The Past, the Present and the Future of Teledermatology: A Narrative Review.

Teledermatology may be defined as the application of telemedicine to dermatology. According to published data, teledermatology is more widespread in Europe and North America, probably where resources for health care are greater than in other areas of the world. Indeed, teledermatology requires advanced technology to be efficient, as high image quality is necessary to allow the dermatologist to make correct diagnoses. Thanks to the recent advances in this field, teledermatology is become routinary in daily clinical practice. However, its use has been improved over time, overcoming several challenges. The aim of this narrative review is to retrace the almost 30-year history of teledermatology, to address the new challenges posed by advancing technologies such as artificial intelligence and the implications it may have on healthcare.

Efficacy and safety of sonidegib for the management of basal cell carcinoma: a drug safety evaluation.

INTRODUCTION: Surgery is the standard management for most of basal cell carcinomas (BBCs). In some cases, also radiotherapy may be a valuable weapon as well as ablative and topical treatments. However, all these approaches may be limited by some tumor features. In this scenario, locally advanced BCCs (laBCC) and metastatic BCC, also defined as 'difficult-to-treat' BCC, remain the real treatment challenge. New knowledge on BCC pathogenesis, particularly the Hedgehog (HH) pathway, led to the development of new selective therapies such as vismodegib and sonidegib. In particular, sonidegib is an orally administered small molecules, which inhibits the HH signaling pathway through the binding to SMO receptor, recently approved for the management of adult patients with laBCC who are not amenable to curative surgery or radiation therapy. AREAS COVERED: The purpose of this review is to analyze and discuss the efficacy and safety of sonidegib for the management of BCC, to provide a broad perspective on the currently available data. EXPERT OPINION: Sonidegib is a valuable weapon for the management of difficult-to-treat BCC. Current data showed promising results in terms of effectiveness and safety. However, more studies are needed to underline its role in BCC management, also considering the presence of vismodegib, and to investigate its use in a long-term period.

Injections Site Reactions and Biologics for Psoriasis: A Questionnaire Based Real Life Study.

Background: Biologic selection for psoriasis treatment should take into account numerous factors including injection site reactions (ISRs) such as swelling at the injection site, pain, burning, erythema, all possibly reducing patient adherence. Methods: A 6-months observational real life study was performed involving psoriasis patients. Inclusion criteria were age ≥ 18 years, moderate-to-severe psoriasis diagnosis since at least 1 year, patients being on biologic treatment for psoriasis ≥ 6 months. A 14-item questionnaire was administered to all patients enrolled to assess whether the patient ever experienced ISRs after the injection of the biologic drug. Results: 234 patients were included: 32.5% received an anti-TNF-alpha drug, 9.4% received anti-IL12/23, 32.5% received an anti-IL17, 25.6% received an anti-IL23. 51.2% of study population reported at least one symptom related to ISR. 35.9% of patients experienced pain, 31.6% swelling, 28.2% burning sensation and 17.9% erythema. 3.4% of the surveyed population experienced anxiety or fear of the biologic injection due to ISRs symptoms. The greater incidence of pain was registered in anti-TNF-alpha and anti-IL17 groups (47.4% and 42.1%, p<0.01). Ixekizumab proved to be the drug with the highest rate of patients experiencing pain (72.2%), burning (77.7%) and swelling (83.3%). No patients reported biologics discontinuation or delay for ISRs symptoms. Conclusion: Our study highlighted that each different class of biologics for psoriasis was linked to ISRs. These events are more frequently reported with anti-TNF-alpha and anti-IL17.

Alopecia Areata after COVID-19 Vaccines.

Introduction: Alopecia areata (AA) is a common autoimmune disease characterized by non-scarring hair loss. New onsets of AA have been associated with coronavirus disease 2019 (COVID-19). Various skin diseases have already been reported because of the vaccines (the Pfizer-BioNTech COVID-19 vaccine, the Moderna COVID-19 vaccine, the AstraZeneca vaccine) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Case Presentation: We report 5 cases of AA after COVID-19 vaccination. The trend shown by patients in this study is an initial worsening after the first dose of the vaccine with the stability of the disease even with subsequent doses. However, it is worth highlighting the case reported by one of our patients who suffered a "booster effect" of the disease with progressive and worsening alopecia with each vaccine booster. Discussion: The possible mechanism of action lies in the ability of COVID-19 vaccines to induce spike protein, which can lead to molecular mimicry phenomena. In an organism predisposed to autoimmunity, the mRNA vaccine acts as a trigger. Furthermore, we would like to point out how even cytokine storm and simple oxidative stress from SARS-CoV-2 infection can induce not only AA but also other types of hair loss such as telogen effluvium. Thus, this highlights how complex and multifaceted the phenomenon is.

Monkeypox: a dermatologist perspective.

Monkeypox (MPX) is a human zoonotic disease due to Monkeypox virus. Morbidity and mortality are lower than in other Orthopox virus diseases, in particular smallpox. MPX is an endemic disease of Western and Central Africa. However, a multi-country outbreak is currently taking place in many non-endemic countries. The clinical and epidemiological characteristics of this epidemic appear peculiar, with significant differences compared to those of the endemic areas. In particular, it predominantly affects males having sex with males, and the route of sexual transmission appears to be particularly frequent. This has led to considerable media interest and concern among the population. Dermatologists are likely to be consulted frequently during the outbreak, especially for the differential diagnosis. Indeed, although MPX can affect various organs, the skin is constantly involved. Since the skin rash have different stages of development, MPX should be differentiate from several, common skin diseases, also because the systemic symptoms can be variable and of different severity. Therefore, dermatologists must be aware of the clinical characteristics of the disease and its management.

Perifolliculitis Capitis Abscedens et Suffodiens after Follicular Unit Transplantation: A Case Report.

Introduction: In the field of hair transplantation (HT) surgery, transplantation techniques from autologous tissue dominate. The most widely used techniques are follicular unit transplantation, also known as strip technique, and follicular unit extraction. Case Presentation: We report a case of an HT sequence of particular interest because of its unusual clinical presentation, chronic relapsing nature, and aggressiveness. The clinical presentation (fluctuating and communicating lesions in the occipital region), course, and symptomatology support the hypothesis of PCAS. Discussion: PCAS or folliculitis dissecans or Hoffmann's disease is a rare disorder of unknown etiology. We speculate that the mechanical extraction of follicular units was the trigger. This case underlines the need for further studies as cases of PCAS may increase concomitantly with the increase in HT.

Efficacy and safety of biologics and small molecules for psoriasis in pediatric and geriatric populations. Part II: focus on elderly patients.

INTRODUCTION: The management of moderate-to-severe forms of psoriasis is becoming a frequent concern in geriatric age due to the higher risk to develop treatment adverse events, logistic issues, vulnerability to immune-related diseases and cancer, presence of comorbidities and the risk of drug interactions. In this context, traditional systemic treatments are often contraindicated, and biologic drugs and small molecules seem to be a valuable option. However, data on their effectiveness and safety in elderly patients are scant. AREAS COVERED: The aim of this review is to analyze the current literature in order to point out data on the efficacy and safety of biologic drugs and small molecules for the management of psoriasis in elderly patients in order to put the basis for universally shared treatment algorithm following available evidence. Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were used for the literature research. EXPERT OPINION/COMMENTARY: Our review suggests biologics and small molecules as an effective and safe option for the management of moderate-to-severe forms of psoriasis in elderly patients.

Efficacy and safety of biologics and small molecules for psoriasis in pediatric and geriatric populations. Part I: focus on pediatric patients.

INTRODUCTION: Psoriasis management is challenging, especially in pediatric age for different factors. The introduction of biologic drugs and oral small molecules (OSM) revolutionized the armamentarium of available weapons in psoriasis treatment. Despite the use of these drugs in adult patients has been widely investigated, pediatric patients have often been unconsidered in clinical trials and real-life studies. However, the high efficacy and speed of action, the safety profile and the ease-to-use administration make these innovative drugs an invaluable therapeutic opportunity. AREAS COVERED: The aim of this manuscript is to perform a review of the current literature examining data on the effectiveness and safety of biologic drugs and OSM for the management of psoriasis in pediatric patients in order to put the basis for universally shared treatment algorithm following available evidence. PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines were used for the literature research. EXPERT OPINION/COMMENTARY: Our review based on currently available evidence suggests biologics and OSM as an ideal treatment option for pediatric patients, with an excellent profile in terms of efficacy and safety as compared to traditional systemic drugs.

Cutaneous Reactions Following COVID-19 Vaccination: A Review of the Current Literature.

The outbreak of coronavirus disease 2019 (COVID-19) represented a new worldwide challenge, strongly impacting on the global economy, overall health and lifestyle. Since then, several strategies have been adopted to contain the widespread of infection. Among these, vaccination is currently the most important measure to fight against the pandemic. However, several concerns such as slower-than-hoped-for rollout, the hurried approval with limited data, the mechanism of action (in particular mRNA-based), and the uncertain duration of protection they afforded were initially raised. Moreover, even if cutaneous reactions have been rarely reported in clinical trials, global mass vaccination showed several dermatologic reactions not initially recognized, leaving dermatologists to decide how to diagnose and treat them. In this scenario, dermatologists should be ready to promptly recognize these clinical manifestations. Thus, the aim of this manuscript is to review current literature on cutaneous reactions following COVID-19 vaccination, particularly inflammatory dermatological diseases, in order to help clinicians to better understand these dermatological conditions and to provide an extensive overview of all the vaccine-related skin manifestations.

Children atopic dermatitis: Diagnosis, mimics, overlaps, and therapeutic implication.

Atopic dermatitis (AD) is a chronic inflammatory, itching skin with a significant psychosocial impact on patients and relatives. In adults and adolescents besides flexural eczema, head and neck eczema, and hand eczema, which are the most frequent clinical phenotypes (84.9% and 84.2%, respectively), there are also other possible presentation such as, portrait-like dermatitis (20.1%), diffuse eczema (6.5%), eczema nummulare-like (5.8%), prurigo nodularis-like (2.1%) and erythrodermia (0.7%). Diagnosis can be easy due to the typically distributed eczematous lesions, albeit with age-related differences, However, it is also extremely heterogeneous in severity, course, and sometimes particular clinical features. Currently, there are no better diagnostic criteria than an experienced dermatologist for the diagnosis of AD. Misdiagnosis and delayed treatment will have an impact not only on the child's physical health, but also and especially on the child's psychological health. The aim of our review was to group the main differential diagnoses in pediatric age where the diagnosis can often hide many pitfalls.

Oral isotretinoin for acne: a complete overview.

INTRODUCTION: Acne is one of the most common and widespread skin conditions, affecting the health as much as patients' quality of life. A wide variety of treatments for acne, topical and systemics, could be prescribed, depending on its degree of severity. Isotretinoin, a derivative of retinol, has been widely used for the treatment of severe forms of acne and those forms not responding to conventional treatments. In literature, there are several studies describing its efficacy, also reporting side-effects related to the drug; therefore, this has led the scientific community to request further studies qualifying its characteristics and comparing its efficacy and safety with other classic acne treatments, as well as with different treatment regimes, in order to find the dose with the best efficacy/safety ratio. AREAS COVERED: The aim of this article is to provide a complete overview on the use of oral isotretinoin for the treatment of acne describing the efficacy, safety, and tolerability of the drug. EXPERT OPINION: Oral isotretinoin represents a valid therapeutic alternative in treating severe and mild-to-moderate acne lesions, also reducing scarring damage. There are no standardized protocols regarding the use of oral isotretinoin and its association with other therapies; however, the correct patient selection and a tailored treatment protocol according to acne lesions severity and type should be considered in order to obtain optimal results.

Real-world practice indirect comparison between guselkumab, risankizumab, and tildrakizumab: results from an Italian 28-week retrospective study.

BACKGROUND: Guselkumab, tildrakizumab, and risankizumab, acting on interleukin(IL)23 axis, have been recently approved for psoriasis management. However, real-life data regarding their comparison are scant. OBJECTIVES: The aim of our real life study was to perform an indirect efficacy and safety comparison among anti-IL23s, particularly focusing on difficult-to-treat areas. METHODS: A 2-year single-center retrospective observational study was performed enrolling moderate-to-severe psoriasis patients treated with anti-IL23. For each patient, clinical and demographical data were collected at baseline and at week4, week16, and week28. PASI, BSA, NAPSI, and specific BSA regarding difficult to treat areas were evaluated. RESULTS: One hundred and fifty patients were included in the study: 63 (42%) received guselkumab, 21 (14%) tildrakizumab, and 66 (44%) risankizumab. The three groups were comparable for age, sex, and disease severity, only differing for psoriasis duration, psoriatic arthritis prevalence (higher in guselkumab), and previous systemic treatment failure (lower for tildrakizumab). Mean PASI and BSA significantly reduced from baseline up to week 28 without significant differences among the 3 drugs (reduction of 95-97.3% for PASI and 94.8-96.7% for BSA). No significant differences were registered for PASI75, 90, or 100 responses, in particular, PASI100 was reached by 73.4-85% of patients. As regards difficult-to-treat areas, all the drugs displayed a high efficacy, with significant differences registered only for the rapidity of action on palmoplantar psoriasis. CONCLUSIONS: Our 28-weeks study demonstrated a comparable efficacy and safety profile for all anti-IL23, with guselkumab and risankizumab appearing slightly faster than tildrakizumab particularly on palmoplantar lesions in the short-term.What is already known about this topic?The interleukins (IL) 23/17 axis seems to play a key role in psoriasis management.Guselkumab, tildrakizumab, and risankizumab, selectively blocking the IL23 signaling, have been recently approved for psoriasis management.Real-world data regarding different anti-IL23 comparisons are scant.What does this study add?Our 28-weeks study showed that there were not any significant differences in terms of efficacy and safety between each anti-IL-23 apart from palmoplantar area where guselkumab and risankizumab showed higher efficacy.Globally risankizumab and guselkumab appeared slightly faster than tildrakizumab.Guselkumab, tildrakizumab, and risankizumab are valid weapons for psoriasis management, also for difficult-to-treat areas (scalp, nails, genitalia, lower limbs, and palmo-plantar area).