirms that dermoscopy is a useful tool to increase the physician's diagnostic accuracy for CMM and allow its differentiation from other cutaneous lesions, always taking into account the patient's medical record.

Skin diseases and tattoos: a five-year experience.

BACKGROUND: Decorative tattooing as a body art form underwent an exponential increase during the last two decades, particularly among teenagers and young adults. Consequently, the number of reported adverse reactions after tattooing has increased. The most frequent reported skin reactions to tattoo include infectious (bacterial, viral, fungal) or inflammatory (allergic contact dermatitis and granulomatous reaction) diseases. Moreover, tattoos can also induce the development of typical skin lesions of pre-existing dermatoses, a phenomenon known as isomorphism reactive or Koëbner phenomenon, which commonly occurs in patients with psoriasis, vitiligo, or lichen planus. METHODS: A retrospective study analyzing records data of patients attending the Department of Dermatology, University of Naples "Federico II" during 2011-2015 was performed. All cases of tattoo-related or closely-located dermatitis were selected. RESULTS: We observed 19 patients (mean age: 26.4 years old) showing cutaneous conditions related to the practice of tattooing. Allergic contact dermatitis was reported as the most common cutaneous disease linked to tattooing (31.6%), followed by granulomatous reactions (26.3%). These data are consistent with those already reported in the literature. CONCLUSIONS: Our results highlight the need to develop detailed regulations regarding tattoos practice, used materials, as well as execution procedures in order to limit the outbreak of tattoo-related skin diseases.

Squamous Cell Carcinomas in Two Cases of Nail Lichen Planus: Is There a Real Association?

Lichen planus (LP) is a chronic inflammatory disease that affects the skin and oral mucosa. Although its etiology is unknown, its potential for cancerization has been confirmed. We herein report the cases of a brother and sister, both with a 15-year history of nail lichen planus of the fingers and toes, who developed squamous cell carcinomas of the nail bed and matrix. This article shows the potential for malignant transformation in lichen planus disease and highlights the importance of periodic clinical follow-up.