Eccrine poroma: dermoscopical and confocal features of five cases

Background: Eccrine poroma (EP) is a rare benign adnexal tumor arising from the intraepidermal ductal portion of the sweat gland. It commonly occurs as a single, slowly growing, erythematous, skin-colored, cyanotic or pigmented papule, plaques or nodule. EP occurs usually at the acral sites, but it can develop in other cutaneous sites. It may occasionally mimic malignant tumors including basal cell carcinoma, squamous cell carcinoma and melanoma. Objective: The aim of this study was to describe dermoscopical and confocal features of EP. Methods: A retrospective analysis of the dermoscopical and confocal characteristics of EP was performed. All diagnosis were confirmed by histological examination. Results: A total of 5 cases of non-pigmented EP was analysed. Dermoscopic evaluation found in all lesions a polymorphous vascular pattern, including at least two type of vessels: hairpin (80%), linear (60%), leaf-like (60%), flower-like (40%) and glomerular (40%) vessels. A white-to-pink halo surrounding the vessels was found in 40% of the lesions. Multiple pink-white structureless areas were found in 4 out of 5 (80%) cases. Only in 2 cases irregular haemorrhagic and blue-white areas were also observed. Reflectance Confocal Microscopy (RCM) revealed the presence of well-demarcated hyporefractile tumor nests, dark holes corresponding to areas of ductal differentiation within the tumor and highly vascularized stroma in all 5 lesions. Conclusions: The great clinical variability of EP gives reason of the appellative of “big simulator”. Dermoscopy does not revealed univocal features except from “leaf-flower-like” vessels that have not been described in other types of skin tumors. This characteristic, when presents, may be considered an useful clue for the diagnosis. RCM examination of EP revealed features (hyporefractile tumor nests and dark holes) that relate with their histopathological findings. Dermoscopy and RCM improve the diagnostic accuracy and help for diagnosis, although they cannot replace histology that is still required

Imatinib-associated hyperpigmentation, a side effect that should be recognized

Introduction & Objectives: Imatinib mesylate is a tyrosine-kinase inhibitor used as the first-line treatment in chronic myeloid leukemia patients who are not candidate for allogeneic bone marrow transplantation. The most frequently reported drug-related side effects are edema, nausea, vomiting, muscle cramps, musculoskeletal pain, diarrhea and rash. Imatinib treatment is often associated with hypopigmentation, but only a few cases of mucocutaneous hyperpigmentation are described in literature. We are reporting an additional case of mucocutaneous blue hyperpigmentation in a patient affected by chronic myeloid leukemia and treated with imatinib since 2003. Material & Methods: A review of the available literature regarding the hyperpigmentation related to imatinib was performed and one additional case was analysed. Results: In our case imatinib therapy was well tolerated for several years and it led to an excellent hematological and cytogenetic response. However, the patient gradually developed an intense blue hyperpigmentation that involved the oral mucosa and part of the skin. Other causes of hyperpigmentation were excluded. Conclusions: Since 2001, when imatinib was approved from Food and Drug Administration for chronic myeloid leukemia, some cases of secondary hyperpigmentation were reported. This rare side effect should be recognized by the physicians. Moreover, the patient should be informed about this benign event before starting the therapy. Currently, no treatment is required for this condition and there is not indication to discontinue imatinib treatment. Further insight into the mechanisms of the pigmentary alterations caused by this drug is suggested for better treatment and prevention of these manifestations

Cutaneous myiasis in a traveller returning from Argentina

In returning travellers, dermatologic diseases are the third most common problems and myiasis accounts 7.3-11% of cases. We present a case of furuncular myiasis in a 52-years-old Caucasian man returning from a 1-month trip to Argentina. Clinical examination revealed an about 2 cm large erythematous, painful, poorly delimitated, tender nodule on the left cheek with a small pore on top through which a serous fluid drained. Moreover, patient described a movement sensation inside the nodule. Diagnosis of myiasis was made. The lesion was firstly squeezed and then incised in order to extract the larva, but these procedures resulted unsuccessful. Subsequently, it was indicated patient to apply an ointment on the lesion to determine the asphyxiation of the parasite and make the extraction easier. Pain did not make possible to remove the larva, so the patient, for psychological reasons, insisted on excision of the lesion. Therefore, we proceeded with local anaesthesia and surgical removal of the nodule containing the maggot. The larva was excised and identified as Dermatobia hominis due to the presence of rows of dark brown, caudally pointing, barblike spines. Since myiasis is uncommon in Europe, it is frequently misdiagnosed and its recognition is often delayed. Due to the continuous growth in international tourism, it is very important for Western dermatologists to became familiar with myiasis and consider this diagnosis in case of furuncle-like lesion, resistant to antibiotics in returning travellers. Moreover, travellers to endemic areas should be informed of preventive measures to reduce mosquito bites and transmission of the infestation

“Lambs” in wolves’ clothing: when basal cell carcinoma mimics melanoma, but it is detected by the use of reflectance confocal microscopy

Background Basal cell carcinoma (BCC) is the most frequent non-melanoma skin cancer. There are some cases in which clinical and dermoscopic examinations do not allow to formulate a unique diagnosis and in particular can be difficult the differential diagnosis with melanoma. Reflectance confocal microscopy (RCM) is a non-invasive technology, which allows an in vivo imaging of the skin with high resolution. Objectives We addressed our research to evaluate the reliability of the well-known RCM criteria for classic BCCs in a group of lesions with atypical dermoscopy presentation, possibly mimicking melanoma. Methods We retrospectively analyzed at RCM excised lesions presenting in dermoscopy ≥1 score at revisited 7-point checklist. The study population consisted of 177 cases showing no melanocytic RCM findings. Lesions were investigated for distinct non-melanocytic RCM features, while blinded from histopathology. Histopathology matching was performed before statistical analysis. Results Among the lesions classified at RCM with no-melanocytic characteristics, we recognized 34 cases, histopathological confirmed as BCCs (21 nodular BCCs and 13 superficial BCCs) and 143 cases classified as other lesions (DFs, SebKs, SCCs and others). The main features of nBCCs (with histopathological confirm) at RCM are peritumoral clefts (20/21 95,2%; p=0,037), peripheral palisading (19/21 90,5%; p=0,001), increased vascularization (20/21 95,2%; p=0,004). In sBCCs we found mild keratinocytic atypia (13/13 100%; p=<0,001), solar elastosis (12/13 92,3%; p=0,002), cords connected to epidermidis (9/13 69,2%; p=<0,001). Dendritic structures, nests of basaloid cells, inflammatory infiltrate can be seen in all tumors. Conclusions RCM classification proved high agreement with histopathology for BCCs with atypical dermoscopy presentations, allowing an early differential diagnosis and even identification of BCCs subtypes. RCM features in this group of lesions were similar to those described for typical cases of BCCs, and may drive clinicians decisions, helped them in the recognition of melanocytic and non melanocytic lesions, increasing the rate of accurate diagnoses and allowing better therapeutic management

Osservazioni dermoscopiche ed in microscopia laser confocale sul poroma eccrino: la nostra casistica

Il poroma eccrino è una neoplasia benigna che clinicamente può simulare molteplici lesioni cutanee sai benigne che maligne. Le immagini dermoscopiche ed in microscopia laser confocale di cinque poroma eccrini non pigmentati, istologicamente provati, sono stati esaminate da due valutatori indipendenti. Le caratteristiche dermoscopiche più frequentemente osservate sono state il pattern vascolare polimorfo (100% dei casi) e le aree prive di struttura rosa-biancastre (80% dei casi). L’esame alla microscopia laser confocale ha evidenziato nei cinque casi di poroma nidi iporiflettenti ben demarcati circondati da abbondante stroma, assenza di cellule con disposizione a palizzata e “dark holes” corrispondenti ad aree di differenziazione duttale. L’integrazione delle caratteristiche clinico-dermoscopiche con l’osservazione alla microscopia laser confocale risulta utile nella diagnosi differenziale del poroma eccrino con altri tumori cutanei e nella sua corretta gestione terapeutica, sebbene la diagnosi definitiva resta affidata all’esame istologico che rimane imprescindibile nei casi dubbi

Combining secukinumab with dimethyl fumarate for treatment of a patient with psoriasis and recent diagnosis of multiple sclerosis

Results We report the case of a 44-year-old male patient referred to our department in 2006 for evaluation and management of psoriasis and psoriatic arthritis not responding to previous topical therapies and to conventional systemic treatments. On initial evaluation, his Psoriasis Area and Severity Index (PASI) was 23 so it was decided to start a biological therapy. Etanercept was firstly introduced with partial control of both cutaneous and articular manifestations and stopped after 2 years due to a loss of efficacy. Then, other different biological drugs were administered but discontinued for loss of efficacy or no clinical response. In 2017, we started a treatment with secukinumab with significant clinical improvement. These results were still maintained after 2 years. In January 2019, due to several episodes of hypoesthesia and paraesthesia, the patient performed a neurological examination and a brain magnetic resonance imaging (MRI) with gadolinium revealing multiple encephalic and spinal hyperintense lesions compatible with focal demyelinated areas. A diagnosis of relapsing-remitting multiple sclerosis was made and therapy with dimethyl fumarate (240 bid) started. Secukinumab therapy was maintained but decreasing the dose to 150 mg/month in order to reduce the immunosuppressive risks. After 12 months of follow-up, the patient tolerates the association of the two therapies and presents good control of both diseases. To the best of our knowledge, this is the first case of a combination of two immunosuppressive drugs, secukinumab and dimethyl fumarate, for the treatment of a patient with concomitant psoriasis and multiple sclerosis. Among the widely different conventional therapies available to treat these two diseases, only dimethyl fumarate has been approved for both conditions. Moreover, interleukin 17 (IL-17) appears to play a key role in the pathogenesis of both diseases; it is produced by lymphocytes Th17, but also by CD8+ cells, Tγδ lymphocytes and some cells of the central nervous system, such as astrocytes and oligodendrocytes, in the context of active lesions of multiple sclerosis. Currently, the efficacy of anti IL-17 has been described only in few cases of multiple sclerosis. In conclusion, our case emphasizes the potential efficacy and safety of combination therapy of secukinumab and dimethyl fumarate, which may be a therapeutic option for such challenging patients

Optimization strategies for HIV, hepatitis and syphilis testing in Infectious Disease Clinic and Dermatology Unit of Modena: seven-years results of collaboration experience

Introduction: Human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV) and syphilis infections modify the epidemiology and presentation of each other. Screening tests are very important for detection of sexually transmitted infections (STIs), for treating them at an early stage and prevent the diffusion inside communities. “Test & Counselling” Ambulatory of Infectious Disease Clinic (T&C-IDC) and Sexually Transmitted Diseases Ambulatory of Dermatology Unit (STDs-DU) of the Azienda Ospedaliero-Universitaria Policlinico of Modena began collaboration in 2010 and adopted a common diagnostic profile since 2013. The main objective was to analyse the results of screening tests performed in the T&C-IDC and STDs-DU during the study period in order to identify early HIV, HBV, HCV and syphilis infections. The secondary objective was to evaluate the efficacy of our collaboration in term of number of new STIs diagnoses and linkage to care. Material and Methods: Consecutive patients referred to the T&C-IDC and STDs-DU from January 2010 to December 2016, with at least one performed screening test for HIV, HBV, HCV and syphilis were enrolled. Demographic and laboratory data were acquired from each patient. Linkage to care of positive patients was obtained through a join of different outpatient clinical databases. Results: During the seven-years observation we collected 13117 admittances for 9154 patients. Median age was 35.1 years ± 12.6 and foreign-born population represents 29% of the tested people. People who resulted positive for at least one screening test increased during the study period. A total of 668 infections were detected in 644 patients. Discussion: The agreement between T&C-IDC and STDs-DU has proven to work well increasing the diagnosis over the time and obtaining a good results in linkage to care, which allows to patients with positive screening test to be sent to the pertinent Clinic for further investigations and therapeutic management

Optimization strategies for HIV, syphilis and hepatitis testings in infectious disease and dermatology clinics: preliminary results of Modena collaboration experience

Background: HIV and sexually transmitted diseases (STDs) screening tests are usually offered in many Italian health institutions. These tests are very important for detection of HIV and STDs, for treating them at an early stage and for prevention of diffusion inside communities. Generally, HIV test is the only screening exam performed in Infectious Disease Clinic (IDC). Increased collaboration between IDC and STDs Centre using the same approach to test sexually transmitted infections could implement the number of new diagnoses. In the Azienda Ospedaliero-Universitaria (AOU) of Modena, the IDC and STDs Centre of Dermatology Clinic began a strict collaboration and adopted a common diagnostic profile including HIV, syphilis, HBV and HCV screening tests since 2013. The aim of the study was to observe the results of a seven-years collaboration in term of number of new HIV and STDs diagnoses. Material & Methods: Consecutive patients who underwent at least 1 screening test for HIV, syphilis, HBV and HCV from January 2010 to September 2016 in IDC or STDs Centre were included. Demographical data were electronically recorded in clinical databases. “Linkage to care” was obtained through a capture and recapture method using Modena HIV surveillance System and Modena HIV clinic databases. Results: During the study period 10675 admittances related to 8623 patients, who carried out at least 1 screening test, were registered in the centres. They were mainly male (68.2%). Median age was 33 years-old (IQR 26-43). Foreigners represented 26.5% of tested people. Since 2013 an increasing number of admittances was observed (1343 accesses in 2010 and 1901 in 2015). HBV, HCV and syphilis tests increased in IDC after 2013 as well as HIV tests in STDs Centre (Figure 1). A total of 700 people were positive for at least 1 screening test: 71 with HIV infection (2016 incidence rate 1.4%), 314 with syphilis (2016 incidence rate 1.3%), 182 with HCV infection (2016 incidence rate 1.64%) and 161 with HBV infection (2016 incidence rate 3.8%). The number of HIV and HBV positive tests increased in the last 2 years but the trend was statistically significant only for HIV (p<0.001). 57% of HIV new infections were observed in Italian men, while 82% of new HBV infections were detected in young foreigners. During the study period the number of new syphilis infections showed a reduction (p<0.001) while HCV positive tests were changeless (p=0.245). 87.6% of new infections were found be linked in care in AOU of Modena. Conclusion: The agreement between IDC and STDs Centre has proven to work well increasing the diagnosis over the time and obtaining a good results in “linkage to care”, which allows to patients with positive screening test to be sent to the pertinent Clinic for further investigations and therapeutical management

Collaboration experience between Dermatology Unit and Infectious Disease Clinic in Modena: optimization strategies for HIV, hepatitis and syphilis screening tests

Introduction Screening tests for HIV, HBV, HCV and syphilis are very important to detect and treat these infections at an early stage and prevent their diffusion inside communities. Sexually Transmitted Diseases Ambulatory of Dermatology Unit (STDs-DU) and “Test & Counselling” Ambulatory of Infectious Disease Clinic (T&C-IDC) in Modena began collaboration in 2010 and adopted a common diagnostic serological profile since 2013. Objective The main aim of the study was to analyse the results of screening tests performed in the STDs-DU and T&C-IDC, comparing the results obtained after the adoption of the shared protocol with the previous period. The secondary objective was to evaluate the efficacy of our collaboration in term of number of new diagnoses and linkage to care. Materials and Methods Consecutive patients referred to the STDs-DU and T&C-IDC from January 2010 to December 2016, with at least one performed screening test for HIV, HBV, HCV and syphilis were enrolled. Referral of patients with a new infection was obtained by capture-recapture methods in hospital databases. Results During the seven-years observation we collected 13117 admittances for 9154 patients. We observed a significant increase in the number of screening tests (p<0.001) and ratio between tests and admissions (p=0.002). 644 (7.0%) people with at least one infection were diagnosed. Among these, the most common was syphilis (41.9%), followed by HBV (25.7%), HCV (21.4%) and HIV (10.9%). Syphilis and HCV occurred predominantly in Italians (72.5% and 81.1%) and males (75.7% and 75.5%), while foreign-born (85.5%) mainly harboured HBV infection. HIV diagnosis was detected more frequently among males (67.1%) with a similar proportion between Italians and foreign-born. 543 out of 644 (84.3%) patients were linked to care. Conclusions The cooperation between STDs-DU and T&C-IDC has proven to work well increasing the diagnosis over the time and obtaining good results in linkage to care

“Agnelli” vestiti da lupi: quando il carcinoma basocellulare imita il melanoma, ma viene smascherato dalla microscopia laser confocale

Background. Nella pratica clinica, molto spesso, l’esame clinico-dermoscopico del carcinoma basocellulare (BCC) non è sufficiente per una diagnosi corretta e la diagnosi differenziale si pone con il melanoma. La microscopia laser confocale (RCM) è una metodica di diagnosi non invasiva che consente di ottenere immagini in vivo ad alta risoluzione. Obiettivi. Nel nostro studio abbiamo valutato l'affidabilità dei ben noti criteri RCM per i classici BCC in un gruppo di lesioni con presentazione clinica e dermoscopica atipica. Metodi. Abbiamo analizzato retrospettivamente alla RCM tutte le lesioni asportate dal 2010 al 2016 con positività per almeno uno dei criteri dermoscopici della 7-point check list revisitata. Risultati. Tra le lesioni esaminate sono stati identificati 34 casi, confermati istologicamente come BCC (21 nodulari, 13 superficiali) e 143 casi classificati come altre lesioni (DF, Sebk, SCC e altri). Conclusioni. Le caratteristiche in RCM dei BCC che mimano dermoscopicamente il melanoma erano le stesse descritte per i classici BCC. Il nostro studio sottolinea l'importante ausilio della microscopia laser confocale nel corretto inquadramento diagnostico di neoplasie con differente comportamento biologico e nella conseguente gestione terapeutica