Laura Atzori

Glycolic acid peeling in the treatment of acne

Glycolic acid chemical peels have been widely accepted as a useful modality in many cutaneous conditions characterized by abnormalities of keratinization.

Cutaneous adverse drug reactions to allopurinol: 10 year observational survey of the dermatology department – Cagliari University (Italy)

Background  Allopurinol is extensively prescribed for conditions associated with urate excess, despite being responsible for severe cutaneous adverse drug reactions (ADR).

The constellation of dietary factors in adolescent acne: a semantic connectivity map approach

Different lifestyle and dietetic factors have been linked with the onset and severity of acne.

Primary cutaneous cryptococcosis in an immunocompetent host.

We report a case of primary cutaneous cryptococcosis in an immunocompetent host. Several nodules, isolated or sometimes joint to form plaques, affected the right arm. The arm was paralytic and hypoplastic, and a history of numerous abrasions picking firewood up preceded the onset of the eruption. Histology on skin biopsy documented a dermal infiltrate constituted of histiocytes, lymphocytes, fibroblasts and rare giant cells. Numerous rounded periodic acid‐Schiff (PAS) bodies were also present. Cryptococcus neoformans var. neoformans grew upon culture. Complete blood, biochemical and instrumental examinations resulted in findings within normal range. Treatment with itraconazole 200 mg daily for 4 months led to complete recovery. During a 2‐year follow‐up, the patient did not present any relapse or dissemination to other organs.

The usefulness of c-Kit in the immunohistochemical assessment of melanocytic lesions

C-Kit (CD117), the receptor for the stem cell factor, a growth factor for melanocyte migration and proliferation, has shown differential immunostaining in various benign and malignant melanocytic lesions. The purpose of this study is to compare c-Kit immunostaining in benign nevi and in primary and metastatic malignant melanomas, to determine whether c-Kit can aid in the differential diagnosis of these lesions. c-Kit immunostaining was performed in 60 cases of pigmented lesions, including 39 benign nevi (5 blue nevi, 5 intra-dermal nevi, 3 junctional nevi, 15 cases of primary compound nevus, 11 cases of Spitz nevus), 18 cases of primary malignant melanoma and 3 cases of metastatic melanoma. The vast majority of nevi and melanomas examined in this study were positive for c-Kit, with minimal differences between benign and malignant lesions. C-Kit cytoplasmatic immunoreactivity in the intraepidermal proliferating nevus cells, was detected in benign pigmented lesions as well as in malignant melanoma, increasing with the age of patients (P=0.007) in both groups. The patient’s age at presentation appeared to be the variable able to cluster benign and malignant pigmented lesions. The percentage of c-Kit positive intraepidermal nevus cells was better associated with age despite other variables (P=0.014). The intensity and percentage of c-Kit positivity in the proliferating nevus cells in the dermis was significantly increased in malignant melanocytic lesions (P=0.015 and P=0.008) compared to benign lesions (compound melanocytic nevi, Spitz nevi, intradermal nevi, blue nevi). Immunostaning for c-Kit in metastatic melanomas was negative. Interestingly in two cases of melanoma occurring on a pre-existent nevus, the melanoma tumor cells showed strong cytoplasmatic and membranous positivity for c-kit, in contrast with the absence of any immunoreactivity in pre-existent intradermal nevus cells. C-Kit does not appear to be a strong immunohistochemical marker for distinguishing melanoma from melanocytic nevi, if we consider c-Kit expression in intraepidermal proliferating cells. The c-Kit expression in proliferating melanocytes in the dermis could help in the differential diagnosis between a superficial spreading melanoma (with dermis invasion) and a compound nevus or an intradermal nevus. Finally, c-Kit could be a good diagnostic tool for distinguishing benign compound nevi from malignant melanocytic lesions with dermis invasion and to differentiate metastatic melanoma from primary melanoma.

Cutaneous Crohn Disease in a Child

Abstract:  Cutaneous Crohn disease refers to granulomatous skin manifestations not contiguous with gastrointestinal affected areas. It is a very rare condition, especially in children, and is easily misdiagnosed when characteristic gastrointestinal symptoms are absent. We report a 10‐year‐old Caucasian girl with a 6‐month history of erythematous, firm tumescence of the left labium majus pudendi and moist vegetations circumscribing the anal ostium. Histologic analysis of skin biopsy specimens from both types of lesions showed a characteristic granulomatous noncaseating infiltrate throughout the dermis. Endoscopic examination and a colon biopsy specimen showed chronic granulomatous inflammation consistent with Crohn disease. Treatment with prednisolone 20 mg daily, metronidazole 250 mg three times daily, topical corticosteroids, and mupirocin ointment produced marked improvement of the vulvar edema, whereas the perianal lesion had a relapsing course. Early recognition of extra‐intestinal manifestations of Crohn disease, which are extremely rare in children, may be difficult. Coexistence of contiguous and noncontiguous lesions, representing the very first signs of the disease, are further peculiarities in our patient.

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

IMP-3 expression in keratoacanthomas and squamous cell carcinomas of the skin: an immunohistochemical study

The protein insulin-like growth factor II mRNA binding protein 3 (IMP-3) is an important factor for cell migration and adhesion in malignancies. Recent studies have shown a remarkable overexpression of IMP-3 in different human malignant neoplasms and also revealed it as an important prognostic marker in some tumor entities. The purpose of this study is to compare IMP-3 immunostaining in cutaneous squamous cell tumors and determine whether IMP-3 can aid in the differential diagnosis of these lesions. To our knowledge, IMP-3 expression has not been investigated in skin squamous cell proliferations thus far. Immunohi-stochemical staining for IMP-3 was performed on slides organized by samples from 67 patients, 34 with keratoacanthoma (KA) and 33 with primary cutaneous squamous cell carcinoma (SCC) (16 invasive and 17 in situ). Seventyfour percent of KAs (25/34) were negative for IMP-3 staining, while 57% of SCCs (19/33) were positive for IMP-3 staining. The percentage of IMP-3 positive cells increased significantly in the invasive SCC group (P=0.0111), and particularly in the SCC in situ group (P=0.0021) with respect to the KA group. IMP-3 intensity staining was significantly higher in invasive SCCs (P=0.0213), and particularly in SCCs in situ (P=0.008) with respect to KA. Our data show that IMP-3 expression is different in keratoacanthoma with respect to squamous cell carcinoma. IMP-3 assessment and staining pattern, together with a careful histological study, can be useful in the differential diagnosis between KA e SCC.

Dermatophyte infections mimicking other skin diseases: a 154-person case survey of tinea atypica in the district of Cagliari (Italy)

Background  Although usually simple, the diagnosis of dermatophyte infection is sometimes neglected. An observational study has been realized to evaluate the role of corticosteroid exposure (tinea incognito) and of other primary characteristics of the dermatophytosis that from onset mimic other diseases and mislead an unexperienced physician.

Leishmaniasis of the lip in a patient with Down's syndrome

Cutaneous leishmaniasis is an endemic protozoan infection in Sardinia, one of the major islands of the Mediterranean Basin. The main causative strain in this country is Leishmania infantum, which rarely involves mucocutaneous areas, but has the potential to cause visceral leishmaniasis. An atypical leishmaniasis involving the inferior lip of a 57‐year‐old female with Downs syndrome was observed at the Dermatology Department of Cagliari (italy). The diagnosis was mainly based upon histopathological examination, revealing intra‐ and extra‐cellular leishmania amastigotes. The leishmania infantum zymodeme MON‐111 was identified by isoenzymatic characterization. Laboratory investigations revealed a normal complete blood count and biochemistry profile, except for an inverted CD4/CD8 ratio. Treatment with meglumine antimoniate 60 mg/kg/day (Glucantime®) intramuscularly for 15 days, followed by intralesional administration 1 ml weekly for 4 weeks led to complete recovery. No relapses were observed at 6‐month follow‐up. The unusual localization is likely to be a reflection of the uncommon site of inoculation of the protozoa, transmitted by bites from flying vectors. Nevertheless, the presence of Downs syndrome in our patient may have contributed to the atypical presentation by traumatic exacerbation of the lesion, due to repeated auto‐induced microtraumas of the inferior lip accompanied by subclinical immunodeficiency. In fact, the specific immune response to Leishmania infection depends on a host‐cell‐mediated immune response, reported as defective in Downs syndrome patients. Differential diagnosis and early detection of the infection are necessary in order to start effective treatment and prevent more serious complications.