Anna Virgili

Medical History, Drug Exposure and the Risk of Psoriasis

Background/Aims: To evaluate the association of psoriasis with selected medical conditions and a number of drugs used before diagnosis. Methods: Multicenter case-control study involving outpatient services of 20 general and teaching hospitals. Entry criteria for cases were a first diagnosis of psoriasis made by a dermatologist and a history of skin manifestations of no more than 2 years after the reported onset of the disease. Controls were the first eligible dermatological patients observed on randomly selected days in the same centers as cases. A total of 560 cases and 690 controls were recruited. Results: The odds ratio (OR) of psoriasis was 0.8 (95% confidence interval, CI, 0.5–1.3) in hypertensive subjects, 1.1 (95% CI 0.6–2.0) in diabetics and 1.1 (95% CI 0.7–1.7) in hyperlipidemic subjects. Histamine 2 receptor antagonist exposure was negatively associated with psoriasis: OR 0.3 (95% CI 0.1–0.8). Conclusion: Our study rules out a strong association of psoriasis at its first ever diagnosis with common chronic conditions. The reported associations of psoriasis with relatively common conditions such as diabetes mellitus, hypertension and hyperlipidemia may represent a late effect of well-known risk factors for psoriasis such as smoking and overweight or reflect factors related to the long course of psoriasis itself.

Primary Cutaneous CD30+ Large T-Cell Lymphoma in a Patient with Psoriasis Treated with Cyclosporine

We report the case of a 61-year-old woman who developed an anaplastic CD30+ cutaneous T-cell lymphoma during oral cyclosporine (CsA) therapy for recalcitrant psoriasis. Two months after CsA discontinuation, clinical and histological resolution of the lymphoma was observed. However, 3 years later extracutaneous involvement of the lymphoma could be detected. The association between CsA administration and the occurrence of the lymphoma may be casual, but a relationship with immunosuppression may also be hypothesized. We have reviewed all relevant data in the literature. To our knowledge, this is the first case of primary cutaneous CD30+ anaplastic large T-cell lymphoma in a patient treated with CsA for psoriasis.

Total body skin examination for skin cancer screening in patients with focused symptoms

BACKGROUND The value of total body skin examination (TBSE) for skin cancer screening is controversial. OBJECTIVE We sought to determine whether TBSE could be helpful in patients with focused skin symptoms who would not otherwise have undergone TBSE. METHODS In a prospective, multicenter, cross-sectional study consecutive adult patients were recruited during a period of 18 months. Physicians first inspected problem areas and uncovered areas and then performed TBSE. Equivocal lesions detected in both steps were excised or biopsied. Primary outcomes were the absolute and relative risks of missing skin cancer and the number of patients needed to examine to detect melanoma or another malignancy. A secondary outcome was the proportion of false-positive results obtained by TBSE. RESULTS We examined 14,381 patients and detected 40 (0.3%) patients with melanoma and 299 (2.1%) with at least one nonmelanoma skin cancer by TBSE. In 195 (1.3%) patients equivocal lesions found by TBSE turned out to be benign. We calculated that 47 patients need to be examined by TBSE to find one skin malignancy and 400 patients to detect one melanoma. The risk of missing one malignancy if not performing TBSE was 2.17% (95% confidence interval 1.25-3.74). Factors significantly increasing the chance to find a skin cancer were age, male gender, previous nonmelanoma skin cancer, fair skin type, skin tumor as the reason for consultation, and presence of an equivocal lesion on problem/uncovered areas. LIMITATIONS The impact of TBSE on skin cancer mortality was not evaluated. CONCLUSIONS TBSE improves skin cancer detection in patients with focused skin symptoms and shows a low rate of false-positive results.

Retinoids in the chemoprevention of non-melanoma skin cancers: why, when and how

Introduction: The chemoprevention refers to the use of various types of chemical agents for preventing carcinogenic progression. Systemic retinoids are the most studied chemopreventive agents due to their capacity to regulate cell proliferation and their demonstrated efficacy in several clinical studies. Objectives: The aim of the authors was to give precise indications regarding the use of the systemic retinoid in the chemoprevention of non-melanoma skin cancer (NMSC). Methods: The authors reviewed the literature found through a search to MEDLINE (from 2001 to December 2011). Results: Both acitretin and isotretinoin are effective for the prevention of NMSC. Isotretinoin is preferred in xeroderma pigmentosum and nevoid basal cell carcinoma syndrome, whereas acitretin is more used in transplant recipients, psoriasis and severe sun damage. Conclusion: Despite numerous studies of the literature concerning retinoids in chemoprevention of NMSC, precise details of the type of retinoid to use, dosage and the duration of this preventive treatment and how to manage side effects in the case of long-lasting treatment are still not uniform and comparable. Moreover, neither guidelines nor approval by Food and Drug Administration exist to regulate the use of retinoids in chemoprevention.

Overweight, diabetes and disease duration influence clinical severity in Hidradenitis Suppurativa ‐ Acne Inversa. Evidence from the national Italian Registry

DEAR EDITOR, Hidradenitis suppurativa–acne inversa (HS-AI) is a chronic inflammatory skin condition that involves the folliculopilosebaceous units. Histopathological studies have suggested that the occlusion of the follicular infundibulum and both innate and adaptive immunity play central roles. Limited data regarding the clinical aspects and prognosis of HS-AI are available. This paper presents data collected within the newly implemented Italian registry of patients with HS-AI. This was a cross-sectional study on baseline data of a cohort of consecutive patients with a new diagnosis of HS-AI, prospectively observed within a network of Italian dermatology departments. Presence and recurrence, for at least 6 months, of nodules, abscesses, draining sinuses and secondary retracting scars localized on the axillae, suband intermammary areas, inguinal folds, buttocks and perianal areas were considered as inclusion criteria. Written informed consent was obtained from the patients, or from their parents for subjects younger than 18 years, before inclusion in the registry. The study was approved by the ethics committee of the Sant’Anna Hospital in Ferrara. The information collected, using a standardized data collection form, included demographic data, anthropometric measures, selected personal habits, clinical history of the disease, clinical features at entry and follow-up, presence of comorbidities, and therapies prescribed for at least 1 month. The severity of HS-AI was assessed by a physician using the Sartorius score. A short course was run among participants to harmonize Sartorius score calculation, and the inter-rater agreement of independent measures obtained by participants on a small series of patients was judged satisfactory (data not shown). Age-standardized prevalence rates were computed using the 2011 Italian population as a reference. The frequency distribution of selected variables within the HS-AI sample was compared with the distribution in the general population using standardized prevalence ratios along with their 95% confidence intervals (CIs). The Mann–Whitney U-test and Kruskal–Wallis test were used to assess differences across different levels of selected variables for HS severity. To assess which factors were independently associated with HS severity, baseline variables with a P-value < 0 10 in the univariate analysis were evaluated in multivariate linear regression models with forward stepwise selection algorithms. The effects of selected factors were expressed in terms of standardized (Pearson) correlation coefficients (q) along with their 95% CIs and P-values. All tests were considered significant at P < 0 05. From January 2009 to June 2013, 245 patients in seven Italian referral centres for HS-AI were included in the registry; 59 6% of patients were female, and the age at entry was between 6 and 85 years (mean 33 4 13 0), with a mean age at first diagnosis by a physician of 28 2 11 8 years, and a mean Sartorius score of 78 4 66 1 (Table 1). The mean age at onset of the disease was 21 3 10 2 years, and the main affected locations at baseline were the groin/genitals (44 1%), axillae (34 7%), buttocks (10 2%) and trunk (9 0%). The most frequently reported comorbidities were acne (5 7%), thyroid diseases (4 5%) and diabetes (4 1%). Compared with the general Italian population, adult patients (aged ≥ 18 years) with HS-AI were more frequently overweight or obese (age-standardized prevalence ratio 1 4, 95% CI 1 1–1 9), and the prevalence of current smokers was substantially higher (age-standardized prevalence ratio 2 5, 95% CI 1 9–3 4). There were some significant variations between sexes. Age at onset was higher in male patients (24 2 12 7 vs. 19 4 7 6, P = 0 003), while groin/genital involvement was more frequent in female patients (50 7% vs. 34 3%, P = 0 01). In the univariate analysis, age, duration of disease, diagnostic delay, body mass index (BMI), smoking habits and presence of diabetes were all associated with an increased severity of the disease at baseline (Table 2). In the multivariate analysis, duration of disease ≥ 5 years, obesity (BMI ≥ 30 kg m ) and the presence of diabetes were maintained as independent factors directly associated with HS-AI severity. Further analysis showed that smoking correlated with both duration of disease and BMI, with a significant linear trend across different levels of the variables (data not shown). Our data show that the implementation of a registry for HS-AI is feasible and could provide useful data to direct disease management. Smoking and obesity have been proposed as risk factors either to trigger or to exacerbate HS-AI. In our cohort approximately 70% of the patients were current smokers (65 7%) or ex-smokers (8 6%), and the number of current smokers was higher than in the general Italian population. However, we lacked a control group of smokers matched for BMI. Smoking has been associated with increased severity of HS-AI in some studies but not others. In our study smoking

Clobetasol propionate vs. mometasone furoate in 1-year proactive maintenance therapy of vulvar lichen sclerosus: results from a comparative trial.

Twice‐weekly proactive application of mometasone furoate 0.1% ointment (MMF) over 52 weeks was found to be an effective and safe therapy option in maintaining vulvar lichen sclerosus (VLS) remission and in preventing relapse.

Thiopronine-Induced Pemphigus Vulgaris in Rheumatoid Arthritis

Thiopronine, a D-penicillamine-like agent, is being prescribed increasingly for RA. Among side effects, only benign skin reactions have been mentioned to date. A single case of pemphigus erythematosus induced by this drug was recently reported. We describe here 3 other patients who developed pemphigus vulgaris during long-term thiopronine therapy and who improved after the drug was stopped.

Continuous vs. tapering application of the potent topical corticosteroid mometasone furoate in the treatment of vulvar lichen sclerosus: Results of a randomized trial

Topical corticosteroids are the first‐line treatment for vulvar lichen sclerosus (VLS). However, evidence on the most appropriate treatment regimen is lacking.

Italian Euromelanoma Day Screening Campaign (2005-2007) and the planning of melanoma screening strategies.

Although no study has definitively shown that unfocused screening of skin cancer is effective, many campaigns have been organized with the aim of increasing awareness on melanoma risk factors. The objective of this study was to analyse the results of the Skin Cancer Screening Day in Italy during the period 2005–2007, to determine the priorities for melanoma control plans in a Mediterranean country. A total of 5002 patients were screened by dermatologists in 31 cities. Individuals who considered themselves to have many naevi and those with a family history of melanoma showed a higher number of common and atypical naevi. Ten melanomas, 20 basal cell carcinomas and two squamous cell carcinomas were histopathologically confirmed. Our observations provide the following suggestions for melanoma prevention strategies: (a) an unfocused campaign is suitable to inform the public about the importance of self-examination of the skin, but is not useful to identify a larger number of melanomas; and (b) melanoma screening campaigns should focus on a selected population, which meets rigorous risk criteria to maintain higher cost-effectiveness. The financial support to effective melanoma screening programmes could be increased, especially in southern populations where lower levels of self-surveillance and socioeconomic conditions represent risk factors for late identification of melanoma.

Preliminary study on dermoscopic features of vulvar lichen planus: New insights for diagnosis

Editor Vulvar lichen planus (VLP) may represent a diagnostic challenge mimicking other inflammatory or tumoural vulvar diseases. In such equivocal cases, histopathological examination is mandatory. With the aim to describe the dermoscopic features of VLP, we conducted an observational, morphologic study in a prospective cohort of patients affected with VLP attending our Vulva Unit (January 2013–April 2014). Ten female patients with both clinical and histological diagnosis of VLP were included. Patients were excluded in the case of: resolution of clinical features of active disease; active vulvar infections; systemic or topical pharmacological treatment during the 4 weeks before dermoscopy. Capture of dermoscopic images was performed using a digital dermoscopy system [Vidix Dermascope 7, Medici Medical srl, Castelfranco Emilia (MO), Italy]. Minimal pressure was applied and ultrasound transparent colourless gel was used to preserve the vessels’ morphology. The instrument was wrapped in a disposable, polyvinyl chloride wrap for food [‘Domopak’ made by Comital Cofresco, Volpiano (TO), Italy] to prevent microbiological contamination. Dermoscopy image capturing was performed by the same dermatologist to avoid diversification, while dermoscopic evaluation was performed independently by three experienced dermatologist dermoscopists. Clinical photographic documentation was performed as well. Selection of the dermoscopic variables included in the evaluation process was based on the available literature and personal expertise. Our observations indicate that VLP exhibits a rather characteristic dermoscopic pattern, combining (i) thick linear irregular vessels (10/10 cases, 100%), including hairpin (80%) (Fig. 1b0) and spermatozoa-like vessels (60%) (Fig. 1e), arranged diffusely throughout lesions, (ii) peripheral Wickham striae (WS) (70%) exhibiting different morphological patterns, even combined, (iii) an intense red background.