Gianluca Nazzaro

Pubic hair removal and molluscum contagiosum.

Dear Editor, In the period from April 2014 to April 2015, 14 Caucasian women, ranging from 21 to 53 years of age, were admitted to our department because of the slow appearance of papular, non-inflammatory lesions on the pubis. Two women also had lesions on the abdomen and one on the right thigh. A clinical diagnosis of molluscum contagiosum (MC) was made. All patients were immunocompetent and in good general health. Furthermore, all of them had performed pubic hair removal (according to clinical history, ten patients by shaving and four by waxing). In the same period, no women with pubic hair were observed with MC on the pubis. As far as men are concerned, no cases of pubic hair removal and MC were recorded in our clinic in the same period. The practice of pubic hair removal is undertaken for cultural and religious reasons and, in recent years, as a fashion phenomenon. In a recent British study, it has been stated that 70 to 80% of adults remove pubic hair, in part or entirety, by means of different methods. However, it was also observed that pubic hair removal is associated with an increased risk of infections and sexually transmitted infections (STIs). A 20-year-old Australian woman with type I diabetes presented with life-threatening group A Streptococcus pyogenes toxic shock syndrome and Herpes simplex (HSV) infection of her external genitalia following a wax for pubic hair removal. In a group of 61 patients with viral infections of the pubis, MC was identified in 44 (71%), human papillomavirus (HPV) infection in seven (11%), concomitant MC and HPV in seven (11%) and HSV in three patients (4.8%). To our knowledge, the co-infection MC–HPV was not reported in other studies. No concomitant MC–HPV infection was observed in our patients. According to the same authors, shaving was a risk factor for a high number of lesions. A prospective 20-year (1988–2007) Spanish study investigating trends of MC showed that there was a three-fold increase from an incidence of 1.3% in the first decade (1988–1997) to 4% in the second (1998–2007) (P< 0.001). In a group of 30 patients with MC, 93% had removed pubic hair (70% by shaving, 13% by clipping and 10% by waxing). These authors concluded that pubic hair removal (especially by shaving) could be a risk factor for MC and other STIs, such as HPV infection. Other authors stated that waxing of the pubis causes abnormalities of the skin barrier that allows the penetration of MC and HPV virus. Conversely, a significant correlation between increase in pubic hair removal and the decreasing incidence of pubic lice infestation was observed. It was hypothesised that the removal of pubic hair may lead to eradication of pubic lice as the natural habitat of this parasite is destroyed. On the basis of our experience, female pubic hair removal, by waxing or shaving, is a practice that could facilitate the local dissemination of MC virus. As previously mentioned, it is possible that waxing and shaving of the pubis causes abnormalities of the epidermis that allows the penetration and dissemination of MC.

Necrobiosis Lipoidica Diabeticorum: A pediatric case report

Introduction: Necrobiosis lipoidica (NL) is a rare chronic granulomatous dermatitis that usually appears in the lower extremities. It affects about 0.3–1.2% of diabetic patients, the majority of whom have type 1 diabetes. The etiology and pathogenesis of this disorder are still unclear. NL is characterized by skin rash that usually affects the shins. The average onset is 30 years, with females being affected more commonly. There are very few reported cases of necrobiosis lipoidica in children. Case report: We report a case of a 16 year old girl affected by type 1 diabetes mellitus (15 years disease duration) who developed an erythematous nodular rash on the lower extremities and interscapular area. In the suspect of necrobiosis lipoidica, a skin biopsy was performed (lower extremities and interscapular area). The microscopic evaluation of the pretibial lesions was suggestive of necrobiosis lipoidica. The smaller lesions in the interscapular area showed signs of perivascular dermatitis which could be consistent with early stages of necrobiosis lipoidica. Local treatment with tacrolimus determined a progressive improvement of the lesions. Conclusion: In patients with T1DM, diagnosis of NL of the lower legs is usually unequivocal. However, diagnosis may be more challenging in the presence of lesions with recent onset and/or atypical clinical presentation and unusual site. In these cases, NL must always be taken in consideration in order to avoid misdiagnosis, wrong/late treatment decisions, and progression to ulceration.

Skin ulcers caused by Serratia marcescens: three cases and a review of the literature.

BackgroundSerratia marcescens is a Gram-negative, encapsulated, motile, anaerobic, non-sporulating bacillus that belongs to the Enterobacteriaceae family. It is found in water, soil, plants, food, and garbage. S. marcescens is an opportunistic pathogen. It usually causes nosocomial infections, such as lung and genitourinary infections, sinusitis, otitis, endocarditis, and sepsis. Skin infections caused by S. marcescens are rare.ObjectivesTo describe three new cases of skin ulcers of the leg caused by S. marcescens and review the relevant literature.Materials & methodsWe investigated three patients admitted for ulcers on the leg.ResultsIn two patients, post-traumatic aetiology was concluded. The modality of infection was not identified for the other patient. One patient was diabetic. All patients recovered with specific antibiotic therapy (ciprofloxacin, ceftriaxone and levofloxacin, respectively).ConclusionSkin ulcers due to S. marcescens are very rare. The three cases presented here add to the limited literature of skin infections caused by S. marcescens.

A case of acquired tufted angioma in adulthood

Tufted angioma is a rare vascular tumor whose name derives from its histopathological appearance, characterized by tufts of capillaries within the dermis. Its etiology and pathogenesis are uncertain. Tufted angioma typically occurs during infancy or early childhood and displays various clinical patterns. It may present as a subtle stain-like area that later thickens as a large plaque, infi ltrated or dusky blue-purple lesion, or as an exophytic, fi rm, violaceous, cutaneous nodule. Medical treatment is not necessary for tufted angioma, given its benign nature and slow progression. Only clinical follow-up is therefore recommended.

Presentation of orf (ecthyma contagiosum) after sheep slaughtering for religious feasts

Abstract We report two cases of orf (ecthyma contagiosum) acquired during religious practices. In the first patient, a 34-year-old Muslim man from Tunisia, orf occurred on the left hand after the patient had handled lamb meat during the “Feast of Sacrifice.” In the second patient, a 57-year-old Jewish man, orf was acquired after the “kosherization” of lamb meat and occurred on a finger of the left hand. As approximately 350,000 Muslims reside in the metropolitan area of Milan (Italy), it is possible that in the next future cases of orf acquired after religious practices will occur more often.

Treatment of hookworm-related cutaneous larva migrans with topical ivermectin

Oral ivermectin was first used in the treatment of hookwormrelated cutaneous larva migrans (HrCLM) in 1992 (1,2). The drug was mainly employed as single dose (1–5); however, in some cases, two or three courses have been necessary (4,6). In rare cases, ivermectin was ineffective (7,8). Percentage of complete remission ranges from 77% (4) to 81% (5) to 97% (4) to 100% (1,5). The time of response ranges from 24–48 h (1) to 3–7 days (4). Oral ivermectin was also successfully used in children (9). To our knowledge, topical ivermectin was never used for the treatment of HrCLM. In 14 Caucasian patients (eight adults (4 males and 4 females) and six children (5 males and 1 female)), with an age ranging from 4 to 55 years, a diagnosis of HrCLM was made by means of history and clinical picture. All patients had recently returned from a trip to Fortaleza (Brazil). Feet and/or ankles were involved in 12 patients; two children had tracks on the buttocks. Ten patients had one track, three patients two tracks and one patient three tracks. All patients were treated with 1% ivermectin cream (2 applications/ day with occlusive plaster for two weeks). All patients were followed up for at least three weeks after the end of the treatment. Complete remission was observed in one child. No clinical improvement was observed in the other patients. Significant reduction in pruritus was recorded in two adults. According to our observations, 1% ivermectin cream seems to be ineffective in the treatment of HrCLM.

Tinea Imbricata in an Italian Child and Review of the Literature

Tinea imbricata is a chronic superficial mycosis caused by Trichophyton concentricum. It is characterized by widespread, annular, concentric, squamous lesions. Tinea imbricata is endemic in three geographical areas: Southwest Pacific, Southeast Asia, and Central and South America. Tinea imbricata in travelers returning from endemic areas is exceptionally rare. We report a case of tinea imbricata in an Italian child who acquired the infection during a trip to Solomon Islands. Three cultures were positive for T. concentricum. The patient was successfully treated with griseofulvin and terbinafine cream.

Cheilitis granulomatosa associated with lupus erythematosus discoid and treated with methotrexate: report of a case

We present the rare case of a 47-year-old patient, suffering from cheilitis granulomatosa and lupus erythematosus discoid: this association is really exceptional because only once reported in English literature. In addition, the treatment of cheilitis granulomatosa is a challenge for the dermatologist: the gold standard, represented by steroids, is in fact designed as a short-time option. Our report confi rms the good efficacy of methotrexate as a steroid-sparing agent.

Mycetomas: The Experience of the Dermatology Unit of the University of Milan

In the period from 1984 to 2016, we observed 16 patients in whom a clinical diagnosis of mycetoma was made. In 8 patients (6 males and 2 females, with an age ranging from 6 to 59 years [mean age: 37.1 years]), this diagnosis was confirmed by histopathological, mycological, and bacteriological examinations. In 2 patients, it was possible to perform polymerase chain reaction (PCR). The histopathological picture was superimposable in all patients. It showed suppurative granulomas surrounding characteristic grains in the deep dermis and subcutis ( Fig. 1 ). In particular, granulomas were composed of neutrophils, histiocytes, and lymphocytes. In actinomycetomas, thin filamentous bacteria were present ( Fig. 2 ); in eumycetomas, eosinophilic structures containing hyphae and spores were observed ( Fig. 3 ). Complete patients’ characteristics and etiological agents are reported in Table 1 . In 2 cases, the infection was acquired in India, in 2 in Ethiopia, an in 1 case each in Senegal, Tanzania, Honduras, and Italy. Etiological agents were identified in 6 patients: Actinomadura madurae and Madurella mycetomatis in 2 patients; Aspergillus nidulans and Phialophora verrucosa in 1 patient; in 2 cases the infection was caused by Acremonium spp. and Fusarium spp. In 5 patients, mycetoma involved the foot; the buttocks, thigh, and ankle were involved in 1 patient each. Mycetomas are chronic and deep infections of the skin caused by bacteria (actinomycotic mycetomas or actinomycetomas) [1, 2] or fungi (eumycotic mycetomas or eumycetomas) [1, 3] . The latter are observed mainly in Sub-Saharan Africa, whereas actinomycotic mycetomas Published online: January 17, 2018

Serratia marcescens: an Italian story

We recently published three cases of skin ulcers caused by Serratia marcescens, a Gram-negative microorganism that rarely infects the skin. The discovery of S. marcescens is an Italian story. In 1819, a farmer named Antonio Pittarello, who lived in Padua, found a bloody polenta in his kitchen. The latter is a typical maize porridge in Northern Italy. In the same period, more than 100 families in the same area reported a blood-like pigmentation on polenta or rice. Maleficent spirits were considered as responsible for the event, and some persons were accused of evil activities, until a priest also observed the phenomenon of the red polenta in his sacristy. A pharmacist and later professor at the University of Padua, Bartolomeo Bizio, examined the red polenta, and carried out some experiments by which he was able to “transmit” the red substance to a polenta that was not affected. He classified the microorganism as a fungus and named it S. marcescens. Serratia was chosen to recall Serafino Serrati, a physicist who had run the first steamboat on the Arno River in 1787, while marcescens comes from the latin word meaning “to decay”. We tried to reproduce the first discovery of this microorganism using a cultural swab of S. marcescens, and finally we noticed that the bacterium may “affect” both the polenta flour and the cooled maize porridge, as shown in Fig. 1.