Camilla Loi

Alopecia areata (AA) and treatment with simvastatin/ezetimibe: Experience of 20 patients.

To the Editor: We read with great interest the prospective pilot study that evaluated the effectiveness of simvastatin/ezetimibe (Vytorin, Merck and Co, Kenilworth, NJ) in patients with alopecia areata (AA) and reported a statistically significant association between being on therapy and stable remission of the disease. We obtained different results with the same treatment using a different protocol. In 2012, after ethics committee approval, we started a prospective study with simvastatin/ezetimibe in 20 patients older than 18 years, with AA totalis/universalis or involvement of the scalp greater than 70% (Table I). These patients had previously undergone 1 or more treatments without satisfying results. Inclusion criteria included interruption of any local or systemic treatments for AA at least 20 days before enrollment. Patients were given simvastatin/ezetimibe 40 mg/ 10 mg daily for 6 months. During this study, the patients were visited every 8 weeks and global photography and blood tests were performed, together with assessment of tolerability of the drugs. At the end of the 6-month treatment period, 17 (85%) patients completed the study and 3 (15%) patients dropped out, 1 for personal reasons and 2 because they were not satisfied by the results. Fourteen of 17 (82%) patients had no hair regrowth, 2 (12%) had a transient diffuse hair regrowth followed by total hair loss in 1 month during the treatment period, and 1 (6%) patient had a patchy hair regrowth of pigmented hair (\20%), which was not considered cosmetically acceptable. Side effects were observed in 3 patients (15%), who reported mild headache or muscle cramps that did not interrupt treatment. In conclusion, we did not obtain any result with simvastatin/ezetimibe therapy in severe AA. Our study has some limitations, ie, the small number of patients enrolled and the absence of a control group. But the complete failure of therapy

Erosive pustular dermatosis of the scalp: Clinical, trichoscopic, and histopathologic features of 20 cases

Background Erosive pustular dermatosis of the scalp is a chronic eruption that leads to scarring alopecia. Objective The clinical, dermoscopic, and histopathological features and the course of the disease in 20 patients were reviewed and compared with the reports in the literature. Methods Gender, age at diagnosis, age at onset, duration, topography, predisposing factors, concomitant diseases, trichoscopy, histology, treatment, and outcome were taken into consideration. Results The mean age was 59.4 years. Androgenetic alopecia was present in 12 patients, 6 of whom showed actinic damage. Trauma was reported in 9 patients. Four patients were affected by autoimmune disorders. The vertex was the most common location. In all 20 patients trichoscopy showed an absence of follicular ostia with skin atrophy. Histopathology revealed 3 different features, depending on the disease duration. A reduction of inflammatory signs was observed in 14 patients treated with topical steroids and in all 3 patients treated with topical tacrolimus 0.1%. Limitations The rarity of this disease is a limitation. Conclusions The relatively high number of patients allowed us to identify a better diagnostic approach, using trichoscopy, and a more effective therapeutic strategy, with high‐potency steroids or tacrolimus, which should be considered as first‐line treatment.

Methyl-aminolevulinic acid photodynamic therapy for actinic keratoses: a useful treatment or a risk factor? A retrospective study.

Abstract Introduction: Photodynamic therapy (PDT) is a non-invasive treatment, used for superficial non-melanoma skin cancer (NMSC) and actinic keratoses (AKs). Although PDT is considered a safe treatment, some authors report that PDT may have carcinogenic risks. We undertook this retrospective study to determine if there is a real risk of carcinogenicity for patients treated with MAL-PDT for AK and which risk factors may increase the rate of the malignant transformation. Methods: We reviewed the records of patients treated with PDT for one or more AKs at the Sant’Orsola-Malpighi Hospital from January 2010 to December 2012. We also considered if patients had one or more risk factors for NMSC. Results: Three hundred fifty-seven patients were treated with PDT for AKs, among them 17 patients developed a squamous cell carcinoma (SCC) in the site of a lesion previously treated with PDT. Comparing these two groups, the group which developed the SCC presented more risk factors for NMSC. Conclusion: PDT is certainly a good method to treat AKs, but it is important also to consider all its side effects. Among them, the carcinogenetic risk is still underestimated. We suggest that patients with multiple risk factors for NMSC treated with PDT should undergo more frequent follow-ups, in order to prevent malignant progression.

Photodynamic therapy with 5-methylaminolevulinic acid in the treatment of multiple warts of the face

The facial flat wart is caused by human papilloma virus and these lesions may be observed on the face, dorsal hands and shins. Although different therapies, such as keratolytic agents, topical immunomodulators and radical measures, have been used for multiple warts of the face, the results may be troublesome (1). In fact, all these treatments may be painful, not successful and there are numerous relapses. Photodynamic therapy (PDT) with topical photosensitizer application followed by irradiation with red light has been recently proposed for the treatment of viral warts. Side effects of this therapy are few: patients complained of moderate pain or burning sensation, and subsequent scars are usually not observed (2). We describe one case of multiple facial warts successfully treated with this method. A22-year-oldman(Fitzpatrickphototype3) came to our attention for recalcitrant andmultiple viral warts of the face lasting 1 year. He presented multiple warts, most of them situated on the beard area (Figure 1). He had developed few lesions after sun exposure, and subsequently the number of warts had increased. He did not have a history of immunodeficiency. After a month of the use of 80% trichloroacetic acid and 0.05% isotretinoin solution to reduce the thickness of lesions, we used MAL-PDT: we applied the MAL with occlusive dressing technique for 2 h and then used a red light source (630 nm, 37 j/cm – Aktilite CL128 LED) for 8 min. The lamp-to-skin distance was 5 cm. After the first session, the patient showed a clearance of the 60% of warts. The second session of PDT was performed after a month with the same modalities. After two sessions of PDT, the patient achieved a complete clearance of the warts (Figure 2). We did not notice any severe reaction or side effect, except transient local erythema. The patient complained only mild burn sensation, moderate pain and some pustules. A biopsy performed 1 month after this treatment did not show any sign of wart. After a year of follow-up, he did not present recurrences. The PDT consists in the topical application of the 5-aminolevulinic acid (ALA) or its methyl ester (5-methylaminolevulinic acid or MAL), followed by irradiation with red light: this process results in the creation of free radicals able to destroy diseased tissues (2). PDT is a method usually employed for the treatment of non-melanoma skin tumors, in particular actinic keratosis, superficial basal cell carcinoma and Bowen disease, and some inflammatory dermatoses (3). The use of PDT for facial plane warts has been reported in three studies (1,4,5), but in these studies the photosensitizer was ALA and this drug requires a longer incubation period (3–6 h) (1,5) and a longer time exposure (20 min) (5) to red light.

Methyl – aminolevulinic acid photodynamic therapy and topical tretinoin in a patient with vulvar extramammary Paget's disease

Extramammary Pagets disease is a rare neoplasm of apocrine gland‐bearing areas of the skin. The most common site of presentation is the vulva. Surgery is the most frequently reported therapy so far; however, it is invasive and it is complicated by a high rate of recurrence. For this reason, several less‐invasive treatments have been recently proposed, including photodynamic therapy. We describe in this article the case of an 84‐year‐old patient with a noninvasive vulvar extramammary Pagets disease successfully treated with methyl‐aminolevulinic acid photodynamic therapy associated with topical tretinoin.

Secukinumab in multi-failure psoriatic patients: the last hope?

Abstract Psoriasis is a multi-systemic chronic inflammatory disease that affects about 1.5–3% of the general population, of which almost 20% suffer from a moderate-severe form. Those patients can be treated with a systemic agent and in case of scarce response or contraindications, they may require a biologic therapy, such as tumor necrosis factor or interleukin-12/23 inhibitors. When also these agents fail, clinicians face a true therapeutic challenge. We report a case series of multi-failure 16 patients, successfully treated with secukinumab, a human monoclonal antibody that selectively neutralizes interleukin-17 A and is recently approved for the treatment of plaque psoriasis, psoriatic arthritis, and ankylosing spondylitis.

Pyoderma gangrenosum in the genital area: successful treatment using adalimumab

263 of staining for AQP3 in keratinocytes, with a focal loss of expression (figure 1J-M). These findings were significantly different from the expression pattern of AQP3 in healthy skin, where this molecule is expressed with greater intensity, mainly on the basolateral membrane of keratinocytes (figure 1H, I). Regarding AQP5 expression, no differences between patient and healthy skin samples were observed, with positive staining in most secretory cells of eccrine glands. We report, for the first time, AQP3 and AQP5 IHC staining in samples from AK and HPA patients, showing an aberrant, reduced expression of AQP3 for both types of keratoderma, which could lead to an excessive capacity to hold water in the epidermis [8]. These data, together with the recent findings of the functional correlation between AQP3 and CFTR protein concerning the regulation of water flow through cell membranes, support a new hypothesis regarding a potential role of AQP3 as an aetiopathogenetic basis of AK and HPA.

Risk of malignancy in psoriatic patients: Our clinical experience

Dear Editor, Biologic drugs are nowadays widely used for the treatment of several inflammatory diseases, such as psoriasis. These agents are considered highly effective and generally safe, but they have been associated to some adverse effects, particularly the increased risk of infections, while malignancies have been more rarely reported and this link is still debated. We retrospectively reviewed the medical records of patients treated with a biologic agent (infliximab, etanercept, adalimumab, or ustekinumab) or a traditional agent (methotrexate, cyclosporine, or acitretin) and followed by the Severe Psoriasis Outpatient Clinic of Sant’Orsola Malpighi Hospital of Bologna from January 2006 through December 2015. All patients had a clinical diagnosis of severe psoriasis, assessed by Psoriasis Area Severity Index (PASI) and Body Surface Area (BSA), which scored at least 20. Three hundred and fifty-six patients, 214 treated with biologic therapies (32 with infliximab, 68 with adalimumab, 38 with etanercept, and 76 with ustekinumab) and 142 with a traditional agent entered this study. The average treatment time was 28.6 months. Solid malignancies occurred in 9 cases, 7 males and 2 females, with a mean age of 60 years. The mean time interval between the therapy onset and the tumor diagnosis was 48 months. Non-melanoma skin cancers were not considered in this study. Three of the nine patients with solid malignancies had been treated with a traditional agent (one acitretin, one cyclosporine, and one methotrexate) and six with a biologic therapy (three infliximab, two adalimumab, and one etanercept), one of which had been taking also methotrexate (Table 1). Psoriasis itself is considered a risk factor for some cancers such as non-melanoma skin cancer or T cell lymphoma (Wilton, Crowson, & Matteson, 2016), so it is often difficult to determine the real risk of malignancy associated to the use of traditional or biologic treatments for this disease. Moreover, this risk seems to be increased in patients with a more severe psoriasis (Patel, Patel, & Kerdel, 2016), frequently treated for a long period. In our cohort, six of nine patients who developed a malignancy were treated with TNFa-inhibitors (TNFIs), specifically two patients with adalimumab, three with infliximab, and one with etanercept. The

An erythematous palmoplantar rash due to human parechovirus

A one-month-old infant was admitted to the paediatric unit with high fever (38.5°C) and irritability. He was otherwise healthy and born at term. His parents reported contact with a cousin with high fever. The physical examination was unremarkable except for tense fontanelle. Suspecting infection, an antibiotic (amoxicillin) and antiviral (ganciclovir) therapies were started. However, the blood count, the C-reactive protein and the cerebrospinal fluid analysis were normal, …

Chronische Graft‐versus‐Host‐Erkrankung am männlichen Genitale: eine unterschätzte Manifestation

wir berichten über den Fall eines 24-jährigen Mannes, der sich mit asymptomatischen lichenoiden Läsionen am Penis vorstellte. Diese umfassten den proximalen Teil der Eichel und erstreckten sich bis zum koronalen Sulcus. Wegen eines hypoplastischen myelodysplastischen Syndroms (JAK2-Mutation) mit Monosomie des Chromosoms 7 in der Vorgeschichte hatte sich der Patient 16 Monate zuvor einer allogenen hämatopoetischen Stammzelltransplantation (HSZT) unterzogen. Eine Woche nach der Transplantation hatte sich eine milde kutane Graft-versus-Host-Reaktion (GVHD) entwickelt (akute kutane GVHD: Stadium 3, Grad II). Fünf Monate später war eine Lichen-ruber-planus-artige Ulzeration in der Mundhöhle aufgetreten (Abbildung 1 a). Eine Biopsie der Läsion in der Mundhöhle bestätigte die Clinical Letter Diagnose der lichenoiden chronischen GVHD (cGVHD). Seit der Transplantation hatte der Patient regelmäßig Ciclosporin, Prednison, Foscarnet, Misoprostol, Trimethoprim-Sulfamethoxazol, Fluconazol und Pantoprazol eingenommen. Die Behandlung der oben genannten Läsion in der Mundhöhle umfasste Clobetasol-Creme (einmal täglich), 0,1%ige Tacrolimus-Salbe (dermale Anwendung) und Schmalband-UVB-Therapie, was zur Stabilisierung der Erkrankung führte. Nach sechs Monaten war die Läsion in der Mundhöhle unter Hinterlassung einer Hyperpigmentierung abgeheilt. Sechzehn Monate nach der Transplantation entwickelten sich beim Patienten lichenoide Läsionen am Penis (Abbildung 1 b, c). Eine Diagnostik auf sexuelle übertragbare und Autoimmunerkrankungen verlief negativ. Die Biopsie einer Läsion zeigte eine Parakeratose, eine kompakte Orthokeratose, eine fokale Hypergranulose mit einigen apoptotischen Keratinozyten sowie eine fokale vakuoläre Degeneration entlang der dermo-epidermalen Junktionszone und ein mononukleäres Infi ltrat (Lymphozyten und Plasmazellen) in der oberen Dermis direkt unterhalb der Epidermis. Das Vorliegen der Parakeratose, der fokalen Hypergranulose und dem dichten lichenoiden Infi ltrat ließ auf eine cGvHD schließen (Abbildung 2 a, b). Ergänzend zur immunsuppressiven Therapie wurden topische Kortikosteroide (Clobetasol-Creme, 1 x täglich) verordnet. Nach zwei Wochen war die lichenoide Ulzeration am Penis abgeheilt und die topische Therapie wurde durch allmähliche Reduktion der Auftragshäufi gkeit ausgeschlichen. Seitdem trat kein Rezidiv auf. Die GVHD ist eine häufi ge Komplikation nach einer HSZT, die 30–70 % aller HSZT-Patienten betrifft [ 1 ] . Ihre