Italian Guidelines in diagnosis and treatment of alopecia areata

Alopecia areata (AA) is an organ-specific autoimmune disorder that targets anagen phase hair follicles. The course is unpredictable and current available treatments have variable efficacy. Nowadays, there is relatively little evidence on treatment of AA from well-designed clinical trials. Moreover, none of the treatments or devices commonly used to treat AA are specifically approved by the Food and Drug Administration. The Italian Study Group for Cutaneous Annexial Disease of the Italian Society of dermatology proposes these Italian guidelines for diagnosis and treatment of Alopecia Areata deeming useful for the daily management of the disease. This article summarizes evidence-based treatment associated with expert-based recommendations

An Ecchymosis with Fulminant Evolution

We present the case of an 83-year-old woman who presented with an advanced cutaneous angiosarcoma of the head. The tumor had first appeared as a small ecchymosis on her forehead 3 months before admission. There was an extremely rapid and dramatic evolution, as evidenced by photographic documentation by her relatives. Unfortunately, the delay in access to the healthcare system due to the COVID-19 pandemic lockdown and the fulminant growth were the main determinants for our patient outcome

Bleomycin-induced flagellate dermatitis: report of four paediatric cases.

The reduced concentration of bleomycin hydrolase enzyme in the skin, pruri- tus and the concomitant radiotherapy could have had a synergistic role in the accumulation of the drug and triggered the flagellate dermatitis

Sézary Syndrome: a clinico-pathological study of 9 cases and review of the literature

BACKGROUND: Sezary Syndrome (SS) is a rare and aggressive variant of cutaneous T-cell lymphoma characterized by erythroderma, generalized lymphadenopathy and atypical lymphocytes in peripheral blood. The aim of the study is to describe our experience with SS patients.METHODS: 9 SS patients were retrospectively identified within 288 patients with cutaneous Tcell lymphomas (CTCLs) followed from 1977 to 2017 in the Unit of Dermatology, IRCCS Policlinico San Matteo Foundation, Pavia.RESULTS: 9 SS patients were described: 5 males and 4 females, mean age at diagnosis 66.1 years (49-87 ys), overall survival (OS) after SS diagnosis was 2.6 years (31.5 ms). All the patients showed erythroderma, pruritus and lymphadenopathy. Palmo-plantar hyperkeratosis, nail lesions, alopecia and ectropion were also present. One patient was excluded for significative differences in management. Three lines treatment -extracorporeal photopheresis plus immunomodulator/s plus photo-photochemotherapy- was the most used first-line option for induction of remission, reached in 4 patients out of 8: 3 with Complete Remission (CR), 1 with Partial Remission (PR). Prognostic variables were investigated by univariate analysis: hypereosinophilia, highly elevated beta2muglobulin >3500 mug/l, male sex and highly elevated LDH >450 U/l resulted with statistical power.CONCLUSIONS: The improved comprehension of SS pathogenesis is progressively increasing the -still poor- survival: 38.5 months (3.2 years) considering only the 6 patients followed in the last five years, versus overall 31.5 months (2.6 years). The correct identification of SS patients remains determinant for the proper overall management. Among unfavorable prognostic markers, levels of beta2muglobulin allow stratification of patients

Giant Morpheaform Basal Cell Carcinoma Mimicking Scarring Alopecia: Exception Prone to Neglect

A 74-year-old woman in good general health presented with a 5-year history of progressive hair loss over several years, interpreted as female androgenetic alopecia (AGA), and was treated with topical 5% Minoxidil without improvement. The patient’s relevant medical history revealed infiltrating, triple-negative apocrine carcinoma of the right breast four years before, treated by quadrantectomy, radiation, lymphadenectomy and chemotherapy, with no recurrence at the last follow-up. On examination, there was an asymptomatic 15 × 15 cm firm and whitish area of scarring alopecia on the central scalp. Dermoscopy revealed multiple arborizing vessels and many telangiectasia. The clinical considerations included mainly cutaneous metastasis of breast carcinoma (alopecia neoplastica), pseudopelade of Broque and morpheaform basal cell carcinoma (BCC). A histopathologic examination revealed characteristic changes of morpheaform BCC with basaloid islands and cords of atypical basaloid cells diffusely infiltrating the dermis, embedded in a sclerotic and hypervascularized stroma. Secondary alopecia neoplastica due to morpheaform BCC on the scalp is an exceedingly rare entity, possessing subtle clinical features that may mimic both scarring and non-scarring alopecia. Delayed recognition may contribute to aggressive behavior and extensive local destruction. Treatment with hedgehog inhibitors in locally advanced BCC of the scalp, both in adjuvant and neoadjuvant modalities, is promising

A Clinico-Pathological Multidisciplinary Team Increases the Efficacy of Skin Biopsy and Reduces Clinical Risk in Dermatology

A clinical risk is an inherent risk in healthcare processes, including skin biopsy procedures, and may lead to misdiagnoses, increased healthcare costs and potential harm to patients. Indeed, clinical and histopathological data must be integrated if we are to reduce clinical risks and improve diagnostic accuracy in the diagnosis of dermatologic diseases. Although dermopathology services used to be part of a dermatologist’s duty, the recent centralization of these laboratories has caused a loss of expertise and increased both complexity and safety issues. Some countries have implemented clinical-pathological correlation programs aimed at facilitating communication between clinicians and dermatopathologists. However, Italy has regulatory and cultural barriers that make the implementation of these programs difficult. Therefore, an internal analysis was carried out to assess the efficacy and impact that skin biopsy procedures for inflammatory and neoplastic conditions have on the quality of care in our dermatology department. As the analysis evidenced a high number of descriptive pathologic reports and discordant diagnoses, a multidisciplinary group of four dermatologists, four general pathologists and one dermatopathologist was set up. Herein, we present the results of this analysis and project and describe the structure of the multidisciplinary group. We also discuss the pros and cons, possibilities and limitations of our project, including the regulatory barriers of the Italian National Health System

Efficacy of propranolol in cutaneous haemangiomas: it is more effective on premature children.

AIM: THE purpose of the present study is to evaluate the efficacy and safety of propranolol for problematic infantile haemangiomas (IH), showing our experience on 24 children, with special focus on prematures. METHODS: A retrospective observational study considered 24 patients who were given oral propranolol for the treatment of "problematic" IH. A multidisciplinary team, composed of a dermatologist, a pediatrician, a pediatric cardiologist, and a neonatologist, took part in the indication for propranolol and follow--up on all the patients. Propranolol was administered orally at the starting dose of 0.5--1 mg/kg/die and was gradually increased to the target dose of 2 mg/kg/die. A clinical gravity score, based on color, major diameter, thickness and texture was calculated for each IH, giving a numeric score before (t 0 ) and after (t f) propranolol therapy. Improvement rate was evaluated in terms of score percentage difference between t 0 and t f . RESULTS: All of the IH except one (96%), showed a variable grade of improvement, with a median score improvement of 69.1%. Median initial score in premature and term infants didn't show any significant difference (p = 0.38). Otherwise the two subgroups showed a significant difference in final scores: medium percentage improvement in premature and term infants, was respectively 80.9% and 49.6% (p < 0,01). No significant side effects were reported during the treatment period. CONCLUSION: As pointed out in our study, IH in premature children showed a significantly better response to propranolol treatment