Giulia Gasparini

Serology of Lupus Erythematosus: Correlation between Immunopathological Features and Clinical Aspects

Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the aberrant production of a broad and heterogenous group of autoantibodies. Even though the presence of autoantibodies in SLE has been known, for more than 60 years, still nowadays a great effort is being made to understand the pathogenetic, diagnostic, and prognostic meaning of such autoantibodies. Antibodies to ds-DNA are useful for the diagnosis of SLE, to monitor the disease activity, and correlate with renal and central nervous involvements. Anti-Sm antibodies are highly specific for SLE. Anti-nucleosome antibodies are an excellent marker for SLE and good predictors of flares in quiescent lupus. Anti-histone antibodies characterize drug-induced lupus, while anti-SSA/Ro and anti-SSB/La antibodies are associated with neonatal lupus erythematosus and photosensitivity. Anti-ribosomal P antibodies play a role in neuropsychiatric lupus, but their association with clinical manifestations is still unclear. Anti-phospholipid antibodies are associated with the anti-phospholipid syndrome, cerebral vascular disease, and neuropsychiatric lupus. Anti-C1q antibodies amplify glomerular injury, and the elevation of their titers may predict renal flares. Anti-RNP antibodies are a marker of Sharps syndrome but can be found in SLE as well. Anti-PCNA antibodies are present in 5–10% of SLE patients especially those with arthritis and hypocomplementemia.

Atypical presentations of bullous pemphigoid: Clinical and immunopathological aspects

Bullous pemphigoid may occur in extremely variegated manners, misleading even experienced dermatologists. Indeed the type and/or distribution of lesions may be unusual. Furthermore, there may be an atypical demographic profile of patients, a different clinical course and a different responsiveness to therapy. Up to 20% of the cases the onset is characterized by a non-bullous phase, lasting weeks, months or in particular cases remaining the only manifestation of the disease. During this early phase lesions are generally pruritic erythematous, eczematous or urticarial; however, lesions may also resemble polycyclic, targetoid, nodular or lichenoid lesions. These atypical lesions may also coexist with typical bullae. Other atypical presentations include a vesicular eruption and an erythroderma. Manifestations in children differ from adult forms, presenting an exclusive genital involvement in 50% of cases or a preponderant involvement of the face, the palms and the soles. Rarely bullous pemphigoid is confined to certain body areas, due to particular triggering factors or to a lower disease activity. Therefore, the need to formulate universally recognized diagnostic criteria is increasingly evident, especially for atypical bullous pemphigoid. Direct immunofluorescence of perilesional skin and detection of circulating autoantibodies are mandatory in the diagnosis, especially when the clinical presentation is doubtful.

Cutaneous Manifestations of Scleroderma and Scleroderma-Like Disorders: a Comprehensive Review

Scleroderma refers to an autoimmune connective tissue fibrosing disease, including three different subsets: localized scleroderma, limited cutaneous systemic sclerosis, and diffuse cutaneous systemic sclerosis with divergent patterns of organ involvement, autoantibody profiles, management, and prognostic implications. Although systemic sclerosis is considered the disease prototype that causes cutaneous sclerosis, there are many other conditions that can mimic and be confused with SSc. They can be classified into immune-mediated/inflammatory, immune-mediated/inflammatory with abnormal deposit (mucinoses), genetic, drug-induced and toxic, metabolic, panniculitis/vascular, and (para)neoplastic disorders according to clinico-pathological and pathogenetic correlations. This article reviews the clinical presentation with emphasis on cutaneous disease, etiopathogenesis, diagnosis, and treatment options available for the different forms of scleroderma firstly and for scleroderma-like disorders, including scleromyxedema, scleredema, nephrogenic systemic fibrosis, eosinophilic fasciitis, chronic graft-versus-host disease, porphyria cutanea tarda, diabetic stiff-hand syndrome (diabetic cheiroartropathy), and other minor forms. This latter group of conditions, termed also scleroderma mimics, sclerodermiform diseases, or pseudosclerodermas, shares the common thread of skin thickening but presents with distinct cutaneous manifestations, skin histology, and systemic implications or disease associations, differentiating each entity from the others and from scleroderma. The lack of Raynaud’s phenomenon, capillaroscopic abnormalities, or scleroderma-specific autoantibodies is also important diagnostic clues. As cutaneous involvement is the earliest, most frequent and characteristic manifestation of scleroderma and sclerodermoid disorders, dermatologists are often the first-line doctors who must be able to promptly recognize skin symptoms to provide the affected patient a correct diagnosis and appropriate management.

A Survey of Current Knowledge on Sexually Transmitted Diseases and Sexual Behaviour in Italian Adolescents.

Worldwide, 500 million people a year acquire a sexually transmitted disease (STD). Adolescents, accounting for 25% of the sexually active population, are the most affected. To analyze sexual behavior among Italian adolescents and their knowledge of STDs, with the goal of preventing their transmission, a questionnaire was administered to 2867 secondary school students (1271 males and 1596 females) aged 14–21 years. For the study, 1492 students were interviewed in Genoa (Northern Italy) and 1375 in Lecce (Southern Italy). For 37% of the respondents, parents and teachers were the main source of information on sex, and 95% believed that school should play the primary role in sex education. However, only 9% considered the sex education they received in school good. Noteworthy, only 0.5% of the teenagers recognized the sexually transmitted diseases from a list of diseases, and 54% of them did not know what a Pap test was. Confusion about the meaning of contraception and prevention was evident; only 22% knew that condoms and abstinence are the only methods for preventing STDs. Finally, a consistent number of students are exposed to risk factors for STDs transmission; e.g., alcohol and recreational drug use, promiscuity and improper condom use. On the basis of our study, there is an urgent need for the introduction of sex education as a proper subject in Italian schools.

Porphyrin Elevation in a Patient on Treatment With Simeprevir: Could It Be a Possible Explanation for Simeprevir-Associated Photosensitivity?

To the Editor: The recent development of novel direct-acting antivirals has been of paramount importance in the treatment of hepatitis C. However, all direct-acting antivirals are known to present with additional dermatological events compared to pegylated-interferon/ribavirin (RBV) (1). In particular, photosensitivity seems to be specifically associated with simeprevir (SMV), a second-generation hepatitis C virus (HCV) protease inhibitor, and has been reported in 3–4% of cases (2, 3). We observed a cutaneous reaction on photo-exposed areas in an HCV patient treated with SMV and sofosbuvir (SOF).

Scutellaria baicalensis extract: a novel botanical allergen in cosmetic products?

A 49-year-old female patient had developed face eczema after using Resveratrol BE cream® (SkinCeuticals, a brand of the “Active Cosmetics Division” of L’Oreal) for several weeks. Her dermatitis cleared after she stopped using the cream, and immediately recurred when she applied it again. Repeated open application testing, twice daily on the antecubital flexures, elicited a positive reaction within

Cutaneous angiosarcoma: the role of dermoscopy to reduce the risk of a delayed diagnosis

We report two cases of cutaneous angiosarcoma (CA) in which dermoscopy played an important role during the diagnosis. A 69-year-old woman presented with an erythematous-violaceus plaque and nodules on her right breast. She had a personal history of ductal carcinoma in situ of her right breast, treated with lumpectomy and local radiotherapy. Seven years later, she developed an ecchymotic lesion in the lower outer quadrant (LOQ) of her right breast. This lesion was interpreted by her physician as bruising and treated with topical heparin. Since no improvement was seen, a punch biopsy was performed. The histological findings were nonspecific; therefore, no further investigations and treatment were deemed necessary. Five years later, the patient was referred to our outpatient clinic for an erythematous-violaceous plaque with papules and nodules surrounding the nipple, extending to the LOQ, and a satellite lesion located on the lower inner quadrant of the right breast (Fig. 1a). The dermoscopy revealed homogeneous structureless whitish-pink areas (Fig. 1b). A new histopathological analysis showed anastomosing sinusoidal vessels, lined by a single layer of markedly atypical endothelial cells and a few larger lacunae with intraluminal endothelial proliferation (Fig. 1c). Immunohistochemistry staining showed elevated KI67 and cell positivity for both CD31 and CD34. A diagnosis of radiation-induced angiosarcoma (RIA) was made. A 77-year-old woman with a history of chronic venous insufficiency and lymphedema of the lower limbs was referred to our outpatient clinic with an asymptomatic, reddish-bluish plaque on the pretibial region of her left leg with an indurated border, surrounded by purplish macules, which developed in approximately 4 months (Fig. 2a). Dermoscopic examination showed structureless, patchy red, purple, blue areas, and whitish veil (Fig. 2b). Histopathology examination showed anastomosing sinusoidal vessels, lined by a single layer of markedly atypical endothelial cells and a few larger lacunae with intraluminal endothelial proliferation. Immunohistochemically, the neoplastic endothelial cells expressed CD31 and showed a high Ki-67 proliferative index. A diagnosis of lymphangiosarcoma (LAS) was made. Cutaneous angiosarcoma is a rare, aggressive malignant vascular tumor classified into: (i) sporadic angiosarcoma of the scalp and face; (ii) lymphedema-associated angiosarcoma as secondary to chronic lymphedema (Stewart–Treves syndrome); (iii) radiation-induced angiosarcoma (RIA), a rare complication of radiotherapy with a wide interval range between radiation and the diagnosis of 6 years. Clinical aspects of CA may be subtle and difficult to identify especially for a nondermatologist, as in our first case, appearing as a violaceous plaque or nodule mimicking different types of lesions: bruising, benign inflammatory disease, hemangiomas, tumid lupus, or cellulitis. Dermoscopic examination can help the clinician by revealing the classic colors of vascular lesions, a graduation of red, purple, and blue. Various color gradiation may be an important dermoscopic feature of CA, since it is not found in common purpura and ecchymosis. In addition, CA is characterized by the absence of well-defined vascular structures, such as lacunae/lagoons (usually found in other vascular lesions as angioma and pyogenic granuloma), and vessels. This is useful for differential diagnosis with amelanotic melanoma, that shows irregularly

Contact allergy caused by methylisothiazolinone in a mouthwash as the likely trigger of oral pemphigus vulgaris

Clinica Dermatologica, Department of Health Sciences (DiSSAL), Università di Genova, Ospedale Policlinico San Martino, Genoa, Italy Correspondence Dr. Rosella Gallo, Clinica Dermatologica, Ospedale Policlinico San Martino, Largo Rosanna Benzi 10, 16132 Genoa, Italy. Email: rs.gallo@unige.it

Can mindfulness-based interventions improve the quality of life of patients with moderate/severe alopecia areata? A prospective pilot study

we found an increased prevalence of thyroid disease, eczema, and anemia and decreased prevalence of diabetes mellitus and irritable bowel syndrome. In addition, patients with AA were more likely to have a vitamin-D deficiency and elevated androgen levels, which has not been described to our knowledge. Further insight into these comorbidities could help physicians better understand and treat AA. Strengths of our study are that our team consisted of a group of hair specialists. Furthermore, the centralized AA registry used was detailed and manually entered, ensuring that relevant data were obtained for all patients. The main limitation of this study is that the comorbidity profile of the control group may be different from the general population. In addition, the study was conducted at a tertiary care center and as such, the patients may have a more severe comorbidity profile than usual, and might have received additional health care elsewhere.