Italian National Registry of Alopecia Areata: an epidemiological study of 699 Italian patients

BACKGROUND

Alopecia areata (AA) is an organ-specific autoimmune disease that affects the hair follicles of the scalp and the rest of the body causing hair loss. Due to the unpredictable course of AA and the different degrees of severity of hair loss, only a few well-designed clinical studies with a low number of patients are available. Also, there is no specific cure, but topical and systemic anti-inflammatory and immune system suppressant drugs are used for treatment. The need to create a global registry of AA, comparable and reproducible in all countries, has recently emerged. An Italian multicentric electronic registry is proposed as a model to facilitate and guide the recording of epidemiological and clinical data and to monitor the introduction of new therapies in patients with AA.

METHODS

The aim of this study was to evaluate the epidemiological data of patients with AA by collecting detailed information on the course of the disease, associated diseases, concomitant and previous events, and the clinical response to traditional treatments. Estimate the impact on the quality of life of patients.

RESULTS

The creation of the National Register of AA has proven to be a valid tool for recording, with a standardized approach, epidemiological data, the trend of AA, response to therapies and quality of life.

CONCLUSIONS

AA is confirmed as a difficult hair disease to manage due to its unpredictable course and, in most cases, its chronic-relapsing course, capable of having a significant impact on the quality of life of patients.

CO2 Laser-Assisted Nail Sampling for Mycological Testing in Onychomycosis

Introduction

Onychomycosis is the most common nail infection, predominantly caused by Trichophyton spp., and is divided into four main types. Confirmatory testing is crucial, but obtaining an adequate sample may be challenging. We suggest the use of carbon dioxide (CO2) laser for painlessly detaching the nail plate during mycological examination and ensuring a sufficient specimen.

Methods

We retrospectively enrolled 25 patients with distolateral onychomycosis, treated according to the following protocol: (1) multiple passes of CO2 laser at 10 W in continuous mode along the proximal border of the affected nail plate; (2) the nail plate was gently cut; (3) the nail bed was curetted; (4) subungual debris and plate fragments were collected for KOH test and culture.

Results

The mean visual analog score (VAS) for pain experienced during the procedure was 0.7 (SD: 2.1), indicating that the sampling was relatively painless for the majority of patients. There were no permanent changes observed in the nail unit of any patients during the follow-up visits as a result of using the CO2 laser.

Conclusion

We firmly believe that the use of lasers offers numerous advantages, including ease of use, reduced pain perception, and the ability to target the proximal margin of fungal infections where viable hyphae are significantly represented.

Elongated linear vessels simulating branching vessels and diffuse structureless orange areas as prominent dermoscopic features of diffuse flat facial and extrafacial granuloma faciale: A case series

Dermoscopy can be an important help for the diagnosis of skin cancers and inflammatory cutaneous diseases. The list of the dermoscopic features reported in granuloma faciale is wide and includes vascular and non-vascular features. We report here three cases of diffuse flat facial and extrafacial granuloma faciale that exhibited elongated linear vessels simulating branching vessels and diffuse structureless orange areas. The differential diagnosis between flat-type granuloma faciale, basal cell carcinoma and cutaneous sarcoidosis can be extremely difficult, making histology mandatory before any treatment.

Ablative CO2-Assisted Laser for Topical Drug Delivery in Nail Psoriasis: A Systematic Review

Background

Nail psoriasis poses challenges for effective treatment, and topical drug delivery through the nail plate is limited. A novel approach to address this challenge involves the use of ablative fractional laser as a pretreatment strategy to enhance topical drug delivery for nail psoriasis.

Summary

This systematic review, conducted in accordance with PRISMA guidelines, involved an extensive literature search across PubMed/MEDLINE, EMBASE, and the Cochrane Library up to July 2023. The primary focus was on exploring studies that investigated the application of ablative laser technology to augment drug delivery for nail psoriasis.

Key Messages

(1) The review included seven randomized controlled trials, all examining the combination of fractional CO2 laser with topical treatments. These trials demonstrated varying degrees of improvement in nail psoriasis. (2) Patients undergoing laser treatment reported experiencing moderate levels of pain, effectively managed through the application of topical anesthesia. (3) Commonly observed side effects included erythema, swelling, and crusting, with the Koebner phenomenon being a rare occurrence. (4) Notably, patient satisfaction levels with the combined approach of laser and topical treatments were consistently high. In conclusion, the utilization of ablative CO2-assisted laser pretreatment, when used in conjunction with topical therapy, appears to be both effective and well-tolerated for the treatment of nail psoriasis. However, the establishment of optimal parameters and treatment intervals for fractional laser therapy remains an area for further research. Standardized studies are imperative to identify the most effective strategy for enhancing topical drug delivery in the context of nail psoriasis treatment.

A critical evaluation of suitability of tralokinumab for treatment of moderate-to-severe atopic dermatitis in adolescents and adults

INTRODUCTION

Atopic dermatitis (AD) is a chronic, intensely pruritic disease associated with significant patient burden. Recent advancements in AD pathogenesis have expanded its therapeutics pipeline. Tralokinumab is a fully human monoclonal antibody that binds specifically Interleukin (IL)-13, inhibiting the downstream IL-13 signaling. Phase 3 clinical trials and some real-world studies showed that tralokinumab, as monotherapy or in combination with topical corticosteroids, is efficacious and safe in adult patients with moderate-to-severe AD. Similar results were reported in a phase 3 trial in adolescents (aged ≥12 years).

AREAS COVERED

We review the role of IL-13 in AD and discuss the value of tralokinumab for treating moderate-to-severe AD, comparing efficacy and safety results derived from clinical trials and real-life data.

EXPERT OPINION

The role of IL-13 in AD supports a targeted therapeutic approach. Tralokinumab has proven efficacious and well-tolerated in a large proportion of patients confirming its value for treating moderate-to-severe AD from age 12 years onwards; it quickly improves itching and can maintain a high-level of response over time; it can be administered with flexible dosing schedules. Future studies will further clarify the role of IL-13 pathway and which patients would be best suited to tralokinumab, shifting AD treatment into an era of precision medicine.

Tinea capitis in newborns: Report of a case and review of the literature with a focus on treatment modalities

Tinea capitis is a common disease in children but rare in newborns younger than 1 month of age. Only 29 cases of tinea capitis in newborns have been described in indexed literature from 1990 until now. While antifungal agents can be used topically and systemically, systemic antifungal therapy is generally accepted as the treatment of choice for tinea capitis due to limited penetration of topical agents into the hair follicle. However, there is a lack of data on the use of systemic antifungal agents in newborns, and there are reports of successful treatment of tinea capitis in newborns using only topical therapy. In this paper, we present a case of tinea capitis in a 29-day-old female baby and review the previous 29 reported cases.

Ultrasound Features of Onychopapilloma at High-Frequency and Ultra-High Frequency

OBJECTIVE

This study aimed to identify the sonographic features of pathologically confirmed onychopapilloma cases.

METHODS

High-frequency up to 24 MHz and ultra-high frequency-ultrasound up to 71 MHz examinations were performed and correlated with their clinical and pathologic presentations.

RESULTS

Twenty-two cases met the criteria. Clinical presentations revealed longitudinal erythronychia in 63.3% of cases. The ultrasound examinations identified a hypoechoic band in the nail bed (86.3%), nail plate abnormalities including upward displacement (68.2%) and thickening (68.1%), focal hyperechoic focal spots on the nail plate (50%) and irregularities of the ventral plate (33.3%). Color Doppler imaging showed no hypervascularity of the nail bed in all studies. These findings correlate with histological characteristics of onychopapilloma, including nail bed acanthosis, papillomatosis, and layered hyperkeratosis. Recurrence occurred in two cases after surgery, with tumors showing proximal extension in the matrix region on ultrasound not evident during clinical examination.

CONCLUSION

High-frequency and ultra-high-frequency can provide anatomical information in onychopapilloma that could enhance understanding and management.

Onychoscopic characteristics of Trichophyton rubrum and Trichophyton interdigitalis fungal infections: A multicentric study

BACKGROUND

Trichophyton rubrum and Trichophyton mentagrophytes variant interdigitalis are the most frequent etiologic agents of onychomycosis. Diagnosis of certainty requires mycological examination, which often results unfeasible.

OBJECTIVES

The aim of our study is to describe pathogen specific dermoscopic features, allowing a differential diagnosis without the need for cultural examination, in order to prescribe the most appropriate treatment anyway.

PATIENTS AND METHODS

We conducted an observational retrospective study on 54 patients with a culture proven diagnosis of distal subungual onychomycosis of the toenail, caused by Trichophyton rubrum or Trichophyton mentagrophytes variant interdigitalis. Using a videodermatoscope we collected data on nail colour (white, yellow, orange, brown, dark) and on dermoscopic patterns (aurora, spikes, jagged, ruin, linear edge, dots, striae).

RESULTS

Fifty-four patients, with a total of 72 nails, were eligible for this study. Analysing the association between discoloration of the nail plate and type of infection (T. rubrum or T. interdigitalis), no correlation turned out to be statistically significant. Instead, significant associations between spikes and T. rubrum infection and striae and infection from T. interdigitalis were identified. Finally, a 100% specificity was identified for white colour and ruin pattern for T. rubrum infection, and brown colour, jagged border and aurora pattern for T. interdigitalis.

CONCLUSIONS

Trying to find relationships between specific pathogens and dermoscopic patterns, we found out an association between spikes and striae and T. rubrum and T. interdigitalis respectively. Further larger studies are however necessary to evaluate our preliminary findings.

Relapsing subcutaneous nodules of the penis in a pediatric patient

A 14-year-old boy presented with a history of non-tender, subcutaneous coalescing nodules located on the ventral-lateral aspects of the penis shaft for one year. Laboratory investigations for blood count and autoimmunity were within normal limits. Complete excision was performed, and on histology, the dermis showed necrobiotic material composed of altered collagen bundles, surrounded by a palisade of histiocytes and scattered lymphocytes, thus allowing a diagnosis of subcutaneous granuloma annulare. Only 18 published cases reported penile granuloma annulare. Medical management was advocated in 7/18 cases, either as a first-line or adjuvant therapy where surgery was not radical. Three patients received high-potency local steroids: two cases underwent adjuvant sessions of intralesional triamcinolone, and one patient received pentoxifylline orally. Surgery should be considered a second-line option since 5/8 of treated cases eventually recurred. The pentoxifylline-treated case witnessed a relapse after drug discontinuation, while topical steroids lead to complete recovery without relapses.

Wickham striae on skin appendages: a helpful dermoscopic feature

Lichen planus (LP) is a chronic inflammatory disease, clinically characterized by purpuric, itchy papules that typically spread on the trunk and extremities. Other body sites can also be affected, including mucosal membranes, nails, and the scalp. The use of dermoscopy is essential in determining the diagnosis of LP, as it may highlight pathognomonic features such as Wickham striae (WS). WS are thin, pearly white structures arranged in a reticular pattern that is observed over LP lesions and histologically correspond to epidermal hypergranulosis. WS is usually most visible on the oral mucosa but can also cover almost every active LP papule. Here, we report two cases of biopsy-proven LP that show WS on dermoscopy in two specific sites: the scalp and proximal nail fold.

Trichoscopy as a Tool to Evaluate Early Dissecting Cellulitis in Patients Affected by Hidradenitis Suppurativa: A Prospective Monocentric Observational Study

Background

Dissecting cellulitis (DC) is a rare neutrophilic dermatosis that leads to cicatricial alopecia. Although DC and Hidradenitis suppurativa (HS) have similar characteristics, their association remains poorly understood.

Objectives

In this prospective observational study, we used trichoscopy to identify subclinical signs of DC in male patients aged 18 years or older, presenting with HS. The objective of this study was to use trichoscopy to identify subclinical signs of DC in patients with confirmed diagnosis of HS.

Method

In this prospective, monocentric, observational study, we used trichoscopy to identify subclinical signs of DC in male patients aged 18 years or older, presenting with HS for their initial visit at our HS outpatient clinic from February 1, 2022, to January 31, 2023.

Results

Of the 23 male patients with HS, 8 (35%) had subclinical trichoscopy findings consistent with DC. The most frequent location was the vertex (6/8), and the majority of patients had early/inflammatory trichoscopic signs of DC (5/8). Additionally, patients with trichoscopic findings consistent with DC had a higher Hurley stage and the International Hidradenitis Suppurativa Severity Score System (IHS4). Among the cases with trichoscopic findings compatible with DC, the majority (6/8) were classified as having a "follicular" HS according to the Canoui-Poitrine classification. Patients were treated according to European S1 guidelines on HS.

Conclusions

This is the first study to evaluate subclinical DC findings in HS patients using trichoscopy. Although the trichoscopic findings of DC are heterogeneous, the use of this non-invasive technique, in conjunction with clinical evaluation, can improve diagnostic accuracy and lead to earlier diagnosis. These findings suggest a potential association between HS and DC, indicating the need for further studies to evaluate this relationship.

Clinical study on the efficacy and tolerability of an oral supplement based on arginine, l-cystine, zinc and B6 vitamin (Cystiphane®) in patients with telogen effluvium

BACKGROUND

Telogen effluvium (TE) is a common cause of non-cicatricial hair loss with no treatment-standardized protocol. The aim of our study was to evaluate the efficacy, tolerability, and patient compliance of a treatment with an oral supplement based on arginine, l-cystine, zinc and B<inf>6</inf> vitamin (Cystiphane^®, Laboratoires Bailleul, Geneva, Switzerland) with hair-growth properties, administered 4 times daily, in patients affected by TE.

METHODS

We recruited 20 patients, aged between 18 and 70 years old, affected by TE. Patients were asked to take the oral supplement as a monotherapy, four tablets daily, in one or two administrations during meals. The study lasted 3 months. We evaluated the efficacy and tolerability of the treatment both qualitatively by collecting the clinician's opinion through a clinical evaluation and clinical-anamnestic form filled in by the researcher, and quantitatively through global photography and trichoscopy. We collected the patient's opinion through a self-assessment test, at the beginning of the recruitment and after 3 months of treatment.

RESULTS

Eighteen patients were evaluated. After 3 months of taking the supplement, the researcher rated an average improvement of 2.89 at the clinical evaluation. For what concerns hair quantity, at the control trichoscopy, the mean trichoscopic value had risen to +2.055, whereas for hair diameter the mean trichoscopic diameter value had increased to +1.83. After 3 months of treatment, patients gave an average efficacy opinion of 3.61.

CONCLUSIONS

The oral supplement has proved effective as an adjuvant in the treatment of TE in our cohort of patients.

Report of terbinafine resistant Trichophyton spp. in Italy: Clinical presentations, molecular identification, antifungal susceptibility testing and mutations in the squalene epoxidase gene

BACKGROUND

Numerous reports of resistance to terbinafine in Trichophyton spp. from all over the world are arousing justified attention and concern. Point mutations in the gene that encodes the squalene epoxidase (SQLE) enzyme are responsible for these therapeutic resistances.

OBJECTIVES

Primary objective of the study was to describe first isolates of Trichophyton spp. resistant to terbinafine among the patients treated between September 2019 and June 2022 at the Dermatology Units of Ospedale Maggiore Policlinico and San Bortolo Hospital. Secondary objective was to study the resistance mechanism.

METHODS

Patients with confirmed Trichophyton spp. infection has been treated with systemic and topical terbinafine. Patients were then re-evaluated 12 weeks after the therapy. Patients with incomplete or absent response to terbinafine underwent a new skin scraping for direct mycological examination, new identification of dermatophyte species from culture and MALDI-TOF, molecular species identification, antifungal susceptibility testing and molecular analysis of SQLE gene.

RESULTS

We identified five patients without clinical response to treatment with terbinafine. The DNA sequencing of the ITS region identified one Trichophyton rubrum and four Trichophyton indotineae. The T. rubrum strain showed minimum inhibitory concentration (MIC) (90% growth inhibition) of 4 mg/L for terbinafine. The four T. indotineae strains showed a MICs range of 0.25-4 mg/L for terbinafine. The analysis of the SQLE gene in the T. rubrum strain showed a nucleotide substitution generating a missense mutation (L393F). The SQLE gene sequencing in the T. indotineae strains showed a nucleotide substitution generating a missense mutation (F397L) in two strains, a nucleotide substitution L393S in one strain and a nucleotide substitution F415C in another strain.

CONCLUSIONS

We report the first cases of terbinafine-resistant Trichophyton isolates in the Italian population. Solid antifungal management programs will be needed to promote more responsible use of antimycotics and preserve their therapeutic efficacy to control antifungal resistance.

Lasers for the treatment of psoriasis: a systematic review

INTRODUCTION

Phototherapy has been one of the first and still frequently used treatment modality for psoriasis. In the last decades, different types of lasers have been used for the treatment of psoriasis and other inflammatory skin diseases with variable success.

AREAS COVERED

Efficacy and safety of laser devices and intense pulsed light for the treatment of psoriasis. The literature search was conducted using the bibliographic databases MEDLINE, EMBASE and Cochrane. Search terms included "laser" AND "psoriasis", "IPL" AND "psoriasis", "intense pulsed light" AND "psoriasis".

EXPERT OPINION

Due to its high efficacy and safety profile 308nm Excimer laser retains its specific place in the treatment of plaque psoriasis as a first- or second-line therapy in mild disease or as an adjuvant treatment in case of partial response to systemic treatments in moderate to severe disease. Vascular lasers remain a last line therapy that can be tried in patients with recalcitrant limited plaques or nail affection. They are easy to apply and have a very good safety profile and tolerability, but the efficacy is limited. Fractional ablative lasers for application of laser assisted drug delivery appear interesting and a topic for further research. When using lasers for psoriasis, a good pre-treatment is mandatory.

Adverse events in patients treated with Jak-inhibitors for alopecia areata: a systematic review

Recently, the impressive efficacy of JAK-inhibitors (JAK-I) in alopecia areata (AA) has been described in several studies; however, to date, there is limited information on the safety of JAK-I in AA patients. For this reason, on the August 18^th 2022, a systematic review was performed to collect the pre-marketing and post-marketing data on the safety of JAK-I in patients treated for AA, evaluating for each molecule the reported adverse events (AEs) in indexed literature and their frequency. The keywords "alopecia areata" AND "Jak-inhibitors OR Janus-kinase Inhibitors" were searched on PubMed, Embase, and Cochrane databases. Of 407 studies retrieved, 28 papers met the requirements and were used in our review, including 5 RCTs and 23 case series, overall 1719 patients were included and the safety of 6 JAK-I was assessed (baricitinib, brepocitinib, deuruxolitinib, ritlecitinib, ruxolitinib, tofacitinib). Systemic JAK-I were well tolerated, most of the AEs were mild, and the withdrawal rate for AEs was very low and inferior to placebo in controlled studies (1.6% vs. 2.2%). Laboratory abnormalities represented 40.1% of AEs associated with oral JAK-I, which mostly included the rise in cholesterol, transaminase, triglycerides, creatine phosphokinase (CPK), and sporadic cases of neutro/lymphocytopenia. The remaining AEs involved the respiratory tract (20.8%), the skin (17.2%), the urogenital (3.8%), or the gastroenterological (3.4%) tract. Increased rates of infections involved not only the upper (19.0%) and lower (0.3%) respiratory tract, but also the urogenital system (3.6%), and the skin (4.6%). Isolated cases of grade 3 to 4 AEs have been reported, including myocardial infarction, hypertensive urgencies, cellulitis, rhabdomyolysis, neutropenia, and high elevation of creatinine kinase. No fatal outcomes were reported. AEs reported with topical formulation included scalp irritation and folliculitis. The main limit of this review is the lack of data related to post-marketing surveillance, which should be maintained on a long-term basis.

Diagnosis and Management of Intravenous Drug Users' Chronic Wounds: A Case Series Collection of a Single Center

Background: Intravenous drug users (IVDUs) represent a very small group of patients affected by chronic wounds (CWs). Objectives: To assess the risk factors for CWs in IVDUs, to improve their treatment. Methods: A retrospective review of 7 IVDUs with CWs was performed at the Dermatology of the University of Bologna. Results: A history of 10 years of the most frequent injection was heroin in the gaiter area. The most observed comorbidities were HIV, HCV and HBV. They were treated most with an alginate with silver dressing with an average follow-up of 2.8 years. Conclusions: We would like to highlight the importance of clinical history in this type of patients and that in our experience specialized skin wounds risk assessment and management could be useful, aside from traditional compression therapy.