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.

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.

Personalization of Minimally-Invasive Aesthetic Procedures with the Use of Ultrasound Compared to Alternative Imaging Modalities.

Ultrasonography is a well-tolerated procedure that aids in the targeted esthetic therapies of special cutaneous regions, as well as in the prevention (vascular mapping, identification of previous filler, and others) and management of potential complications (vascular occlusion, external vascular compression, product misplacement or migration, inflammatory reactions, and others). It has lately been promoted as the first-line imaging tool to address injectables. In this article, we aim to review the evolving role of ultrasonography in cosmetic filler procedures, from the fundamental ultrasound characterization of cosmetic fillers to the ultrasound-enhanced detection and management of cosmetic filler complications, including ultrasound's role in hyaluronidase-guided injections for cosmetic filler dissolution. Furthermore, the paper explores the integral role played by ultrasound in enhancing the precision, efficacy, and safety of additional minimally invasive aesthetic techniques such as mesotherapy, radiofrequency, cryolipolysis, and polydioxanone procedures.

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.

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.

Complementary Strategies to Promote Hair Regrowth in Post-COVID-19 Telogen Effluvium.

Post-COVID-19 telogen effluvium has been largely reported as a sequela in the post-acute phase of COVID-19, causing major emotional distress among the affected patients. The affected individuals are further exposed to a vast amount of misinformation from the internet and social media and it is important for physicians to be familiar with the phenomenon and provide appropriate counselling to their patients regarding this condition. This article aims to review the evidence-based complementary strategies that can help enhance hair regrowth after post-COVID-19 hair loss, from psychological support and patient education to the importance of optimal nutrition and potential indications and benefits of oral nutritional supplementation, as well as the role of both topical and injectable hair growth stimulators.

Dysplastic nevus syndrome and pancreatic cancer: A case report.

Multiple primary cancers may occur in the same patient, with a prevalence that follows an ascendant trend. Their development is dictated by a complex interplay between a variety of factors, both patient-dependent and external. The case of a 38-year-old female patient diagnosed and treated for pancreatic cancer (PC) is presented in whom the digital dermoscopic monitoring of melanocytic nevi revealed a marked change of two nevi that acquired rapidly highly atypical features. They were surgically excised and the histopathological examination revealed two completely excised dysplastic compound nevi. Clinicians should be aware of the strong association between dysplastic nevus syndrome and PC, a malignancy associated with an extremely poor prognosis. Familial atypical multiple mole melanoma syndrome (FAMMM) predisposes to the development of melanoma, pancreatic cancer and other neoplasms. The common genetic background of PC and hereditary melanoma is discussed and the importance of regular skin checkup and screening for PC in these patients is underlined.

Tele-Rehabilitation Strategies for a Patient With Post-stroke Spasticity: A Powerful Tool Amid the COVID-19 Pandemic.

During the COVID-19 pandemic, stroke remains a leading cause of death and disability. Since the approach towards patients, treatments, and follow-up regimens has changed, tele-rehabilitation became a pillar for patients with ongoing recovery processes and rehabilitation strategies, especially for post-stroke patients. We describe the case of a 50-year-old male, suffering from right spastic hemiplegia and patellar clonus, for whom rehabilitation services were delivered both in-person (conventional physical therapy and radial extracorporeal shock wave therapy) as well as with the aid of a tele-rehabilitation program. Assessments were conducted remotely via a self-adapted treadmill and stabilometric equipment, both connected to the Internet. At discharge and at 20 weeks follow-up, the patient showed decreased spasticity grade, improvement in sensorimotor function, balance, functional mobility, clonus score, ambulation distance, and decreased pain intensity. The case highlights the utility of tele-rehabilitation strategies in complementing and enhancing the effects of conventional physical therapy and radial extracorporeal shock wave therapy (rESWT) in post-stroke spasticity.

The immunoexpression of epidermal growth factor receptor in cutaneous squamous cell carcinoma.

Although cutaneous squamous cell carcinomas (cSCCs) account for only 20-25% of non-melanoma skin cancers (NMSCs), they are responsible for most deaths attributable to NMSCs. Apart from SCC seric level, which increases in late-stage disease, no other predictive biomarker for cSCC exists. Epidermal growth factor receptor (EGFR) serves as a predictive biomarker and therapeutic target in numerous malignancies. EGFR immunoexpression is highly elevated in head and neck mucosal SCC. However, its immunoexpression pattern, its relationship with prognosis and survival, and the effect of EGFR targeted therapy in advanced cSCC have not been clarified. We assessed EGFR immunoexpression in 18 cases of cSCC and correlated our findings with the clinicopathological features. Immunohistochemical stainings with anti-EGFR monoclonal antibodies were practiced and the membrane and cytoplasmic immunostaining intensity and quality in the tumors and the non-lesional epithelium were analyzed. Membrane EGFR immunoexpression within the tumors increased with the tumor grade. EGFR overexpression was more frequently found in head and neck cSCCs. We did not find a direct relationship between cytoplasmic EGFR immunoexpression and clinicopathological findings and prognosis. Our results confirm that increased EGFR immunoexpression correlates with aggressive cSCC phenotypes and underline the need for novel treatments for these patients.

Autologous Platelet-Rich Plasma Efficacy in the Field of Regenerative Medicine: Product and Quality Control.

Platelet-rich plasma (PRP) has emerged as a significant regenerative therapy used alone or combined mainly with stem cells, autologous fat grafts, hyaluronic acid, and biomaterials in a variety of medical fields, especially in hair regrowth, wound healing, and sports and rehabilitation medicine. However, the results obtained with this biologic therapy are heterogeneous and conflicting. The observed disparities in the effectiveness of PRP therapies may be due to a lack of standardization in blood processing and preparation. This article is aimed at reviewing the main biological parameters that need to be documented for a thorough reporting of quantitative and qualitative characteristics of the PRP injected, to allow a comparison between the quality of samples and the clinically obtained results and advance the efforts towards treatment standardization.

Electrochemotherapy and Other Clinical Applications of Electroporation for the Targeted Therapy of Metastatic Melanoma.

Electrochemotherapy (ECT) is an effective bioelectrochemical procedure that uses controlled electrical pulses to facilitate the increase of intracellular concentration of certain substances (electropermeabilization/ reversible electroporation). ECT using antitumor drugs such as bleomycin and cisplatin is a minimally invasive targeted therapy that can be used as an alternative for oncologic patients not eligible for surgery or other standard therapies. Even though ECT is mainly applied as palliative care for metastases, it may also be used for primary tumors that are unresectable due to size and location. Skin neoplasms are the main clinical indication of ECT, the procedure reporting good curative results and high efficiency across all tumor types, including melanoma. In daily practice, there are many cases in which the patient's quality of life can be significantly improved by a safe procedure such as ECT. Its popularity must be increased because it has a safe profile and minor local adverse reactions. The method can be used by dermatologists, oncologists, and surgeons. The aim of this paper is to review recent literature concerning electrochemotherapy and other clinical applications of electroporation for the targeted therapy of metastatic melanoma.

Repetitive Peripheral Magnetic Stimulation (rPMS) in Subjects With Lumbar Radiculopathy: An Electromyography-guided Prospective, Randomized Study.

BACKGROUND/AIM: Lumbar radiculopathy refers to the disruption of one or more lumbosacral nerve root functions, usually causing radiating pain and functional impairments. PATIENTS AND METHODS: We aimed to analyze the role of repetitive peripheral magnetic stimulation (rPMS) alone or in association with physiokinesiotherapy (PKT) in treating lumbar radiculopathy. A total of 41 patients diagnosed with lumbar radiculopathy were randomly allocated to the rPMS group and the rPMS plus PKT group. Subjects were then administered a total of 10 treatment sessions. RESULTS: A statistically significant improvement was highlighted in both groups in terms of pain score, and electromyography (EMG) analysis depicted a far superior functional recovery in the rPMS plus PKT group. CONCLUSION: rPMS can constitute an effective treatment for subjects with lumbar radiculopathy and its association with a complex physical rehabilitation program could improve the outcome in these patients.

The Impact of COVID-19 Pandemic on Long-Term Care Facilities Worldwide: An Overview on International Issues.

The COVID-19 pandemic had a great negative impact on nursing homes, with massive outbreaks being reported in care facilities all over the world, affecting not only the residents but also the care workers and visitors. Due to their advanced age and numerous underlying diseases, the inhabitants of long-term care facilities represent a vulnerable population that should benefit from additional protective measures against contamination. Recently, multiple countries such as France, Spain, Belgium, Canada, and the United States of America reported that an important fraction from the total number of deaths due to the SARS-CoV-2 infection emerged from nursing homes. The scope of this paper was to present the latest data regarding the COVID-19 spread in care homes worldwide, identifying causes and possible solutions that would limit the outbreaks in this overlooked category of population. It is the authors' hope that raising awareness on this matter would encourage more studies to be conducted, considering the fact that there is little information available on the impact of the SARS-CoV-2 pandemic on nursing homes. Establishing national databases that would register all nursing home residents and their health status would be of great help in the future not only for managing the ongoing pandemic but also for assessing the level of care that is needed in this particularly fragile setting.

More Than Skin Deep: A Case of Nevus Sebaceous Associated With Basal Cell Carcinoma Transformation.

Nevus sebaceous is a congenital epidermal lesion that typically presents in infancy from the neck up and rarely undergoes malignant transformation. In patients who do present with malignancy, both RAS oncogene and PTCH tumor suppressor gene mutations have been implicated. We report an unusual case of nevus sebaceous in a 41-year-old male patient that developed into basal cell carcinoma on the forehead, and elaborate on the prolonged nature and unique location of its presentation. The case highlights the need for early intervention and how variable access to primary care can impact patient outcomes. We further explore the role of gene mutations in the circumstance that nevus sebaceous does become malignant, as well as pertinent differential diagnoses to consider.

Frequent Hand Washing for COVID-19 Prevention Can Cause Hand Dermatitis: Management Tips.

Coronavirus disease 2019 (COVID-19) continues to spread globally, outpacing the capacity and resources of health systems worldwide. A therapeutic vaccine is not yet on the rise, and preventive measures are the current approach to restraint the transmission of cases. As the virus is highly contagious via respiratory route (droplets from infected persons, widely spread by coughing or sneezing) and via contact with contaminated surfaces, community transmission and spread can be decreased through the practice of regular and diligent hand hygiene. Frequent hand washing implies a prolonged exposure to water and other chemical or physical agents and may induce several pathophysiologic changes, such as epidermal barrier disruption, impairment of keratinocytes, the subsequent release of proinflammatory cytokines, activation of the skin immune system, and delayed-type hypersensitivity reactions. Adverse dermatologic effects, such as excessive skin dryness or even contact dermatitis (particularly the irritant subtype and, to a lesser extent, the allergic subtype), can occur, especially in individuals with a history of atopic dermatitis. These skin conditions are perfectly manageable, and applying a moisturizer immediately after washing hands or after using a portable hand sanitizer is the cornerstone in preventing the development of eczematous changes in the hands. In the current global context, the potential occurrence of these dermatological adverse events should in no way cause people to deviate from strict hand hygiene rules.

Melanonychia - Clues for a Correct Diagnosis.

Melanonychia represents a brown to black discoloration of the nail plate that may be induced by benign or malignant causes. Two main mechanisms are involved in the appearance of melanonychias, i.e., melanocytic activation and melanocytic hyperplasia. The distinction between the two can be made based on the medical history of the patient, the clinical picture, dermoscopy, and histopathological examination and is essential for the adequate management of the patient. We review the main causes of melanonychia, with emphasis on the clues to the diagnosis of subungual melanoma.

Atypical Tinea Corporis Revealing a Human Immunodeficiency Virus Infection.

Dermatophytes are fungi that commonly cause superficial skin infections. While these rashes are typically benign and easily treated with topical antifungal medications, extensive presentations can indicate a more serious underlying immunodeficiency. We report on a teenage girl whose extensive rash led to a diagnosis of human immunodeficiency infection.

Nanosystems for Improved Targeted Therapies in Melanoma.

Melanoma is one of the most aggressive forms of skin cancer, with limited therapeutic options. Since its incidence has been rapidly rising in recent years, the study of new targeted therapeutic strategies has increased. The implication of nanoscience in the development of alternative targeted therapies for melanoma has multiple benefits and could significantly improve the outcome of melanoma patients. In this paper, we review the most recent progress in the field of targeted therapies, emphasizing the impact of nanoscale materials on the targeting and controlled release of anti-tumor drugs. The applications of nanomedicine in the management of melanoma are extensive and refer to sentinel lymph node mapping, chemotherapy, and RNA interference; each of these applications harboring the potential to develop efficient and personalized diagnostic techniques and therapies. Further research, especially in clinical trials, is needed to establish whether fighting melanoma on the nanoscale level represents the key to reaching a critical inflection point in mankind's battle with metastatic melanoma.

Darier Disease - A Clinical Illustration of Its High Variable Expressivity.

Darier disease (DD), also known as dyskeratosis follicularis, is a rare genodermatosis classically characterized by persistent hyperkeratotic papules and plaques affecting the seborrheic areas. Due to its variable expressivity, it can present with very discrete clinical features for many years, leading to diagnostic errors and incorrect treatments. We report an unusual case of Darier disease in a 69-year-old male patient in which the classical features of DD had a remarkably late onset. This patient had a several decades' history of small, recurrent, scattered papules, limited to the face, for which he had received multiple diagnostic interpretations, such as acne or recurrent staphylococcal skin infection. We established the diagnosis of DD with superinfected lesions, and initiated treatment with intravenous antibiotics and oral retinoids. Results were extremely satisfactory in a very short time. This case shows an extremely unusual clinical course of Darier disease and is illustrative for the variable expressivity of the disease. It highlights the need to take dyskeratosis follicularis into account in patients with a longstanding history of persistent, hyperkeratotic papules, from unknown origin, even in the absence of the classical clinical findings.

Epidermolysis Bullosa Acquisita: A Case Report of a Rare Clinical Phenotype and a Review of Literature.

Epidermolysis bullosa acquisita (EBA) is an autoimmune subepidermal bullous disorder of the skin and mucous membranes. The disease results from the production of immunoglobulin G (IgG) antibodies against type-VII collagen, a major component of anchoring filaments in the dermal-epithelial junction. The disease has two major forms of presentation: the classical (non-inflammatory) type and the inflammatory type. Classical EBA is mainly characterized by the following features: development of non-inflammatory tense blisters on trauma-prone areas, multiple milia cysts, minimal or no inflammation findings on histopathology. Alternatively, inflammatory EBA is defined by widespread inflammatory blistering eruptions and a neutrophil-rich inflammatory infiltrate on standard histopathology. In both cases, specialized immunopathological findings are further required to establish an accurate diagnosis. In this article, we present an atypical case that shares features of both inflammatory and non-inflammatory forms of EBA. The case also serves to review and synthesize current concepts on the etiopathogenesis, diagnosis, and treatment of this extremely rare disease.