New investigative tools applied to the nail

Nail disorders can be very annoying for the patient and diagnostically challenging to the dermatologist. New investigative and noninvasive tools might be very useful in the diagnosis of nail disorders to reduce the number of nail biopsies and for follow up. Reflectance confocal microscopy is a high-resolution emerging imaging technique, with resolution at a cellular level, that can be used to explore the entire body surface, including skin, mucosa, hair and nails. Using the \u201cVivaStack\u201d function, the nail plate can be scanned from the surface to the transition of the plate to the underlying nail bed in horizontal images. According to the intensity of the reflection, three different layers can be differentiated with reflectance confocal microscopy. The superficial layer shows a brighter reflection, followed by a zone with slightly poorer signal, again followed by a brighter zone in the depth. The transition to the underlying nail bed is clearly visible only in thin nails (<500 \u3bcm) and displayed in wave-like structures, which are directed towards the fingertip. Reflectance confocal microscopy is able to display single corneocytes and the integrity of their borders. Optical Coherence Tomography is a non-invasive optical imaging technique that has the advantage of incredibly high spatial resolution compared to other clinically available methods. It provides images of the nail plate, the nail bed and the matrix up to a depth of 2 mm and a width of 6 mm, with a lateral resolution better than 7.5 \u3bcm and axial resolution better than 5 \u3bcm. The combination of these two investigative and noninvasive tools play an important role in the diagnosis and follow up of nail disorders such as onychomycosis, leukonychia, nail psoriasis and lichen planus. Moreover, they help to distinguish between benign and malignant causes of nail pigmentation

Applicazioni nelle patologie annessiali

Le malattie dei capelli e delle unghie sono molto frequenti, possono creare preoccupazioni nel paziente ed essere di difficile diagnosi per il dermatologo. Pertanto, per un corretto inquadramento diagnostico, è necessario talvolta ricorrere all’esecuzione di una biopsia, una procedura chirurgica invasiva che esita in una piccola cicatrice e che spesso viene percepita con disagio dal paziente. In questo contesto, le tecniche di imaging non invasive, come la tomografia a coerenza ottica (Optical Coherence Tomography or OCT), risultano di particolare interesse nelle patologie dei capelli e delle unghie. L’OCT è uno strumento che emette un fascio di radiazioni luminose, con frequenza vicino a quella degli infrarossi, a bassa coerenza che permette di visualizzare in tempo reale l’architettura della cute e degli annessi cutanei fino ad una profondità di 2 mm con un’alta risoluzione (<10 μm). Inoltre, tale strumento permette lo studio della vascolarizzazione di tali strutture. Quindi, grazie alla sua capacità di valutare in vivo i cambiamenti morfologici che avvengono in corso delle patologie dei capelli e delle unghie, consente di individuare le caratteristiche distintive di tali disordini e di giungere rapidamente ad una corretta diagnosi. In tal modo è possibile ridurre il numero delle biopsie eseguite a scopo diagnostico e, quando tale procedura risulta comunque necessaria, lo strumento risulta d’ausilio nella scelta del sito più significativo su cui eseguirla. Anche nel follow-up del paziente, l’OCT risulta utile consentendo di valutare la risposta alla terapia e di individuare precocemente una possibile riattivazione o recidiva di malattia

Ruolo della microscopia laser confocale nella diagnosi e follow-up delle patologie dei capelli e del cuoio capelluto

Le patologie dei capelli e del cuoio capelluto sono molto frequenti, possono essere difficili da diagnosticare e spesso costituiscono la proiezione di patologie sistemiche o disagi psicologici. Pertanto, per un corretto inquadramento diagnostico, \ue8 necessario talvolta ricorrere all\u2019esecuzione di una biopsia, una procedura chirurgica invasiva che esita in una piccola cicatrice e che spesso viene percepita con disagio dal paziente. In tale contesto, la microscopia laser confocale (Reflectance Confocal Microscopy or RCM), una tecnica diagnostica non invasiva che produce immagini tessutali in vivo con una risoluzione quasi come istologica (biopsia ottica), risulta di particolare interesse. L\u2019RCM impiega un raggio laser a bassa potenza (830 nm, vicino all\u2019infrarosso) che scansiona la cute orizzontalmente producendo dettagliate immagini in bianco e nero, dall\u2019epidermide al derma papillare superiore con uno spessore che arriva fino a 200-300 \ub5m. Pertanto, l\u2019RCM consente di valutare i cambiamenti morfologici che avvengono nei pazienti affetti da patologie dei capelli e del cuoio capelluto e di individuare rapidamente le caratteristiche distintive di tali disordini, permettendo di giungere rapidamente ad una corretta diagnosi. Quindi, grazie all\u2019utilizzo di tale strumento \ue8 possibile ridurre il numero delle biopsie effettuate a scopo diagnostico e, quando tale procedura risulta comunque necessaria, l\u2019RCM risulta d\u2019ausilio nella scelta del sito pi\uf9 significativo su cui eseguirla. Infine, l\u2019RCM risulta particolarmente utile nel valutare la risposta terapeutica, consentendo durante il follow-up di individuare precocemente una possibile riattivazione o recidiva di malattia

Permanent implants for lip augmentation: Results from a retrospective study and presentation of tips and tricks

Introduction: Lip augmentation request is increasing. Nowadays, several techniques to obtain temporary effects are available. On the other hand, permanent results can be reached through lip prosthesis implantation. This procedure represents an innovation in the field of aesthetic medicine and surgery. Material & Methods: A total of 110 women with atrophic or hypoplastic lips were treated with lip implants. The treatment was performed in a single session and controls were scheduled at fixed time intervals. A standard digital photo was used for measurement and analysis. Data concerning patient satisfaction and complications of the technique were collected and analysed. Variations to the original technique were also considered. Results: Patient evaluation revealed that a permanent and natural result without discomfort for the patient and/or the partner was reached with the implantation of silicone prosthesis in the upper and/or lower lip. Swelling, bruising, and malpositions were the most frequent adverse events. A case of severe edema was reported. Practical tricks acquired through experience were analysed to prevent complications. Conclusions: The request of permanent results for lip augmentation allowed the development of silicone prosthesis. Advantages of this prosthesis are: safety, definitive result, and reversibility considering the possibility to remove the implanted prosthesis in case of request

The Role of Anti-IgE Antibodies in Urticaria

Chronic urticaria, a common mast cell driven disease, has been considered so far an underestimated and difficult to treat disease, very often resulting in high physical, psychological and socio-economic burden. More than 60% of these patients are unresponsive to second generation H1 antihistamines, the first-line symptomatic treatment for urticaria. However, anti-IgE drugs (omalizumab and ligelizumab) showed improved activity in urticaria-treated patients with inadequate symptom control. Omalizumab has been widely proven to be very effective and well-tolerated in patients with antihistamine-refractory chronic spontaneous urticaria and inducible urticaria and is currently licensed for these indication as third-line treatment. Ligelizumab, a next-generation monoclonal anti-IgE antibody with higher affinity to IgE compared to omalizumab and a similar safety profile, has recently demonstrated to be even more effective than omalizumab. This review is focused on the role of anti-IgE antibodies in chronic urticaria

Synergic effect of buccal fat pad pedicled flap and dermal acellular matrix for large cheek defect

Introduction & Objectives: Reconstruction of large defects of the upper cheek defects still remains a challenge for the surgeon, than can apply different techniques. We present a new method involving the use of a dermal regeneration template to achieve an improved, faster healing of pedicled buccal fat flap in a 75-years-old woman affected by melanoma of the upper-middle cheek. The tumor involved soft tissue, zygomatic arch and periocular fact. Material & Methods: The choice of the surgical technique consisted first in the creation of a buccal fat pad to restore the important lack of tissue over the underlying bones, then in the positioning of a dermal acellular matrix. Three weeks later, once the neodermal formation was finished, a split thickness graft was placed. Results: This is a not yet described association that represents a good surgical option for the restoration of large cheeck defects that allows good functional and cosmetic result in older patient when minimal surgical invasion and operative duration are necessary because of a patient’s general condition. The post-operative course with this surgical technique was regular and a good functional result was achieved. Conclusions: This technique provides an adequate functional coverage, a restoration of soft tissue lacking and an acceptable cosmetic result without ectropion

Role of dynamic optical coherence tomography for in vivo investigation of nails

Introduction Nail diseases are often troubling to the patient and diagnostically challenging for dermatologists. Therefore, a nail biopsy is required in some cases although often perceived uncomfortable by the patient and potentially scarring. Non-invasive imaging techniques are of particular interest in the diagnosis of nail diseases, reducing the number of nail biopsies. Objective The main objective of this study was to describe the typical aspect of healthy nail in Dynamic OCT (D-OCT) and assess the morphological changes that occur in different affected nails. Secondary objective was to detect the main characteristics of each nail disease. Material and Methods This was an observational, retrospective study carried out in our dermatology center from January 2016 to June 2018. Consecutive patients affected by nail diseases and volunteers with healthy nail were recruited. There were no limitations in age or gender. Standardized clinical and dermoscopic images were acquired per patient. D-OCT (VivoSight®: Michelson Diagnostics, Maidstone, UK) was performed on the surface of any nail investigated at three different distances: proximal nail fold, proximal and distal part of the nail plate. In case of suspicious nail tumour, for a better identification of the lesion and its borders, more D-OCT acquisitions were executed. Results 25 nail diseases from 126 patients were evaluated and divided in six main groups: nail changes, ungual infections, ingrowing toenails, nail pigmentation, nail neoformations and inflammatory nail disorders. Mean age of our patient population was 45.7 years (range 9-87) and the majority were female (81 cases, 64.3%). Moreover, 2 healthy nails from 5 volunteers (2 men and 3 women) with a mean age of 34.4 years (range 26-56) were collected. Conclusions D-OCT allows an early diagnosis of nail disease, reduces the number of nail biopsies, helps for the biopsy site selection, detection of the nail tumours borders and for the treatment monitoring

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