Leg skin ulcer with atypical features: vascular wound or advanced melanoma?

BACKGROUND: Leg ulcers have various etiologies, including malignancy, although vascular issues are the most frequent cause. Malignant wounds present diagnostic challenges, with a reported prevalence rate ranging from 0.4% to 23%. This significant variability in reported prevalence appears to be due to the different settings in which data are collected, which suggests potential influence by medical specialty. Consequently, the misdiagnosis of neoplastic ulcers (eg, ulcerated melanoma) as vascular wounds is relatively common, leading to delayed diagnosis, inadequate treatment, and a dramatic worsening of the patient's prognosis. Identifying malignancy in nonresponsive wounds involves recognizing signs such as hypertrophic granulation tissue, bleeding, unusual pigmentation, and raised edges. The appearance of the perilesional skin, together with dermoscopic observation, is also crucial to differentiation. Ultimately, a biopsy may provide valuable diagnostic clarification. CASE REPORT: A case is presented of lower limb melanoma that for years was misdiagnosed as a vascular wound by multiple specialists, with delayed referral to a dermatologist and resulting recognition and diagnosis, at which time nodular satellite metastases were found. Dermoscopy and biopsy confirmed the diagnosis. The disease was already advanced, with in-transit and distant site metastases, and the prognosis was regrettably poor. CONCLUSION: This case underscores the importance of early detection and accurate diagnosis of malignant wounds, emphasizing the need to refer patients with suspicious nonresponsive ulcers to a dermatologist.

Pulsed Radiofrequency Electromagnetic Fields as Modulators of Inflammation and Wound Healing in Primary Dermal Fibroblasts of Ulcers.

Venous leg ulcers are one of the most common nonhealing conditions and represent an important clinical problem. The application of pulsed radiofrequency electromagnetic fields (PRF-EMFs), already applied for pain, inflammation, and new tissue formation, can represent a promising approach for venous leg ulcer amelioration. This study aims to evaluate the effect of PRF-EMF exposure on the inflammatory, antioxidant, cell proliferation, and wound healing characteristics of human primary dermal fibroblasts collected from venous leg ulcer patients. The cells' proliferative and migratory abilities were evaluated by means of a BrdU assay and scratch assay, respectively. The inflammatory response was investigated through TNFα, TGFß, COX2, IL6, and IL1ß gene expression analysis and PGE2 and IL1ß production, while the antioxidant activity was tested by measuring GSH, GSSG, tGSH, and GR levels. This study emphasizes the ability of PRF-EMFs to modulate the TGFß, COX2, IL6, IL1ß, and TNFα gene expression in exposed ulcers. Moreover, it confirms the improvement of the proliferative index and wound healing ability presented by PRF-EMFs. In conclusion, exposure to PRF-EMFs can represent a strategy to help tissue repair, regulating mediators involved in the wound healing process.

Etiology of Chronic Leg Ulcers in a Dermatologic Wound Clinic: A Retrospective Observational Study.

BACKGROUND: Chronic leg ulcers affect approximately 1% to 2% of the European population, with an increasing prevalence. The treatment of chronic wounds is a socioeconomical problem worldwide. PURPOSE: The main purpose of the current investigation was to detect the etiology of leg ulcers treated in a dermatologic wound clinic from January 1, 2010, to December 31, 2019. METHODS: This retrospective observational study was performed at the Dermatologic Clinic of Spedali Civili in Brescia, Italy. The authors enrolled 465 patients with chronic leg ulcers. RESULTS: The 3 most represented causes of ulcers were vascular (238 patients, 51.2%), inflammatory (71 patients, 15.3%) and traumatic (43 patients, 9.3%). Altogether, a total of 13 different entities were identified as a cause of leg ulcer. CONCLUSION: Vascular genesis was the most common etiology of leg ulcers in this population, even though uncommon causes were also represented. These findings are in agreement with other studies reported in the literature.

Post-SARS-CoV-2 Acute Telogen Effluvium: An Expected Complication.

Post-SARS-CoV-2 telogen effluvium has been described in case reports of COVID-19 patients. We evaluated the prevalence of post-SARS-CoV-2 telogen effluvium in patients from a single medical center, exploring any causal links with the infection. Our hospital-based, cross-sectional study was conducted with patient participants discharged with a diagnosis of SARS-CoV-2 pneumonia from 1 March to 4 April 2020. All patients were evaluated by the same senior dermatologist; a clinical/dermatoscopic evaluation was performed. Alopecia was assessed in 31.3% of patients, with a significant difference in sex (females 73%, males 26.7%). The average time detected from the onset of the first symptoms to alopecia was 68.43 days. Overall, there were no significant associations between alopecia and COVID-19-related features (length of hospitalization, virologic positivity, or duration of fever), treatment characteristics, or laboratory findings. In this paper, we report that post-infection acute telogen effluvium occurs in a significant number of COVID-19 patients. The burden of this condition may impair the quality of life, with a significant impact on individuals.

Allergic contact versus irritant contact dermatitis in patients with hard-to-heal leg ulcer: clinical and diagnostic approach.

BACKGROUND: Dermatitis of surrounding skin may complicate hard-to-heal leg ulcers, delaying wound healing. The coexistence of hard-to-heal leg ulcers and irritant or allergic contact dermatitis may create difficulties for both diagnostic and therapeutic management. OBJECTIVE: The aim of our study was to evaluate the incidence of dermatitis occurring in the surrounding skin in a population affected by hard-to-heal leg ulcers during treatment, and to differentiate between allergic contact dermatitis (ACD) and irritant contact dermatitis (ICD) with the use of a patch test. Furthermore, we investigated which medications were most probably related to these conditions. METHOD: We conducted an observational study from 21 February to 21 July 2017, enlisting all patients affected by hard-to-heal leg ulcers who attended the Wound Care Service of the Dermatologic Department of ASST, Spedali Civili, Brescia, Italy. RESULTS: We enrolled 95 patients; 81 patients did not develop dermatitis, while 14 patients developed dermatitis of the surrounding skin. These patients underwent a patch test which gave a positive result in seven patients, permitting the diagnosis of ACD. CONCLUSION: Our study confirmed the incidence of dermatitis of the surrounding skin reported in the literature but reassessed the incidence of ACD as opposed to ICD.

Nested graft for chronic ulcer in scar tissue after heroin extravasation in a drug addict.

INTRODUCTION: Nested graft is a surgical technique that allows to manage difficult-to-treat medical conditions such as chronic cutaneous ulcers, thanks to the high efficacy it has in reverting the fibroblasts senescence. Because of its peculiar regenerative property, nested graft is a surgical technique suitable also for the treatment of cutaneous ulcers developing on fibrotic scar tissue. CASE REPORT: We reported the case of a 45-year-old man, drug-addict, with a large ulcer on the back of the right forearm in the context of scar fibrotic tissue. This lesion resulted from a previous heroin extravasation treated with a dermo-epidermal skin graft, that was accidentally scratched away by mechanical trauma. After several therapeutic failures with topical medications, we decided to treat the ulcer performing a skin graft using the nested graft technique. No adverse events were reported by the patient during or after the surgery. At the clinical evaluation performed three years later the wound was completely healed. CONCLUSIONS: Nested graft represents a safe and easy-to-use technique that can be successfully used to treat ulcers on scar tissue, ensuring the achievement and the long-term maintenance of optimal resistance and aesthetic results.

Tattoo: Ancient art and current problems.

The popularity of tattoos in the today's society brings with it a significant increase of the incidence of associated cutaneous reactions. Among the several complications that may occur after a tattooing procedure, allergic and photo-allergic reactions, infections, and Koebner phenomenon are the most common ones observed. Most of these complications may be avoided by identifying, before tattooing, the presence of risk factors or comorbidities that may increase the risk of their onset.

Correlation between chronic skin ulcers dimension and burden of suffering evaluated with PRISM test.

BACKGROUND: In the practice of dermatology, many tools are available to help the physician measure the patient's quality of life. The Pictorial Representation of Illness and Self Measure (PRISM) is a novel and simple method to measure personal suffering. The aim of our study was to evaluate, using PRISM, whether the reduction of the ulcers' size positively correlated with an improvement of the patients' suffering. METHODS: This was a multicenter national prospective study. 143 patients from five dermatological centers were enrolled in the study. At times T0 and T1 (after 1 month), the size of the ulcers was collected for each patient. At the same time, the PRISM test was also administered, in order to calculate the Self-Illness-Separation (SIS). RESULTS: First, a substantial decrement of the size of the ulcer seemed to correlate with a significant difference between the SIS score obtained at T0 and T1. On the contrary, the duration of the wound did not seem to influence the SIS value. No relationship between the age of the patient and the SIS value was found either. CONCLUSIONS: Our study showed that the decrease in the wound dimension positively affects the patient's suffering. In fact, ulcer's size reduction is correlated with an improvement in the patient's disease perception.

Epidemiology of skin diseases in the Tigray region of Ethiopia.

BACKGROUND: Skin diseases are very common among people living in poor countries. Although many of these pathologies might not be fatal, some can have a great impact on the patient, impairing their ability to work or worsening his/her relationship with the community. Understanding the epidemiology of skin diseases in these areas, determining the prevalence of different disorders, is fundamental to develop better educational and preventative programs. METHODS: We collected data from 467 consecutive patients referring to the Dermatology Center of the Axum Referral Hospital (Tigray region, Ethiopia). We investigated health status and environmental data. Diagnoses were classified into 6 groups (i.e. infectious, inflammatory, etc.). A statistical analysis was performed using IBM SPSS™ software version 25.0.1 (IBM SPSS Inc. Chicago, Illinois) and Stata™ software release 14.2 (Stata Corporation, College Station, Texas). Normality of the distributions was assessed using the Kolmogorov-Smirnov test. Categorical variables are compared with the use of the Chi Square test or the Fisher's exact test, as appropriate. RESULTS: Inflammatory and infectious diseases were the most frequently observed. No significant differences in inferential tests between access to water, housing, education level, and any diagnoses group were found. Curiously, a statistically significant difference between inflammatory diseases and unemployment was found. CONCLUSIONS: Easier access to medical care, medications, and clean water, together with a cleaner work and home environment, are the first goals to be achieved in order to decrease morbidity in these areas.

Characterization of Basosquamous Cell Carcinoma: A Distinct Type of Keratinizing Tumour.

Basosquamous carcinoma is a rare clinical entity, which comprises 1.7-2.7% of all skin carcinomas. It is described as a basal cell carcinoma with features of squamous differentiation. To date, studies of the epidemiology of basosquamous carcinoma have been few and small in size. We report here the most extensive series of basosquamous carcinomas published to date, highlighting the differences between basosquamous carcinoma and other keratinizing tumours. Patients undergoing surgical excision for keratinizing tumours were enrolled in this study. Age, sex and tumour characteristics were recorded. A total of 1,519 squamous cell carcinomas, 288 basosquamous carcinomas and 4,235 basal cell carcinomas were collected. Basosquamous features were compared with those of basal cell and squamous cell carcinomas. For basosquamous carcinomas, 70.5% were located on the head and neck, particularly on the nose, forehead and cheeks, and represented almost 10% of the keratinizing tumours on the ears. Significant differences were found between basosquamous carcinoma and basal cell or squamous cell carcinomas. Basosquamous carcinoma should be considered a distinct type of keratinizing tumour with different anatomical, sex and age distributions.

When basal cell carcinomas became giant: an Italian multicenter study.

BACKGROUND: Giant basal cell carcinoma (GBCC) is a basal cell carcinoma (BCC) enlarged in a diameter more than 5 cm. Since GBCCs are a highly infrequent entity and the occurrence rate is approximately 0.5-1% out of all BCC types, only anecdotal cases are reported, and causes and characteristics inducing development of this tumor are not defined. OBJECTIVES: Evaluate causative factors and clinico-histological characteristics of GBCCs. METHODS: The study is a 6-month, hospital-based case series study performed in 12 Italian dermatologic centers. RESULTS: A total of 59 cases and 458 control BCCs were collected. No significant differences existed between the two groups if we take into account social or cultural factors. The average duration of GBCCs is considerably longer than controls. GBCCs are located on unexposed areas while BCCs are on areas not usually covered by clothes. Superficial histological subtype was more frequent in the BCCs group, while infiltrative in GBCCs. GBCCs showed significantly higher local invasiveness, and greater metastatic capacity. More than half of GBCCs had been previously treated with one or more treatments. CONCLUSIONS: Patients with GBCCs appear to belong to two categories: (i) those who present with GBCC due to delay in accessing medical attention, and (ii) those who have BCCs previously treated with inappropriate strategies. Only very few cases can be carried out with intrinsic biological features of tumor aggressiveness. Social and cultural conditions do not appear to be involved in the development of GBCCS. These observations may help clinicians in selecting correct therapeutic strategies in the treatment of BCCs, which give rise to GBCC.

Hyaluronic Acid-based Products are Strictly Contraindicated in Scleroderma-related Skin Ulcers.

INTRODUCTION: Evidence of the role of hyaluronic acid (HA) in the tissue repair process is extensive. Hyaluronic acid produces a positive effect on skin ulcer healing, so many companies produce it in various topical applications. OBJECTIVE: This retrospective, observational study examined the use of different HA-based products in patients with chronic skin ulcers of various etiologies (vascular, scleroderma, postoperative) to assess the indication, effectiveness, and possible adverse reactions. MATERIALS AND METHODS: A retrospective case review was conducted on 79 patients presenting to the Department of Dermatology of the Spedali Civili (Brescia, Italy) with multiple chronic skin ulcers of the legs of various etiologies. The authors counted a total of 106 chronic wounds with granulating appearance but not responsive to common wound dressings; for this reason, these wounds were treated with a HA-based product. The efficacy of the treatment was evaluated by dividing the population into 2 groups: sclerodermic (41 ulcers) and nonsclerodermic (65 ulcers). RESULTS: Initial results confirmed HA-based products were effective for healing chronic skin wounds. However, when wounds are grouped by etiology, it was evident that patients with sclerodermic ulcers showed a rapid inflammatory response that led to a clinical deterioration and worsening of skin ulcers (92.7%). In contrast, patients with noninflammatory ulcers (vascular, postoperative) had the severe inflammatory event reduced to 1.5%, with a recovery of 98.5%. CONCLUSIONS: The negative effects of HA-based products on a patient with scleroderma could be explained by the fact that HA can produce a proinflammatory effect causing keratinocyte migration.

Epidemiology of pyoderma gangrenosum: Results from an Italian prospective multicentre study.

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis characterised by painful, necrotic ulcerations. PG is described as a rare disease: the world-wide incidence is estimated to be around 3 to 10 cases per million population per year. These estimations are based mostly on case reports and retrospective case series; there are no prospective, multicentre studies on the matter. The apparent rarity of PG is in contrast with our clinical perception as dermatologists: in our opinion, PG is not so uncommon. Therefore, we decide to investigate the epidemiology of PG in the Italian population and confirm our clinical suspicions that it is not an orphan disease. We enrolled all patients diagnosed with PG in 8 Italian Dermatological Departments from 1st October 2014 to 1st November 2015, and we recorded their features. Our data, collected from 64 patients, are in accordance with those of the published literature regarding the epidemiology and features of PG. In an Italian population of roughly 8 million inhabitants of 7 provinces, we found an incidence of 5.17 new cases per million population per year. Unlike our predictions before the study, we confirmed the world-wide incidence of PG. To our knowledge, this is the first observational, multicentre study on PG. We hope that it provides a stimulus for further researches on PG and for the creation of an Italian register.