Scalp dysaesthesia and lichen simplex chronicus: diagnostic and therapeutic update with literature review

Scalp dysaesthesia, considered a variant of the cutaneous dysaesthesia syndrome, is characterized by chronic sensory symptoms, including pruritus, pain, burning and stinging in a well‐defined location, without objective findings. Its aetiology is not well elucidated and treatment options are limited, thus it can be challenging and frustrating for both patient and physician. It can be associated with lichen simplex chronicus. In this paper, we review the literature on the pathogenetic factors, diagnostic methods and therapeutic options in the management of scalp dysaesthesia. Dissociation, cervical spine disease and muscle tension seem to be the most important pathogenetic factors. Trichoscopy, reflectance confocal microscopy and biopsy are all helpful for the diagnosis of the disease. Therapies include high‐potency topical or intralesional corticosteroids, capsaicin and topical anaesthetics, sedative antihistamines, tricyclic antidepressants, transcutaneous electric nerve stimulation, botulinum toxin and vitamin B12.

Chloracne: a case series on cutaneous expression of CYP1A1 as diagnostic biomarker

Chloracne, also known as metabolizing acquired dioxin-induced skin hamartomas (MADISH), is a rare disfiguring disease related to dioxin exposure. There is a paucity of literature on the clinical manifestations and pathogenesis of chloracne/MADISH. The aim of this study was to assess the clinical features of this very unusual acneiform eruption and to explore the pathogenesis of the disease. This was a retrospective, observational report study was conducted on five patients belonging to the same nuclear family (father, mother and three children) and a relative (father's brother) living in the same house. Histopathological, immunohistochemical, laboratory and toxicological analyses were performed for all patients. The results suggest that CYP1A1 in human skin is a diagnostic biomarker in chloracne, and was positive for all the patients in our sample. Tetrachlorodibenzo-p-dioxin is the most investigated dioxin responsible for chloracne; however, several other agonists, whether dioxin-like or not, can activate the aryl hydrocarbon receptor. To our knowledge, this Italian case series is the first study to suggest polychlorinated biphenyls as a possible cause of an overstimulation of aryl hydrocarbons causing the consequent acneiform eruption.

Major cluster of paediatric 'true' primary chilblains during the COVID-19 pandemic: a consequence of lifestyle changes due to lockdown

BACKGROUND

Over the last months, during the COVID-19 pandemic, a growing number of chilblain-like lesions were reported mainly in children and rarely in young adults. The relationship with SARS-CoV-2 infection was postulated, often without any laboratory, instrumental or clinical confirmation. The disclosure of information about chilblain-like lesions as a COVID-19 manifestation in social media has created concern in children's families and paediatricians.

OBJECTIVES

To verify whether the chilblain-like lesions were caused by SARS-CoV-2 infection.

METHODS

Prospective study on a case series including children who presented with acral lesions at the Pediatric Dermatology Outpatient and Pediatric Emergency Unit of the University of Bologna, from 1 April to 30 April 2020. We reported demographical, laboratory and clinical features, history of close contact with COVID-19 patients, presence of similar skin lesions in other family members, precipitating and risk factors for chilblain onset.

RESULTS

We evaluated eight patients (five females, three males) aged between 11 and 15 years. We excluded acute or previous SARS-CoV-2 infection with RT-PCR nasopharyngeal swab, serum antibody levels using chemiluminescent immunoassays. Other acute infections causing purpuric lesions at the extremities were negative in all patients. Skin lesion biopsy for histological and immunohistochemical evaluation was made in two cases and was consistent with chilblain. PCR assay on skin lesion biopsy for parvovirus B19, Mycoplasma pneumoniae and SARS-CoV-2 was performed in a patient and resulted negative. We identified common precipitating and risk factors: physical (cold and wet extremities, low BMI), cold and wet indoor and outdoor environment, behaviours, habits and lifestyle. We therefore reached a diagnosis of primary chilblains.

CONCLUSIONS

During the COVID-19 pandemic, a 'cluster' of primary chilblains developed in predisposed subjects, mainly teenagers, due to cold exposure in the lockdown period. Laboratory findings support our hypothesis, although it is also possible that an unknown infectious trigger may have contributed to the pathogenesis.

Calciphylaxis in dialysis patients, a severe disease poorly responding to therapies: report of 4 cases

Calciphylaxis or calciphic uremic arteriolopathy (CUA) is a rare syndrome characterized by the deposition of calcium within the walls of small and medium size vessels in the dermis and in the subcutaneous tissue. The disease mainly affects patients with end-stage renal disease. We report here our experience with 4 cases of calciphylaxis in dialysis patients. The main predisposing factor observed in our 4 patients was warfarin use (2 patients, 50%), while local traumas and diabetes were respectively present in only one patient. None of our patients was obese. Lower legs were the most frequently involved site of CUA (3/4 patients, 75%). In our experience biopsy was crucial to achieve a correct diagnosis and did not cause aggravation of the ulcers. Therapeutic approach was multimodal: mainly hyperbaric oxygen therapy, cinacalcet and sodium thiosulphate. Although many recent case reports have shown exceptional results and healing with the use of sodium thiosulphate, we did not experience any change in the poor prognosis of our patients with the use of this drug, at a dosage of 5 g thrice weekly endovenously.

Nail apparatus melanoma: is trauma a coincidence? Is this peculiar tumor a real acral melanoma?

Nail Apparatus Melanoma (NAM) is rare, particularly in Caucasians. Understanding its pathogenesis and collecting epidemiologic data may be difficult due to its location and the exiguity of the case series of this cancer. Cutaneous melanoma has been thought related to UV radiation, and NAM is considered an acral variant of melanoma, even if the nail presents a specific anatomy. Little is reported about pathogenesis, except reports suggesting traumatic injuries as a causal factor. UV exposure is debated in nail melanoma because of its structure. The nail is, in fact, a unique structure with sun-exposed and non exposed melanocytes. NAM arises from the nail melanocytes, located in the nail matrix, which is the germinative part of the nail and composed of a proximal and distal portion. The proximal nail matrix lays under the proximal nail fold that covers it and is non-sun exposed, while the distant nail matrix, clinically visible as the lunula, is sun-exposed, though lying underneath the nail plate. According to these anatomical data, NAM is a distinct melanoma type, and studies need to classify it as acral melanoma or as a particular type of melanoma with its own pathogenesis and prognostic criteria. This study investigates potential risk factors of NAM, emphasizing (i) trauma and (ii) UV exposure among our NAM patients.

Frontal Fibrosing Alopecia and Lichen Planopilaris: Clinical, Dermoscopic and Histological Comparison

Frontal fibrosing alopecia (FFA) and lichen planopilaris (LPP) are classified as scarring alopecia. Most authors consider FFA as a clinical variant of LPP on the basis of their similar histological findings; other authors think these pathologies are two different entities. We studied 48 cases of FFA and 86 cases of LPP. Clinical diagnosis was histologically confirmed and all patients underwent videodermoscopy. Moreover, histological study, identifying the main targets of these diseases, results helpful to confirm the diagnosis. FFA selectively affects vellus-like hair in the frontoparietal region and is characterized by a mild skin atrophy and a total loss of follicular openings. In LPP an involvement of total preterminal, terminal and vellus-like follicles, partial or total loss of follicular openings, diffuse hair thinning and twisting, perifollicular erythematous or violaceous papules and mild/severe spinous follicular hyperkeratosis with scalp sclerosis are the features observed. Videodermoscopy improves diagnostic capability, appearing to be helpful to underline FFA and LPP features, confirmed by histologic studies which identify and show different intensity of inflammatory process. Therefore, the two diseases could be considered two different entities on the basis of the different clinical features and the different targets, that can be related to a different pathogenetic mechanism.

Superficial acral fibromyxoma: a clinicopathological and immunohistochemical analysis of 12 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes

AIM

Superficial acral fibromyxoma (SAFM) is a rare soft tissue tumor, recently delineated and documentated as a separate entity. We report 12 cases of SAFM observed in our department from June 2004 to June 2010 and highlight pathological features and differential diagnosis.

METHODS

Radiographic examination of the affected digit was performed in all patients. All the tumors were surgically excised under local anesthesia. Follow-up was made every 6-8 months for a maximum period of five years.

RESULTS

The patients consisted of 8 men and 4 women, age range 28-76 years (mean 51), presenting with a solitary mass or nodule located in the toes and fingers. Histologically the lesions were well circumscribed dermal nodules composed of stellate and spindle cells, arranged in a myxoid matrix. Very low grade atypia and a few mitotic figures were found in only one case. Neoplastic cells showed immunoreactivity for CD34 (12 patients). In contrast focally positive or negative staining was shown for the epithelial membrane antigen (EMA) and CD 99. Actin, S100 protein, HMB45 and cytokeratin were negative. In three cases marked hyperkeratosis and acanthosis of the epidermis was present. Pathological analysis confirmed the diagnosis of superficial acral fibromyxoma. No recurrences were observed even in a long term, 2-5 year follow-up.

CONCLUSION

Complete surgical excision of the tumors and a careful follow-up is suggested, despite the benign course previously reported.

Periungual and subungual pyogenic granuloma

BACKGROUND

Nail pyogenic granuloma (PG) is common, often seen as an urgent case, given the recent onset as a bleeding nodule. Nail PGs are due to different causes that act through different pathogenetic mechanisms and may be treated in several ways. Both causes and treatments of nail PG have never been classified.

OBJECTIVES

To classify nail PG according to the pathogenesis, describe the clinical and pathological features and provide guidelines for a correct diagnosis and treatment.

METHODS

A retrospective, observational study was performed reviewing epidemiological and clinical features of 58 cases of PG seen at our Departments in the last 5 years. A review of the literature was also carried out, using PubMed database and dermatological textbooks.

RESULTS

Nail PG is usually due to the following causes: drugs, local trauma and peripheral nerve injury. Histopathology shows similar features in every type of PG, irrespective of cause and location.

CONCLUSIONS

The localization of nail PG, the number of digits involved and clinical history help to identify the cause. When PG is single, especially if it involves the nail bed, histological examination is necessary to rule out malignant melanoma. Treatment must be chosen according to the underlying cause.

Diffuse skin spread of HIV-associated visceral leishmaniasis: cumbersome diagnostic and therapeutic issues

An infrequent and atypical case report of HIV-associated visceral leishmaniasis complicated by a diffuse, aspecific maculo-papular cutaneous involvement was characterized by a prolonged course, and a lack of response to repeated attack/maintenance cycles performed with liposomal amphotericin B, despite a satisfactory immune response maintained thanks to a concurrent, potent combination antiretroviral treatment. Only a very prolonged administration of the older i.v. pentamidine isethionate together with oral paromomycin led to a slow, but complete cure of both visceral leishmaniasis and its related skin dissemination, in absence of adverse events and long-term disease relapses.

Isolated generalised anhidrosis induced by postganglionic sympathetic skin nerve fibre degeneration: an incomplete Ross syndrome?

Ross syndrome is characterised by tonic pupil, areflexia and anhidrosis, and the underlying lesion affects postganglionic skin sympathetic nerve fibres. We describe a 51-year-old man who had complained of anhidrosis since adolescence, at which time this problem was limited to the lower arms. The thermoregulatory sweating test disclosed generalised anhidrosis (GA) except for two small skin areas that were located in the right palm and left neck. Immunofluorescence analysis disclosed no cholinergic sudomotor fibres around the sweat glands of non-sweating skin areas, which were evident although sparse and deranged in the sweating site. In our patient, GA was induced by degeneration of postganglionic sympathetic skin nerve fibres, as found in Ross syndrome, although his clinical picture was incomplete as it lacked tonic pupil and areflexia. Isolated GA induced by degeneration of postganglionic sympathetic nerve fibers, directly evaluated by skin biopsy, has not previously been described.

Secondary syphilis with intestinal involvement: description of a case

As it is well-known, during secondary syphilis, it is possible to observe a systemic involvement of the treponemal infection. The visceral localizations are rarely observed, and they usually present themselves as asymptomatic or with aspecific symptoms. This report concerns a case of a homosexual patient who referred to us in order to perform blood tests for the main sexually transmitted diseases (HIV, HBV, HCV, TPEIA). Moreover, he reported a history of palmo-plantar erythematous desquamative lesions, spontaneously resolved. For this reason all the serological tests for syphilis have then been performed. Once the diagnosis of recent syphilis was made, and the antibiotic therapy with penicillin begun, the patient reported to have fever, abdominal pain and diarrhoea. The gastroenterological consultation highlighted the presence of a chronic active granulomatous colitis, but excluded an inflammatory or autoimmune aetiology. Because of this findings, and also because of additional histopathological examinations of the colon, the diagnosis of recent syphilis with intestinal involvement was made. The present case report confirms, once again, how the nickname ''great imitator'' is appropriate for calling syphilis. It highlights moreover that, as the incidence of syphilis is arising, in the presence of intestinal symptoms of unknown origin in patients with a history of unprotected sexual intercourse, syphilis should always be comprised among the possible diagnoses.

Permanent alopecia after busulfan chemotherapy

Systemic chemotherapy is a well known cause of reversible hair loss. Busulfan chemotherapy, however, is responsible for a permanent alopecia that usually occurs in bone marrow transplant patients. We report two patients with permanent alopecia due to busulfan chemotherapy. Both patients had a diffuse alopecia characterized by greatly reduced hair density with short, thin hair. The pathology showed reduced follicular density in the absence of fibrosis, suggesting that alopecia may result either from hair follicle stem cell destruction or from acute damage to the keratinocytes of the lower portion of some follicles.

Generalised anhidrosis: different lesion sites demonstrated by microneurography and skin biopsy

Generalised anhidrosis (GA) shows a uniform clinical picture whether the pathogenesis involves intrinsic abnormalities of sweat glands or postganglionic sympathetic cholinergic nerve dysfunction. We describe two patients who presented intolerance to heat and anhidrosis. In the first patient, symptoms started at 33 years of age, and were associated with absent tendon reflexes and a mydriatic right pupil unreactive to light. The other patient had been unable to sweat since birth. GA was diagnosed on the basis of clinical findings and thermoregulatory tests. Microneurography and morphological analysis of the skin and its innervation disclosed a different lesion site underlying GA in the two patients, and distinguished between a postganglionic autonomic nerve fibre lesion and sweat gland dysfunction.

Unusual inflammatory and hyperkeratotic halo naevus in children

Although the classic halo naevus (HN) is a melanocytic naevus with a surrounding rim of depigmentation, these naevi can present unusual features. We describe an unusual and previously unreported variety of HN in children. Between March 1999 and September 2002, 14 children (11 boys and three girls, age range 6-14 years) were referred to us for evaluation of one or more 'inflamed' naevi. All the affected naevi showed the same clinical development: (i) after an initial inflammatory stage their surfaces gradually became thickened and rough, then (ii) verrucous and raised, and finally (iii) scaly crusted. A marked halo of depigmentation subsequently developed in all lesions, with simultaneous disappearance of the hyperkeratotic surface appearance. Lesions were multiple in five cases and single in nine, and were mainly located on the back (nine cases). Excisional biopsy was performed in eight cases. The biopsies were all taken in the 'prehalo phase'. In each case, histopathology revealed a compound melanocytic naevus, with additional features that varied depending on the clinical stage of the lesion. Immunohistochemical staining of the dense inflammatory infiltrate showed a predominance of CD3(+)/CD8(+) T lymphocytes, as usually occurs in HN. On the basis of these observations, we believe that the described naevi represent an unusual variety of HN in children. Knowledge of this possible clinical evolution of HN is important to avoid unnecessary surgical excision in these young patients.

Granular parakeratosis: four paediatric cases

Axillary granular parakeratosis (GP) was first described in 1991 as a peculiar eruption presenting with erythematous hyperpigmented and hyperkeratotic papules and plaques of the cutaneous folds frequently associated with pruritus. Histopathology shows a characteristic picture with a conspicuous granular appearance of the parakeratotic horny layer. Until now, only 24 adults, mainly women aged over 40 years, have been reported with GP. We demonstrate that this condition can also occur in young children. Four children aged between 10 and 24 months had asymptomatic hyperpigmented scaling papules 2-3 mm in diameter located on the groin, lower back, buttocks and flanks. In all cases the mothers reported the habit of frequent washing followed by application of many topical products. Biopsy revealed the same features in all four patients: the epidermis showed a thickened horny layer with a unique compact parakeratosis with maintenance of the stratum granulosum and marked retention of keratohyaline granules throughout the stratum corneum.

Concordance between telepathologic diagnosis and conventional histopathologic diagnosis: a multiobserver store-and-forward study on 20 skin specimens

OBJECTIVE

To study the validity and feasibility of transferring images of cutaneous biopsy specimens via e-mail to remote physicians active in dermatopathology for teleconsultation.

DESIGN

Twenty skin specimens previously diagnosed at the Department of Dermatology, University of Graz, Austria, were subsequently sent for teleconsultation using the store-and-forward method. For each case, 3 or 4 images at different magnifications were sent by e-mail to 16 colleagues (11 dermatopathologists and 5 pathologists) in 15 centers in 6 different countries. Six weeks later each observer received the hematoxylin-eosin-stained specimens to render a conventional diagnosis.

SETTING

Dermatopathology and pathology units within institutional and private settings.

MATERIAL

Twenty small skin biopsy specimens of cutaneous diseases were selected randomly from a study set of 80.

MAIN OUTCOME MEASURE

Concordance between telepathologic diagnoses and conventional histopathologic diagnoses of 20 skin specimens.

RESULTS

On average, 78% of the telediagnoses were correct (range, 60%-95%), whereas 85% of the conventional diagnoses were correct (range, 60%-95%). A perfect diagnostic concordance was obtained in 7 (35%) of 20 cases, and a significant difference was identified in only 1 case.

CONCLUSIONS

Results suggest that telepathology performed by physicians active in dermatopathology may serve as a reliable technique for the diagnosis of cutaneous diseases when experts in dermatopathology are not available locally. Furthermore, teledermatopathology is attractive because it provides an opportunity to obtain timely consultation on difficult cases.

Necrobiotic xanthogranuloma without periorbital involvement: an ultrastructural investigation

A case of necrobiotic xanthogranuloma without typical periorbital involvement is described at the ultrastructural level. The patient, a 58-year-old Italian man, presented in 1995 with a brief history of nodulo-papular lesions commencing on the lower limbs, and mild paraproteinemia. During 6 years of follow-up, anemia, neutropenia with marked lymphopenia, and increased ESR were found, while serum cholesterol and triglyceride levels decreased from hyper to hypo values. Systemic diseases, such as diabetes, malignancy, or extracutaneous lesions, often associated with NXG, have not developed. Conventional histology was distinctive for NXG, and immunohistochemistry confirmed that dermal histiocytes were not of Langerhans cell lineage. At ultrastructure, regeneration and degeneration ("regen-degen") features were observed in some individual deep dermal histiocytes, which have not been previously documented in the literature. Identification of giant histiocytes showing 'regen-degen'' aspects might prove to be a useful ultrastructural diagnostic marker for NXG.

Pustular psoriasis of the nails: treatment and long-term follow-up of 46 patients

BACKGROUND

Pustular psoriasis of the nail apparatus is a common disease that greatly influences the quality of life because of its chronic course and poor response to treatment.

OBJECTIVES

To review the clinical and histopathological features, the response to treatment and the long-term follow-up of 46 patients with pustular psoriasis of the nail unit.

METHODS

Treatments utilized included oral retinoids (n = 12), oral nimesulide (n = 13), topical calcipotriol (n = 15) and topical steroids (n = 18). Retinoids were utilized as first choice in seven patients with involvement of several digits and in five patients with severe relapses, whereas topical calcipotriol, oral nimesulide or topical steroids were utilized in patients with involvement of a single nail. Topical calcipotriol was also prescribed as maintenance therapy in patients who responded to oral treatment. Twenty-five patients were followed for more than 5 years.

RESULTS

Improvement or regression of the lesions was obtained in 23 of 46 patients. Retinoids were effective in six of 12 patients, nimesulide in four of 13, topical calcipotriol in nine of 15 and topical steroids in four of 18. The long-term follow-up showed a complete remission of the disease in only two patients, both affected by pustular psoriasis involving multiple nails. All other patients experienced periodic relapses which were in most cases controlled by regular use of topical calcipotriol.

CONCLUSIONS

Severe cases of pustular psoriasis of the nail are best treated with systemic retinoids. Topical calcipotriol is effective in about 50% of patients with localized disorder and is also useful as maintenance therapy after retinoid treatment.

Hair diameter diversity: a clinical sign reflecting the follicle miniaturization

BACKGROUND

The degree of androgenetic alopecia is generally evaluated either by global clinical scales or time-consuming methods like phototrichogram or histological studies. We describe a new clinical and reliable scoring method based on hair diameter diversity.

OBSERVATIONS

(1) The clinical macroscopic scoring we propose for hair density was significantly correlated with Hamilton classification and with histological hair density. (2) Diversity in hair diameter was the main and most accurate clinical parameter linked to follicle miniaturization. (C) The anagen-telogen ratio decreased in parallel with the decrease in clinical hair density score.

CONCLUSIONS

Considering that hair follicle miniaturization is the key point during androgenic alopecia onset and development, diversity in hair diameter represents an important feature to consider as an accurate clinical sign reflecting hair follicle miniaturization. Moreover, diversity in hair diameter seems to be an easily accessible and reliable parameter that should be taken into consideration for further characterization of hair disorders. By itself, we believe that this clinical feature constitutes a new tool of substantial help for the diagnosis and management of androgenic alopecia.

Comparison of spironolactone, flutamide, and finasteride efficacy in the treatment of hirsutism: a randomized, double blind, placebo-controlled trial

To compare objectively the efficacies of spironolactone (100 mg/day), flutamide (250 mg/day), and finasteride (5 mg/day) in the treatment of hirsutism, 40 hirsute women were randomly assigned to double blind treatments with 1 of these 3 drugs or placebo for 6 months. Before and at the end of treatment, hirsutism was quantitatively measured in each subject by determination, by computer-assisted light microscopy, of the largest diameter of 5 hairs plucked from the linea alba. These measurements were averaged to produce a mean hair shaft diameter. For each subject, baseline and posttreatment assessments were carried out at the same time by an investigator blinded to both time and type of therapy. In addition, a semi-quantitative clinical evaluation was carried out by a modification of the Ferriman-Gallwey (F-G) scoring method, performed by a single investigator. At baseline the 4 groups of women had similar hair diameters and F-G scores. After 6 months of therapy all groups of subjects given active drugs showed reductions of their hair diameters, without statistically significant differences among groups (mean change +/- SEM, -11.7+/-5.6%, -18.0+/-6.1%, and -12.6+/-6.7%, respectively, in the spironolactone, flutamide, and finasteride groups). F-G scores were also significantly reduced in women receiving antiandrogen drugs, again without differences among groups (mean change, -41.0+/-5.5%, -38.9+/-7.2%, and -31.6+/-3.7%, respectively). No significant changes from baseline values were recorded by either hair diameter (-1.4+/-5.2%) or F-G score (+5.4+/-3.7%) assessment in the placebo group. In conclusion, spironolactone, flutamide, and finasteride are all effective in the treatment of hirsutism. After a 6-month course of therapy, the clinical efficacies of these drugs, at least at the doses used, are similar.