Bullous pemphigoid triggered by dulaglutide: a case report and a review of the literature

Bullous pemphigoid (BP) is an autoimmune disease with a chronic relapsing course, predominantly affecting elderly people. Drugs are one of the possible triggers. A class of antidiabetic drugs often associated with the development of BP are inhibitors of dipeptidyl peptidase 4 (DPP-4 inhibitors or gliptins), while less known is the association with glucagon-like-peptide-1 receptor agonists. We describe a case of BP caused by dulaglutide and summarize the other few cases described in the literature. As a class of drugs widely used in clinical practice, it is important to know about this possible adverse event.

Pilomatrix Carcinoma: Report of Two Cases of the Head and Review of the Literature

BACKGROUND

Pilomatrix carcinoma (PC) is a rare skin tumor arising from hair follicle matrix cells. It is locally aggressive with a high rate of local recurrence after surgical excision. Few cases in the literature have been described and the management is not well defined.

OBJECTIVES

The aim of this study was to present two cases of PC located on the head and review the relevant literature about epidemiology, clinical and dermoscopic evaluation, characteristics of local and distant metastases, local recurrence rate and management of this rare skin tumor.

METHODS

We consulted databases from PubMed, Research Gate and Google Scholar, from January 2012 to November 2022. We reviewed the literature and reported two additional cases.

RESULTS

We selected 52 tumors in middle-aged to older patients located mostly on the head. Dermoscopy evaluation was rarely performed in the pre-operative diagnostic setting. The most definitive treatment was wide local excision, but local recurrences were common. In total, we observed 11 cases of recurrences and 9 patients with locoregional or distant metastases. Four patients received adjuvant radiotherapy, two patients needed chemotherapy and local cancer therapy and one patient received radiochemotherapy.

CONCLUSION

Our reports and the review of the literature can provide a better awareness and management of this rare tumor.

Case Report: Lyme Borreliosis and Pregnancy - Our Experience

Lyme Borreliosis (LB) is an infection transmitted by Ixodes sp. ticks. Its early manifestation includes erythema migrans rash. Since the discovery of LB in 1975, the question arose as to whether this infection could be vertically transmitted from mother to fetus during pregnancy, as transplacental transmission has already been known for other spirochetoses, such as syphilis, relapsing fever and leptospirosis. The first confirmed case with positive Lyme serology was described in 1985 in a 28-year- old mother who had acquired Lyme in the first trimester and then developed an erythema migrans rash. Subsequently, transmission of Borrelia burgdorferi sl. in humans from mother to fetus has been documented through identification of Borrelia spirochetes in fetal tissues/and or placenta by various methods including culture, PCR and indirect immunofluorescence. Adverse birth outcomes, which are limited in case of prompt LB treatment, included spontaneous miscarriage, preterm birth and hyperbilirubinemia, but also cardiac involvement and cutaneous angiomas have been documented although rarely. No significant associations were found between adverse outcomes at birth and the trimester of infection. Patients treated for gestational LB had a lower frequency of miscarriages and premature births, as also the frequency of congenital malformations was similar to that observed in the normal population. The recommended treatment for LB in pregnancy is Amoxicillin, 1 g 3 times a day for 14-21 days. In the present study, we report our case series, which includes 11 pregnant women, 6 of which developed erythema migrans during pregnancy (between week 8 and 34), 3 had myoarticular or neurological symptoms and 2 had positive serology, but did not develop any clinical symptoms. Our data stress on the importance of early antibiotic treatment also in seropositive gestating women without symptoms in order to avoid any possible complication to fetus and newborns.

Locally advanced basal cell carcinoma: real-life data with sonidegib

In recent years, the category of hedgehog pathway inhibitor (HHI) has shown great results in patients with advanced basal cell carcinoma (aBCC), but few real-life data on efficacy and safety profile of sonidegib are available. We report our management of locally advanced BCCs (laBCCs) with sonidegib, also describing the favourable response of locally advanced basosquamous carcinomas (laBSCs) treated with this hedgehog signaling inhibitor. Sonidegib was generally well tolerated and it achieved high response rates, improving quality of life. Our single-center experience could be useful to better delineate long-term efficacy and tolerability profile demonstrated in the trials described in literature. Moreover, our cases provide preliminary evidence that sonidegib might be effective for laBSC. This article is protected by copyright. All rights reserved.

Regression of nevi, vitiligo-like depigmentation and halo phenomenon may indicate response to immunotherapy and targeted therapy in melanoma

We present two patients with stage IV melanoma, the first with BRAF wild-type melanoma with multiple visceral metastases treated with immunotherapy (pembrolizumab) and the second with BRAFV600E melanoma with subcutaneous and lymph nodes metastasis treated with BRAF and MEK-inhibitors (dabrafenib/trametinib). Already after the second cycle of immunotherapy, the first patient developed a diffuse regression of nevi, perceptible only with the use of dermoscopy and 3 months later a clinically evident poliosis of the eyebrows. The second patient, treated with dabrafenib/trametinib, developed small areas of leukoderma on his chest and white halos around nevi with a dermoscopic globular or structureless pattern. Both observations are suggestive for an immune reaction against melanocytic cells, which is further supported by the complete response to systemic therapy in both patients. It has been demonstrated that the development of vitiligo-like depigmentation during immunotherapy is associated with a better prognosis; in our patient, the phenomenon of poliosis appeared much later than the dermoscopic presence of regression among his nevi, suggesting that the latter may be an early sign (along with vitiligo-like phenomena) of good response to immunotherapy. On the other hand, the development of halo nevi and leukoderma during treatment with BRAF/MEK-inhibitors, suggests that not only immunotherapy but also targeted therapy may induce an immunologic response against melanoma and nevi, again indicative of a favorable prognosis. More data are needed to confirm these findings; however, they indicate that dermatologists should be involved in the follow-up of patients with melanoma, both in studies and clinical practice.

Borreliae Part 2: Borrelia Relapsing Fever Group and Unclassified Borrelia

Borreliae of the relapsing fever group (RFG) are heterogenous and can be divided mainly into three groups according to vectors, namely the soft-tick-borne relapsing fever (STBRF) Borreliae, the hard-tick-borne relapsing fever (HTBRF) Borreliae, the louse-borne relapsing fever (LBRF) Borreliae, and the avian relapsing fever ones. With respect to the geographical distribution, the STBRF Borreliae are further subdivided into Old World and New World strains. Except for the Avian relapsing fever group Borreliae, which cause avian spirochetosis, all the others share infectivity in humans. They are indeed the etiological agent of both endemic and epidemic forms of relapsing fever, causing high spirochaetemia and fever. Vectors are primarily soft ticks of Ornithodoros spp. in the STBRF group; hard ticks, notably Ixodes sp., Amblyomma sp., Dermacentor sp., and Rhipicephalus sp., in the HTBRF group; and the louse pediculus humanus humanus in the TBRF one. A recent hypothesis was supported for a common ancestor of RFG Borreliae, transmitted at the beginning by hard-body ticks. Accordingly, STBRF Borreliae switched to use soft-bodied ticks as a vector, which was followed by the use of lice by Borrelia recurrentis. There are also new candidate species of Borreliae, at present unclassified, which are also described in this review.

Borreliae Part 1: Borrelia Lyme Group and Echidna-Reptile Group

Simple Summary

Borreliae are spirochaetes, which represent a heterogeneous phylum within bacteria. Spirochaetes are indeed distinguished from other bacteria for their spiral shape, which also characterizes Borreliae. This review describes briefly the organization of the phylum Spirocheteales with a digression about its pathogenicity and historical information about bacteria isolation and characterization. Among spirochaetes, Borrelia genus is here divided into three groups, namely the Lyme group (LG), the Echidna-Reptile group (REPG) and the Relapsing Fever group (RFG). Borreliae Part 1 deals with Lyme group and Echidna-Reptile group Borreliae, while the subject of Borreliae Part 2 is Relapsing Fever group and unclassified Borreliae. Lyme group Borreliae is organized here in sections describing ecology, namely tick vectors and animal hosts, epidemiology, microbiology, and Borrelia genome organization and antigen characterization. Furthermore, the main clinical manifestations in Lyme borreliosis are also described. Although included in the Lyme group due to their particular clinical features, Borrelia causing Baggio Yoshinari syndrome and Borrelia mayonii are described in dedicated paragraphs. The Borrelia Echidna-Reptile group has been recently characterized including spirochaetes that apparently are not pathogenic to humans, but infect reptiles and amphibians. The paragraph dedicated to this group of Borreliae describes their vectors, hosts, geographical distribution and their characteristics.

Abstract

Borreliae are divided into three groups, namely the Lyme group (LG), the Echidna-Reptile group (REPG) and the Relapsing Fever group (RFG). Currently, only Borrelia of the Lyme and RF groups (not all) cause infection in humans. Borreliae of the Echidna-Reptile group represent a new monophyletic group of spirochaetes, which infect amphibians and reptiles. In addition to a general description of the phylum Spirochaetales, including a brief historical digression on spirochaetosis, in the present review Borreliae of Lyme and Echidna-Reptile groups are described, discussing the ecology with vectors and hosts as well as microbiological features and molecular characterization. Furthermore, differences between LG and RFG are discussed with respect to the clinical manifestations. In humans, LG Borreliae are organotropic and cause erythema migrans in the early phase of the disease, while RFG Borreliae give high spirochaetemia with fever, without the development of erythema migrans. With respect of LG Borreliae, recently Borrelia mayonii, with intermediate characteristics between LG and RFG, has been identified. As part of the LG, it gives erythema migrans but also high spirochaetemia with fever. Hard ticks are vectors for both LG and REPG groups, but in LG they are mostly Ixodes sp. ticks, while in REPG vectors do not belong to that genus.

Breast Cancer-Related Neoplastic Alopecia: A Case Report and Review of the Literature

Neoplastic alopecia (NA) is defined as an organized hair loss in single or multiple areas of the scalp caused by a primary tumor that has metastasized to the skin of the scalp. Due to its localization and clinical appearance, NA should be placed in differential diagnosis with alopecia areata or other entities. To date, pathognomonic dermoscopic criteria of NA have not yet been described: the absence of classical criteria of other scalp diseases in addition to a major neovascularization with on-focus arborizing vessels and erosions or ulcerations may help the clinician to suspect a diagnosis of secondary alopecia. Dermatologists should pay more attention to these rare forms of secondarism because in exceptional cases, a simple alopecia of the scalp can hide a new, relapsing or metastatic neoplasia.

Basal cell carcinoma and dermal nevi of the face: comparison of localization and dermatoscopic features

BACKGROUND

Basal cell carcinoma (BCC) and dermal nevi located on the face can easily be confused on clinical examination. Little is known about the different preferential localizations of these entities, and a systematic analysis of dermatoscopic features for differential diagnosis is lacking.

METHODS

Clinical and dermatoscopic images of BCCs and dermal nevi were retrospectively evaluated to study their relation to various face anatomical areas, BCC histotype, classic and nonclassic dermatoscopic BCC criteria, as well as typical dermatoscopic criteria for dermal nevi.

RESULTS

We examined 118 BCCs and 77 dermal nevi, all having histopathological confirmation. BCCs were most frequently located on the lateral side of the forehead (12.7%), nasal dorsum (10.2%) and nasal ala (9.3%), while dermal nevi were found predominantly on the buccal area (11.8%), scalp (11.8%), and perioral region (10.8%). The prevalent dermatoscopic criteria for BCC were the classic arborizing vessels (94.1%) and arborizing microvessels (89%). The most common BCC histotype on the face was sclerodermiform (47.5%), followed by nodular (28%) and superficial (24.6%).

CONCLUSIONS

This study shows that BCCs are preferentially located on the lateral side of the forehead, nasal dorsum and nasal ala, while dermal nevi of the face are preponderantly located on the buccal area, scalp, and perioral region. The dermatoscopic features confirmed the frequency of classic and nonclassic criteria for BCCs already demonstrated in other studies. No significant site-specific features were observed for either BCCs or dermal nevi.

Effectiveness and tolerability of treatment for isolated actinic keratoses: A retrospective comparison between cryotherapy, CO2 laser and 5-fluorouracil 0.5%/salicylic acid 10

Actinic keratoses (AK) have been described as either intraepithelial keratinocytic dysplasia that can evolve into invasive squamous cell carcinoma (SCC) or as in situ SCC that can progress into an invasive form. A retrospective study was conducted to compare outcomes of three different topical therapies for patients with single AK (<4): cryotherapy, CO₂ laser and 5-fluorouracil 0.5%/salicylic acid 10%. We included 72 patients who presented at the Dermatology Clinic of Maggiore Hospital of Trieste between 1 November 2019 and 31 January 2020 for the treatment of AKs. All treatments led to a significant reduction in the average diameter of AK. Pain felt by patients was significantly lower after 5-FU 0.5%/SA 10%. Side effects appeared similarly distributed among the three groups, with erythema and crusts being the most frequent. Aesthetic outcomes were highest in the 5-FU 5%/SA 10% group, as evaluated by both the patient and the operator. Cryotherapy, CO₂ laser and 5-FU 5%/SA 10% were all effective, with no significant efficacy differences among them. Additionally, 5-FU 5%/SA 10% was proved to have the best aesthetic result and to cause the least pain, while necessitating long-term administration. This should be taken into account for patients with low pain tolerance and low treatment adherence. Cryotherapy and CO₂ laser have the advantage of requiring a single session, which might be more suitable for uncooperative patients.

Cutaneous Manifestations in Confirmed COVID-19 Patients: A Systematic Review

There have been increasing reports of skin manifestations in COVID-19 patients. We conducted a systematic review and included manuscripts describing patients with positive RT-PCR coronavirus testing from nasopharyngeal swabs who also developed cutaneous manifestations. A total of 655 patients were selected, with different types of skin rashes: Erythematous maculopapular (n = 250), vascular (n = 146), vesicular (n = 99), urticarial (n = 98), erythema multiforme/generalized pustular figurate erythema/Stevens-Johnson syndrome (n = 22), ocular/periocular (n = 14), polymorphic pattern (n = 9), generalized pruritus (n = 8), Kawasaki disease (n = 5), atypical erythema nodosum (n = 3), and atypical Sweet syndrome (n = 1). Chilblain-like lesions were more frequent in the younger population and were linked to a milder disease course, while fixed livedo racemosa and retiform purpura appeared in older patients and seemed to predict a more severe prognosis. For vesicular rashes, PCR determined the presence of herpesviruses in the vesicle fluid, which raised the possibility of herpesvirus co-infections. The erythema-multiforme-like pattern, generalized pustular figurate erythema and Stevens-Johnson syndrome were most frequently linked to hydroxychloroquine intake. A positive PCR determination of SARS-COV-2 from conjunctival swabs suggest that eye discharge can also be contagious. These cutaneous manifestations may aid in identifying otherwise asymptomatic COVID-19 carriers in some cases or predict a more severe evolution in others.

Melanoma in pregnancy: certainties unborn

Melanoma diagnosed during childbearing period or up to 1 year after delivery is defined as pregnancy-associated melanoma (PAM). There is some evidence that PAM has worse prognosis if compared with melanoma in nonpregnant women, although literature is still inconclusive. Many biological mechanisms could explain this behavior, such as hormonal and immune status, increased lymphangiogenesis but also delay in diagnostic and therapeutic management. If PAM is suspected, a prompt excisional biopsy under local anesthesia can be performed regardless of the gestational period. Conversely, additional staging procedures (such as sentinel lymph node biopsy or imaging) and systemic therapy are still debatable during pregnancy. A multidisciplinary tailored approach should be preferred, together with exhaustive counseling of the mother.

Current therapies for actinic keratosis

Actinic keratosis (AK) is a very common skin disease caused by chronic sun damage, which in 75% of cases arises on chronically sun-exposed areas, such as face, scalp, neck, hands, and forearms. AKs must be considered an early squamous cell carcinoma (SCC) for their probable progression into invasive SCC. For this reason, all AK should be treated, and clinical follow-up is recommended. The aims of treatment are: (i) to clinically eradicate evident and subclinical lesions, (ii) to prevent their evolution into SCC, and (iii) to reduce the number of relapses. Among available treatments, it is possible to distinguish lesion-directed therapies and field-directed therapies. Lesion-directed treatments include: (i) cryotherapy; (ii) laser therapy; (iii) surgery; and (iv) curettage. Whereas, field-directed treatments are: (i) 5-fluorouracil (5-FU); (ii) diclofenac 3% gel; (iii) chemical peeling; (iv) imiquimod; and (v) photodynamic therapy (PDT). Prevention plays an important role in the treatment of AKs, and it is based on the continuous use of sunscreen and protective clothing. This review shows different types of available treatments and describes the characteristics and benefits of each medication, underlining the best choice.

Dermoscopy and the experienced clinicians

For several decades, melanoma diagnosis was based on symptoms rather than clinical features. In fact, until the 1970s melanoma was widely not recognized and only diagnosed when presenting as a large, ulcerated, and bleeding nodule. Today it is well known that ulceration and bleeding are symptoms of an advanced stage; thus, it comes not as a surprise that the prognosis of melanoma at that time was very poor. This paper was developed to recognize dermoscopy as an integrative part of the clinical examination, bearing in mind that naked eye diagnosis can change after dermoscopy outcomes, and to help clinicians avoid the concept: "If in doubt, cut it out".

Dermatoscopic features of Koebner phenomenon in lichen planus on light and dark skin

The Koebner phenomenon is well described and well known in clinical practice. Sometimes it can take on a linear appearance, the diagnosis of which can be facilitated by the use of dermatoscopy. In this case, we present a comparison between a linear Koebner phenomenon on light and dark skin, reporting the salient dermatoscopic characteristics and relating them to histopathology.

Touch Imprinting Cytology may be useful in the intraoperative evaluation of the sentinel lymph node in melanoma

PURPOSE

The aim of the study was to assess whether the reliability of Touch Imprinting Cytology (TIC) of Sentinel lymph node biopsy (SLNB) in skin melanoma patients allows intraoperative decisions regarding simultaneous radical lymphadenectomy to be made. Previous experiences have shown that the limit of TIC in extemporaneous diagnosis was represented by the minimal deposits of the tumor. Many current data seem to show that in this situation radical lymphadenectomy is no longer necessary, so we wondered if TIC could regain importance in the intraoperative management of these patients.

METHODS

TIC results of Sentinel Lymph Nodes Biopsy (SLN) were compared with those of standard histopathological and immunohistochemical examinations.

RESULTS

A total number of 110 SLN were detected from 50 melanoma patients.TIC revealed the presence of metastases only in 1 out of 13 melanoma-positive SLN (sensitivity 7.6%). There were no false-positive results of TIC (specificity 100%). The negative predictive value was 75.5%, the positive one 100% with a total diagnostic accuracy of 76%.

CONCLUSIONS

TIC for SLNs is a reliable method, relatively fast and not very expensive. Although with a very high specificity, its sensitivity was very low, and almost exclusively limited to macro-metastases (>2mm). Furthermore, it was not possible to identify a subgroup of patients, based on the characteristics of the primary tumor, in which the method could have been more useful. Finally, even in positive cases, the method rarely reduced the need of a tactic in two stages, principally for the management of the operating room.

KEY WORDS

Melanoma, Sentinel lymph node (SLN), Touch Imprinting Cytology (TIC).

Pushing the edge of dermoscopy in new directions: entomodermoscopy of Trombicula autumnalis

Dermatologists are often faced with the challenge of patients presenting with non specific symptoms such as itching and or erythema. These symptoms may be attributed to a number of diseases, many of which are trivial, and others even life-threatening. In order to establish the correct diagnosis, dermatologists must rely on good diagnostic tools and knowledge. Dermoscopy was introduced mainly for inspection of pigmented lesions, but its use has now also spread to non-melanoma skin cancer, inflammatory diseases, and almost any skin disease. This diagnostic technique also applies to skin infestation today, often offering the opportunity to rapidly identify new hidden features of parasites. This case report describes an unusual but representative case in which entomodermoscopy enabled a rapid diagnosis in a patient with a non specific erythematous patch. Whereas differential diagnosis of such skin manifestations could have been too laborious and misleading, dermoscopy easily allowed us to find a small parasite, later identified as Trombicula autumnalis.

A transient cutaneous relapse of AML M1 in hematological remission: a case report

Leukemia cutis (LC) is described as cutaneous infiltration by neoplastic leukocytes into the epidermidis, dermis, or subcutis, resulting in clinically various skin lesions. When the infiltrate is characterized by neoplastic granulocytic precursors, LC is defined as granulocytic sarcoma. Multiple, erythematous, and infiltrated papules and nodules localized on the legs, arms, and trunk are the most common clinical presentation. Here we report a case of granulocytic sarcoma in a patient with a previous diagnosis of acute myeloid leukemia currently in hematological remission.

Monolateral Grover's Disease with Blaschkoid Distribution

Dear Editor, Grover's disease, also known as transient acantholytic dermatosis, is an idiopathic and acquired pruritic eruption of small vesicles and erythematous papules, classically on the central chest. The pathogenesis is not clearly defined, although heat sweating and occlusion have been interpreted as predisposing factors. We describe a case of monolateral acantholytic eruption with blaschkoid distribution in a patient treated with an orthopedic bandage for a shoulder injury. A 53-years-old man was referred to the dermatologic department because of an acute eruption of pruritic, discrete, pinkish grey papulovesicles, developed on the right side of the trunk 14 days after the positioning of an orthopedic bandage for a shoulder injury. This skin eruption followed a multilinear distribution along Blaschko lines (Figure 1, a, b). The medical history was unremarkable. The patient's family history was negative for similar dermatosis. Histopathological analysis showed acantholytic dyskeratosis with suprabasal cleft. A basket weave epidermic pattern with hyperkeratosis was observed, with a perivascular lymphocytic infiltration in the upper dermis (Figure 1, c, d). Given the clinical and histopathological features, a diagnosis of monolateral Grover's disease was established. The patient was treated with topical mometasone furoate 0.1% cream for 3 weeks with clinical improvement. Monolateral blaschkoid distribution in Grover's disease is extremely rare, with only 1 case reported in the literature (1). Two cases of zosteriform distribution have been described (2,3). The exact pathogenesis and the differential diagnosis with linear Darier's disease were the main topics of discussion, while the pathogenesis is still in debate. In our case, it appears that a shoulder bandage can cause an occlusive environment that can elicit the disease (4). Similar conditions were present in a previously described cases of bedridden patients (1). Some authors have postulated that such conditions may act as precipitating factors on a genetically predisposed epidermis (1). In monolateral and localized cases, postzygotic somatic mutations along Blasckho's lines or in dermatomes could be present. It is also important to distinguish this monolateral and blasckhoid Grover's disease from other acantholytic dermatoses. In this case, the differential diagnosis with an eruptive linear Darier's disease is very difficult (5). Histopathological analysis is not useful. Both monolateral and ordinary variants of Darier's disease can be elicited by environmental factors such as heat, sweating, or occlusion. The diagnosis of monolateral blaschkoid Grover's disease was preferred due to the patient's anamnesis (late-onset and no familiar history of similar dermatosis) and the clinical features (sparing of the head, extremities, and flexures). Since only additional genetic analysis could definitively resolve this question, it was performed. No mutation in genes coding the Ca2+ pump using genomic DNA from the patient's white blood cells or from a skin biopsy was found. A clinical anamnestic and genetic correlation is always crucial in these rare and unique acantholytic dermatoses.

Adamantiades-Behçet Disease at the Beginning of the Silk Route: North-East Italian Experience

Dear Editor, Adamantiades-Behçet's disease (ABD) is an inflammatory disease classified as vasculitis, which was originally diagnosed in patients with aphthous stomatitis, genital ulcerations, and ocular manifestations. However, any organ or system may be involved, particularly the central and peripheral nervous systems, joints, as well as the gastrointestinal tract. The etiology of ABD is still not fully understood, but some evidence indicates that an autoimmune process could be triggered by an infectious or environmental agent specific for the geographic region (1). Although BD can occur worldwide, it is most prevalent in the region along the ancient commercial route called the "Silk Road". In Italy, studies on the precise prevalence of ABD are lacking (2). As there are no specific diagnostic laboratory tests or histopathologic findings which confirm the preliminary diagnosis, the final diagnosis should be based on clinical criteria (3). Skin and mucosae are the target organs of this disease, and therefore their involvement has been considered in the numerous diagnostic criteria developed over the years (4). The first most important and popular criteria were created in 1990 by the International Study Group (ISG) (5). Because of their low sensitivity, the new International Criteria for Behçet's Disease (ICBD) were established, and were presented at the International Conference of Behçet's Disease in Lisbon in 2006 (6,7). In 2014, the International Team for the Revision of the International Criteria for BD submitted new criteria assigning 2 points to ocular lesions, oral aphthosis, and genital aphthosis, and 1 point to skin lesions, central nervous system involvement, and vascular manifestations. The pathergy test, when used, was assigned 1 point. A patient scoring ≥4 points is classified as having BD (8). We performed a single center, case-control study on a cohort of patients of Friuli Venezia Giulia, enrolled from January 2010 to September 2015 in the Dermatology Unit of the University of Trieste. The aim was to analyze the clinical features and compare the sensitivity, specificity, and accuracy of the three diagnostic criteria for ABD presented above in patients born in this particular region which is located at the very start of the "Silk Route". We enrolled 153 consecutive patients (74 cases and 79 controls) in the study. The characteristics and clinical features of patients and controls are summarized in Table 1. The most common diagnoses in the control group were recurrent oral aphtosis, lichen planus, mucous-membrane pemphigoid, and lupus erythematosus. The inclusion criterion was the presence of at least one principal clinical feature of ABD (oral aphtosis, genital aphtosis, skin lesions, ocular involvement) properly recorded in clinical records. Patient recruitment was done in a consecutive manner. Exclusion criteria were incomplete clinical records and absence of follow-up data. The diagnosis of ABD was established by expert dermatologists, without the use of any particular diagnostic criterion. For ABD, diagnosis agreement among dermatologists was required. The study was conducted according to the Declaration of Helsinki protocols. Possible associations between categorical variables were detected by the use of Fisher's exact test or Pearson χ2 test, depending on the sample size. Logistic regression was performed in order to identify which symptoms are of higher impact in the diagnosis of ABD. A comparison in terms of sensitivity, specificity, and accuracy among the three diagnostic criteria (ISG 1990, ITR 2006, and ITR 2014) was performed. The receiver operator characteristic (ROC) curve was obtained for each diagnostic criterion. Data were produced with a 95% confidence interval; P values <0.05 were considered statistically significant. Statistical analysis was done using Stata SE12 software (Stata Corporation, Tx, USA). According to our data, patients with ABD had a significantly lower age at diagnosis compared with controls (P=0.0001); this was confirmed for both men (P=0.0006) and women (P=0.004). The presence of oral aphtosis was not necessarily pathognomonic of ABD (P=0.005) as it was found in 97.3% of patients with ABD and in 83.5% of controls. Genital aphtosis was directly associated with ABD diagnosis (P<0.001), as it was present in 79.7% of patients with ABD, but in only 8.9% of controls. Furthermore, even skin manifestations and ocular lesions were observed at different rates in patients with ABD and controls (P<0.001 and P=0.003, respectively). The presence of pseudofolliculitis was significantly more frequent in patients than in controls (P<0.001), whereas erythema nodosum and skin aphtosis did not differ considerably between ABD and controls. Joint manifestations were as common in patients with ABD as in controls (P=0.6): arthralgia and arthritis alone do not indicate a diagnosis of ABD. Neurological symptoms as well as vascular involvement, if present, can be suggestive of ABD, but their absence does not exclude an ABD diagnosis (P=0.06 and P=0.04). Positive pathergy tests and positive HLA B51 tests were significantly more frequent in patients than in controls (P=0.007 and P=0.009, respectively), although if negative they did not exclude a diagnosis of ABD. Logistic regression showed that genital aphtosis (odds ratio (OR)=12948, P<0.001), neurological manifestations (OR=819.263, P=0.001), vascular manifestations (OR=240.2573, P=0.001), cutaneous manifestations (OR=104.5625, P=0.002), oral aphtosis (OR=145.3229, P=0.004), and younger age at diagnosis (OR=0.8950334, P=0.000) were associated with ABD diagnosis (Table 2). There was no single pathognomonic symptom of ABD. We found that the ITR criteria -both from 2006 and 2014 - had a higher sensitivity (98.7% and 100%, respectively), specificity (94.9% and 97.9%, respectively), and accuracy (96.7% and 98.7%, respectively) compared with the ISG 1990 criterion, which scored 66% sensitivity, 100% specificity, and 83.7% accuracy. Area Under Roc Curve (AUC) was significantly different between ISG 1990 and ITR 2006 and between ISG 1990 and ITR 2014 (Figure 1). Even though no statistically significant difference was found between the ITR 2014 and ITR 2006 criteria, the former had a better performance according to our records. The clinical features reported in our retrospective case-control study are comparable to data found in the literature from European and international reports. A recent study (8) found a similar organ involvement percentage to our study, although we found a higher prevalence of HLA B51 positive patients and a lower percentage of ocular manifestations in our records. The results of the logistic regression performed based on our records indicate genital aphtosis, oral aphtosis, ocular involvement, neurological signs, and vascular features are more strongly linked to the diagnosis of ABD. According to our data, the presence of oral aphtosis is not paramount for the diagnosis of ABD, which fits well with the intent of the ITR 2006 and 2014 diagnostic criteria. The new ITR 2014 criteria added neurological signs to the diagnostic symptoms of ABD, emphasizing the importance of a multidisciplinary approach to patients suspected to have ABD.

Interobserver agreement on dermoscopic features of small basal cell carcinoma (<5 mm) among low-experience dermoscopists

The basal cell carcinoma (BCC) assessment in dermoscopy is based on the recognition of specific characteristics synthesized and described as classical and non-classical criteria, but which may not necessarily present all at the same time. Consequently, a deep knowledge in detecting the aforementioned dermoscopic criteria is crucial in diagnosis. The aim of the study was to evaluate which criteria are more frequently recognized among a group of low-experienced dermoscopists when confronted with the difficult diagnosis of BCC with a diameter lower than 5 mm. We examined 100 BCC finding that data displays a full agreement only for one classical criterion, the lack of pigmented network (Fleiss' κ = 1), while among other classical criteria only arborizing vessels and ulceration exhibit a good agreement among observers (Fleiss' κ > 0.40). Analyzing non-classical criteria, only blue-whitish veil and blue in-focus dots show a good agreement among low-experience observers (Fleiss' κ > 0.40). It is evident that in small size BCC classic dermoscopic criteria are often substituted by non-classical criteria, which represent the neoplasm's early phase. Thus, it is of importance, especially for low-experience dermoscopists, to analyze even the non-classical criteria in order to obtain a diagnosis of early BCC.

Dermoscopy of Skin Adnexal Neoplasms:A Continuous Challenge

Dear Editor, Apocrine hidradenoma is a rare benign adnexal tumor related to the more common poroma, as they both originate from sweat glands. Hidradenoma usually has an eccrine differentiation, but an apocrine differentiation is possible. Due to its rarity and non-specific clinical appearance it is difficult to differentiate it from other malignant cutaneous lesions. In this challenging task, dermatoscopy could be particularly helpful to better describe, recognize, and differentiate these lesions. Unfortunately, the literature offers only few dermatoscopic descriptions of this rare cutaneous neoplasm. A 70-year-old woman in fair general condition was referred to our Department for an asymptomatic 10×8 mm single nodule on her left scapula. This nodule was red, dome shaped, well circumscribed, firm, and mildly tender (Figure 1). The patient reported that it had been present since approximately 7 months. The lesion was neither painful nor itchy and there was no bleeding. A skin examination did not show any other lesions with the same features or other suspicious lesions. Dermatoscopy revealed milky-pinkish areas with dotted vessels, linear-irregular vessels, and hairpin vessels: some of these aspects can also be found in amelanotic melanoma (1). There were also homogeneous blue areas similar to lacunae, characteristic but not exclusive to vascular or sarcomatous neoplasms and basal cell carcinoma (1,2). Furthermore, small ulcerations covered by an amber crust were identified, which can usually be found in basal cell carcinoma. Regarding the background of the lesion, we noticed peculiar, translucent, pinkish, soft, large lobular areas (Figure 2). On the basis of this analysis, we suspected an atypical presentation of a basal cell carcinoma, an amelanotic melanoma, or a sarcomatous skin neoplasm. A metastasis of an unknown solid tumor was also taken into consideration. The histological examination revealed an adnexal neoplasm and specifically an apocrine hidradenoma. The neoplasm had variably sized nests and nodules of neoplastic epithelial cells, with a small ductular lumens confined within the upper dermis. The lesion was composed mainly of two cell types: polygonal and smaller, elongated, and darker cells. The cuboidal/polygonal cells were seen lining the duct-like spaces and slots and resembled those of poroma (Figure 3). The adnexal skin tumors group includes a complex variety of uncommon tumors that can be distinguished only histologically, and most of them are benign (3). Searching the literature for "hidradenoma dermoscopy" and "adnexal dermoscopy" yields multiple descriptions of poromas but few dermatoscopic descriptions of hidradenoma (4). There was only one report of the presence of "arborizing vessels"(5), and another described "reddish purple areas and some linear or hairpin-like vessels on the surface of the tumor" (6). In another paper we found: "irregular scar like whitish areas and a polymorphous vascular pattern including irregular reddish-purple areas mimicking lacunar appearance of hemangiomas with thick hairpin vessels at the periphery" (7). It is very difficult make use of such scant data especially in order to detect a leading pattern for a specific diagnosis. Moreover, the described structures lack in specificity, being also present in many other lesions. Analyzing our dermatoscopic image and comparing it to the other ones available in the literature, we identified a peculiar background. It consisted in the presence of multilobular translucent and pinkish soft areas, which fit the previously described dermatoscopic criteria. We hypothesize there is a correlation between this feature and the histopathological presentation with variably sized nests and nodules. Of course, further case reports of hidradenoma are needed to identify the soft lobular background as a distinctive dermatoscopic feature. Due to the lack of specific features both clinically than dermatoscopically, histopathological analysis remains the only gold standard for diagnosis of these benign mimicking lesions.

DRESS syndrome with autoimmune hepatitis from strontium ranelate

Strontium ranelate, which is used for postmenopausal osteoporosis, has been associated with drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, a severe, acute, potentially fatal, multisystem adverse drug reaction characterized by skin rash, fever, hematological abnormalities, and lymphadenopathy with involvement of several internal organs. We report the case of a woman who developed DRESS syndrome with a generalized maculopapular rash, eosinophilia, dyspnea, bilateral cervical lymphadenopathy, and reactivation of Epstein-Barr virus (EBV) with liver damage 3 weeks after administration of strontium ranelate for postmenopausal osteoporosis. Approximately 6 months after total remission of cutaneous symptoms, the patient developed autoimmune hepatitis. This case confirms that strontium ranelate should be considered as a possible factor in the etiopathology of DRESS syndrome as well as in the subsequent development of autoimmune hepatitis. The possibility of developing autoimmune hepatitis as a part of DRESS syndrome related to strontium ranelate use can occur months after the acute episode.