Emi Dika

Generalized psoriasis induced by topical treatment of actinic keratosis with imiquimod.

Generalized psoriasis induced by topical treatment of actinic keratosis with imiquimod Dear Sir, Imiquimod cream (Aldara, 3M Pharmaceuticals, St Paul, MN), an immune response modifying drug which demonstrates potent antiviral and antitumorous activity, has been used for the treatment of several skin conditions. Clinical trials have shown efficacy in the treatment of precancereous lesions such as actinic keratoses, Bowen’s disease, and inflammatory skin diseases. Efficacy has been reported in the treatment of other cutaneous or mucosal malignancies like lentigo maligna, squamous cell carcinoma, and VIN; hence, no controlled clinical trials have yet been published on applications of the drug. A 77-year-old man presented with seven actinic keratosis localized at the parietal region of his balding scalp. The clinical history revealed that the patient had psoriasis. This dermatological pathology had been stable for the past 7 years, during which time he had not received any topical or systemic treatment for psoriasis. No evidence of psoriasis was shown on clinical examination. The patient’s laboratory examinations showed no abnormalities and he was otherwise healthy. Topical treatment with Imiquimod 5% cream was prescribed once daily 3 times/week for 6 weeks for the actinic keratosis. After the second week of treatment the patient developed moderate psoriasis from changes at the sites of application of the imiquimod cream (Fig. 1). A 4-day rest period from application of the drug was advised, after which the treatment was restarted. After the fourth week, the patient was referred to our clinic showing a severe psoriatic reaction of the scalp and widespread small erythemato-scaling plaques over the trunk, face and limbs (Fig. 2). We interrupted the treatment of the imiquimod cream and prescribed no therapy after the psoriatic flare-up. No systemic disorders were noted by our patient and his blood analysis showed no change, demonstrating no systemic absorption. At a 10-day review, the patient and the lesions of the scalp had improved. At the 4-week post-treatment follow up the generalized psoriatic eruption had resolved. The clinical examination of the scalp showed clearance of the actinic keratosis. A biopsy was performed at the scalp area where the lesions were previously localized and showed no signs of actinic keratosis on histologic examination after only 12 applications. Psoriasis is a chronic multifactorial inflammatory disease. Its onset has reportedly been triggered or exacerbated by a few exogenous factors such as the weather, emotional stress, drugs and infections. Drugs may result in exacerbating a preexisting psoriasis, or by inducing psoriatic lesions on clinically uninvolved skin in patients with psoriasis. Imiquimod [1-(2-methylpropyl)-1, H-imidazo(4,5-c), quinolin-4-amine] is an immune response modifier which activates immune cells via toll-receptor (TLC) 7, initiating a cascade that leads to the induction of cytokines such as IFN-alfa, gamma and IL-12, which promote a Th-1 immune response. These cytokines are capable of inducing psoriasis. Evidence that psoriasis is an immune-mediated disorder comes from laboratory studies, clinical observation, and use of targeted therapies. Lately there have been immunohistochemical studies offering the hypothesis of a predominance of Th-1 cytokines in psoriatic skin. Figure 1 Localized psoriasiform eruption in the scalp area following imiquimod application

Inverse Association Between Dietary Vitamin D and Risk of Cutaneous Melanoma in a Northern Italy Population

The possibility of an inverse association between vitamin D and risk of cancer and, in particular, of cutaneous malignant melanoma has been suggested, but results of epidemiologic studies are still conflicting. We examined the relation between dietary vitamin D intake and melanoma risk through a population-based case-control study (380 cases, 719 controls) in a northern region of Italy, a country with an average vitamin D intake lower than that in northern Europe or the United States. We assessed average daily intake of vitamin D from foodstuffs using the European Prospective Investigation into Cancer and Nutrition (EPIC) semiquantitative food frequency questionnaire. In this population, levels of vitamin D intake were considerably lower than those observed in recent U.S. studies. We found an inverse relation between dietary vitamin D and melanoma risk in the sample as a whole, in both crude and adjusted analyses. In sex- and age-specific analyses, this association appeared to be stronger among males and among older subjects. These findings suggest that, at the relatively low levels of intake observed in this sample, an inverse relation between dietary vitamin D and risk of cutaneous malignant melanoma may exist.

Partial excision of matrix and phenolic ablation for the treatment of ingrowing toenail: a 36-month follow-up of 197 treated patients.

BACKGROUND Several options for the treatment of ingrowing toenails are available, ranging from simple conservative approaches to extensive surgical procedures. OBJECTIVE To evaluate in a long‐term follow‐up (36 months) the efficacy of chemical matricectomy with phenol for the treatment of ingrowing toenails. METHODS AND MATERIALS A total of 197 phenol ablations were performed in 139 patients with stage 2 and 3 disease. Each patient was examined weekly until full wound healing was achieved and was followed for 36 months to assess the long‐term efficacy of the treatment. The healing period after surgery ranged from 2 to 4 weeks; few postoperative complications were seen. RESULTS Only three recurrences were observed (after 2, 4, and 11 months). Short‐term results were excellent. No severe complications occurred during the 36‐month follow‐up period. Cosmetic results were remarkable. The success rate was 98.5%. CONCLUSIONS Phenol cauterization is an excellent surgical method for the treatment of ingrowing toenails, being simple and associated with low morbidity and a high success rate, even over the long term (36 months). The authors have indicated no significant interest with commercial supporters.

Drug-Induced Psoriasis: An Evidence-Based Overview and the Introduction of Psoriatic Drug Eruption Probability Score

ABSTRACT Psoriasis is a common skin disorder that needs a long-term management, not only because, of its prevalence but also because of the profound impact it can have on patients quality of life. Drugs may result in exacerbation of a preexisting psoriasis, in induction of psoriatic lesions on clinically uninvolved skin in patients with psoriasis, or in precipitation of the disease in persons without family history of psoriasis or in predisposed individuals. The knowledge of the drugs that may induce, trigger, or exacerbate the disease is of primary importance in clinical practice. By reviewing the literature, there are many reports on drug-induced psoriasis, but the data are not univocal. We propose, when possible, the use of a probability score from the authors to obtain a better classification and further understanding of drug-induced psoriasis.

Tips for Diagnosis and Treatment of Nail Pigmentation with Practical Algorithm

The observation of a black-brown pigmentation of the nail is often alarming for the patient and for the clinician, as they are aware that it can be a possible clinical manifestation of melanoma of the nail apparatus. Luckily, however, nail melanoma is a much less frequent cause of brown-black nail color than other melanocytic and nonmelanocytic pigmentations, which include subungual hematoma, exogenous pigmentations, and melanonychia due to benign conditions. A correct clinical history and careful examination help the clinician to distinguish the different conditions and to decide the correct management of melanonychia both in children and in adults.

Mohs surgery for squamous cell carcinoma of the nail: report of 15 cases. Our experience and a long‐term follow‐up

Background  Subungual squamous cell carcinoma (SSCC) is the most common malignancy of the nail unit. Mohs micrographic surgery (MMS) is a microscopically controlled surgical technique that has a high cure rate for skin cancers despite allowing narrow surgical margins.

Diet Quality and Risk of Melanoma in an Italian Population

BACKGROUND Some results from laboratory and epidemiologic studies suggest that diet may influence the risk of melanoma, but convincing evidence for a role of single nutrients or food items is lacking. Diet quality, which considers the combined effect of multiple food items, may be superior for examining this relation. OBJECTIVE We sought to assess whether diet quality, evaluated with the use of 4 different dietary indexes, is associated with melanoma risk. METHODS In this population-based case-control study, we analyzed the relation between 4 diet quality indexes, the Healthy Eating Index 2010 (HEI-2010), Dietary Approaches to Stop Hypertension (DASH) index, Greek Mediterranean Index (GMI), and Italian Mediterranean Index (IMI), and melanoma risk in a northern Italian community, with the use of data from 380 cases and 719 matched controls who completed a semiquantitative food frequency questionnaire. RESULTS In the overall sample, we found an inverse association between disease risk and the HEI-2010 and DASH index, but not the Mediterranean indexes, adjusting for potential confounders (skin phototype, body mass index, energy intake, sunburn history, skin sun reaction, and education). However, in sex stratified analyses, the association appeared only in women (P-trend: 0.10 and 0.04 for the HEI-2010 and DASH index, respectively). The inverse relations were stronger in women younger than age 50 y than in older women, for whom the GMI and IMI scores also showed an inverse association with disease risk (P-trend: 0.05 and 0.02, respectively). CONCLUSIONS These results suggest that diet quality may play a role in cutaneous melanoma etiology among women.

Association Between Dietary Vitamin C and Risk of Cutaneous Melanoma in a Population of Northern Italy

Cutaneous melanoma incidence has been increasing during the last few years, and diet has been suggested as one of the lifestyle factors responsible for this increase. Since antioxidant nutrients such as ascorbic acid might prevent skin carcinogenesis, we investigated the risk of cutaneous melanoma related to vitamin C intake in a population-based case-control study in Northern Italy based on 380 melanoma patients and 719 matched controls, to whom we administered a semiquantitative food-frequency questionnaire. After adjusting for potential confounders, odds ratio of melanoma were 0.86 (95 % confidence interval 0.65 - 1.15) and 0.59 (95 % confidence interval 0.37 - 0.94) in the intermediate and highest categories of vitamin C dietary intake respectively, compared with the bottom one. The association between vitamin C and decreased risk persisted after adjustment for some potential confounders. In age- and gender-stratified analyses, this association was seen in young females (< 60 years old), and was found to be enhanced in subjects with phototypes II and III. These results suggest a possible protective activity of vitamin C intake against cutaneous melanoma in specific subgroups of this population of Northern Italy.

Spitzoid tumors in children and adults: a comparative clinical, pathological, and cytogenetic analysis.

Spitzoid neoplasms may represent a difficult diagnosis in the practice of dermatopathology. We evaluated the concordance of the fluorescence in-situ hybridization (FISH) assay, histopathology, and dermoscopy in a group of adults and in a group of children with spitzoid neoplasms. The FISH assay, designed to detect the copy number of the RREB1 (6p25), MYB (6q23), and CCND1 (11q13) genes and of centromere 6 (Cep 6), was performed in a group of children and in a group of adults with a histopathologic diagnosis of spitzoid neoplasms. FISH data were compared with dermoscopy and histopathology. Fifteen spitzoid neoplasms were collected from 13 patients (five children and eight adults): nine lesions were histologically diagnosed as typical Spitz nevi; three lesions were melanomas and three were atypical Spitz nevi. The conventional FISH criteria were concordant with the clinical and histopathologic diagnosis of Spitz nevi in four adults and in three children. FISH criteria of the other neoplasms showed a concordance with the histopathologic diagnosis in three cases. Discordant results were obtained in five cases (two children, three adults). The FISH melanoma assay proved more reliable in spitzoid lesions found in adults than in children. This assay should be interpreted carefully in pediatric patients with Spitz nevi in the context of histological features as melanomas in the pediatric population may show distinct chromosomal aberrations.

Mohs Surgery for Squamous Cell Carcinoma of the Nail Unit: 10 Years of Experience.

BACKGROUND Squamous cell carcinoma (SCC) is the most frequent malignant tumor of the nail unit. OBJECTIVE The aim of this study was to review the long-term outcome of patients affected by SCC of the nail who underwent Mohs surgery. MATERIALS AND METHODS Patients affected by nail SCC were enrolled, including cases where x-ray examination had revealed bone changes. The tumor was completely excised and the defect filled with a skin substitute based on hyaluronic acid where bone involvement was not observed. Where Mohs sections indicated bone involvement, the distal phalanx was disarticulated and the remaining end of the digit repaired using a volar/plantar flap. Follow-up was performed every 6 months for 5 years. RESULTS Mohs technique was performed in 43 cases. Microinvasive SCC was diagnosed in 5 cases, in situ SCC in 7 cases, and invasive SCC in 45 patients. Recurrences were observed in 2 patients (3.5%). Disarticulation was performed in both of them, and no further tumor recurrences were observed in 4 to 5 years of follow-up. CONCLUSION Mohs surgery provides the highest cure rate for the treatment of nail SCC. It allows the evaluation of periosteal invasion and therefore bone invasion to be reliably distinguished from inflammation or compression. This technique reduces the number of unnecessary amputations, a critical consideration for patients quality of life.