Laura Bartoli

Perineal extramammary Paget disease responsive to topical imiquimod

Extramammary Paget disease (EMPD) is a rare neoplasm that arises in skin rich in apocrine glands, such as the axillae and anogenital region and usually affects the elderly. In most cases, EMPD is an apocrine carcinoma in situ, but it can be associated with internal malignancy spreading to overlying skin. Surgical excision with margin control is the generally accepted standard of care. A 74‐year‐old woman presented with a 1 year history of a pruritic eczematous eruption in perineum which on biopsy was diagnosed as EMPD. Because of the location and extent of the tumor, any surgical approach would have been problematic. Imiquimod 5% cream applied three times weekly for 16 weeks induced complete resolution. Topical imiquimod appears to be a promising treatment option for EMPD, especially when surgery is a challenge, but only a few cases have been reported.

Perinealer extramammärer Morbus Paget: Ansprechen auf topisches Imiquimod

Extramammary Paget disease (EMPD) is a rare neoplasm that arises in skin rich in apocrine glands, such as the axillae and anogenital region and usually affects the elderly. In most cases, EMPD is an apocrine carcinoma in situ, but it can be associated with internal malignancy spreading to overlying skin. Surgical excision with margin control is the generally accepted standard of care. A 74-year-old woman presented with a 1 year history of a pruritic eczematous eruption in perineum which on biopsy was diagnosed as EMPD. Because of the location and extent of the tumor, any surgical approach would have been problematic. Imiquimod 5 % cream applied three times weekly for 16 weeks induced complete resolution. Topical imiquimod appears to be a promising treatment option for EMPD, especially when surgery is a challenge, but only a few cases have been reported.

Successful treatment of localized pyoderma gangrenosum with topical pimecrolimus.

Journal of Cutaneous Medicine and Surgery, Vol 16, No 5 (September/October), 2012: pp 295-297 295 regularly administered for 3 years. The sites of injection of interferon were the abdominal wall and the buttocks. On physical examination, the ulcerative lesion showed bluish, raised, undermined edges with a halo of erythema and a reddish, granulomatous center partially covered by fibrin (Figure 1). The greater diameter measured approximately 4 ern. A biopsy from the border of the lesion showed an epidermis with acanthosis, ulceration, and a diffuse mixed inflammatory infiltrate, with abundant neutrophils in the dermis. The histologic picture was compatible with the clinical diagnosis of PG. A fungal or mycobacterial infection was ruled out by skin cultures and periodic acid-Schiff and Fite stains. Bacteriologic culture was positive for Staphylococcus aureus. Further serologic and instrumental investigations excluded concurrent hematologic or bowel diseases. The patient underwent oral treatment with ciprofloxacin 1 gld for 7 days to eradicate the bacterial infection and gentle debridement of the ulcer with 0.5% silver nitrate baths. Afterward, pimecrolimus cream 1% (Elidel, Novartis Farma, Italy) was applied twice daily into and around the ulcer. After 21 days, significant improvement with a reduction in ulcer size, pain, and perilesional inflammation was evident (Figure 2). Complete healing was observed 6 weeks after starting pimecrolimus (Figure 3). The treatment was well tolerated, without any adverse effect. The ulcer remained healed at 8 months. Although PG is frequently associated with many conditions, the association with multiple sclerosis has up to now been described in only two cases. In one report, the patient presented with PG, ulcerative colitis, multiple sclerosis, and ankylosing spondylitis, whereas in another case, PG was associated solely with multiple sclerosis .9.10 Due to its rarity, this combination may be fortuitous. In addition, it appears unlikely that IFN-~-lb treatment may have enhanced the occurrence of PG in our patient because this drug had been administered for 3 years, and administration continued regularly during the course of PG and after clearing. Recently, there have been several reports on the efficacy of topical tacrolimus in the management of PG.6•7,1114 This agent has been successfully used as monotherapy for early lesions of PG and may be beneficial in combination with systemic immunosuppressants, including corticosteroids and cyclosporine, in the management of more severe and advanced lesions. In addition, topical tacrolimus (with or without occlusion) Successful Treatment of Localized Pyoderma Gangrenosum with Topical Pimecrolimus

Topical tacrolimus in the treatment of granuloma faciale

that distinguishes among the classical, the malignancyassociated, and the drug-induced form of SS. However, there are various atypical forms of SS that have been reported so far. Unusual clinical variants include neutrophilic dermatosis of the dorsal hands and SS with bullous or pustular lesions. Although SS with bullous lesions is well known, SS with pustules is uncommon. To our knowledge, a case with numerous and disseminate plaques accompanying erosion or pustules mimicking vasculitis or bullous disease, which were more numerous on the legs than the face, arms, and trunk, has not been reported yet. In addition, it is also atypical for SS that this patient had been afebrile in his long clinical course despite his extensive skin lesions.

Oral verrucous carcinoma treated with imiquimod 5% cream and carbon dioxide laser

ejd.2011.1397 Auteur(s) : Roberto Cecchi r.cecchi@usl3.toscana.it, Laura Bartoli, Luigi Brunetti, Mario Pavesi U.O. Dermatologia, Ospedale di Pistoia, V. Matteotti 1, 51100 Pistoia, Italy Oral verrucous carcinoma (VC), also called oral florid papillomatosis, is a rare variant of squamous cell carcinoma, which can affect the oral mucosa, gingiva, tongue, floor of the mouth, and lips [1]. It generally discloses an indolent behaviour, with a slow expanding growth, and minimal metastatic potential. [...]

Micrographic surgery (fresh-tissue Tübingen technique) for treatment of basal cell carcinoma of the head: A single-centre report

Dear Editor, Basal cell carcinoma (BCC) is the most common malignancy in humans. It often arises on sunexposed areas of the head and neck, where it may be locally aggressive and invade vital structures. The biological behavior of BCC depends on its histological pattern and clinical features, including the anatomical site, size and whether it is primary or recurrent. Although a variety of surgical and nonsurgical treatment modalities are available for BCC, micrographic surgery (MS) is one of the most effective methods. The procedure warrants a high cure rate, minimizing healthy tissue sacrifice. It has become the treatment of choice particularly for high-risk BCC. Reported recurrence rates with Mohs’ micrographic surgery (MMS) range 1–3% for primary tumors and 5–7% for recurrent tumors in different studies. A recent prospective study by Leibovitch et al. on a series of 3370 patients with BCC treated with MMS found a 5-year recurrence rate of 1.4% for primary and 4.0% for recurrent tumors. Although standard MMS is the most widely used MS technique, several variants of this procedure have been developed. The common denominator of all these methods is a complete, 3-D control of excised skin tumor margins. The Tübingen technique is a variant of MMS, that was introduced in 1984 by Breuninger and generally uses routine histology on paraffin-embedded sections. This procedure provides a complete microscopic margin control through the use of vertical surface sections of the full perimeter of the excised tumor. In addition, horizontal strips are taken from the tumor base. We report our preliminary experience with this procedure, that has been modified using fresh/ frozen sections in a group of patients with BCC of the head region. All patients had completed a 3-year follow up. A retrospective study of 60 patients (40 men and 20 women; mean age, 65.5 years; median, 64 years; range, 38–87 years) with 60 BCC of the cephalic region, treated by fresh-tissue Tübingen micrographic technique between June 2002 and November 2004 was carried out. The diagnosis of BCC was clinical or in some cases histological. Selection criteria for MS were tumors with ill-defined clinical margins (>90% of cases), recurrent or incompletely excised tumors, high-risk anatomic sites (perioral, nasolabial, periorbital, nasal ala), or biopsy-proven aggressive histological pattern (infiltrating, morpheaform, baso/squamous). Primary BCC were 32 (53.3%) and recurrent BCC were 28 (46.7%). Most of the tumors were located on the nose or perinasal area (45.0%, n = 27), and on the forehead or temporal area (15.0%, n = 9). Mean tumor size was 1.4 cm (range, 0.7–4.6 cm), with 25% of lesions having a diameter of more than 2 cm. The mean number of MS stages required for complete tumor resection was 1.65 (range, 1–4 stages). In 48.3% (n = 29) of cases, BCC were eradicated in one MS stage, while in 41.7% (n = 25) of patients two stages were necessary. Only two patients required four stages of surgery for histologically clear margins. The mean defect size was 2.6 cm (range, 1.0–6.2 cm). None of the patients showed recurrence during a mean follow up of 53.2 months (median, 53 months; range, 39–68 months). Patient characteristics and results of MS are given in Table 1. All procedures were performed under local anesthesia, without any relevant complication. The functional and cosmetic results were quite satisfactory. In conclusion, our experience supports the feasibility and effectiveness of the fresh-tissue Tübingen technique in the treatment of BCC. The method

Epididymal more than testicular abnormalities are associated with the occurrence of antisperm antibodies as evaluated by the MAR test

STUDY QUESTION Is there any association between mixed antiglobulin reaction (MAR) test positivity and clinical features or genital tract ultrasound (US) parameter values in males of infertile and fertile couples? STUDY ANSWER In males of infertile and fertile couples MAR test positivity was associated with clinical and US features suggestive of chronic epididymal inflammation. WHAT IS KNOWN ALREADY MAR test positivity has been more often reported in males of infertile couples than in fertile men. A positive MAR test has been detected in men with a history of testicular or post-testicular damage. No previous study has reported US alterations related to MAR test positivity. This is the first study that has systematically evaluated associations between a positive MAR test and clinical, seminal and US characteristics of the entire male genital tract. STUDY DESIGN, SIZE, DURATION This cross-sectional analysis included 109 fertile men and 699 consecutive subjects seeking medical care for couple infertility from September 2012 to September 2017. PARTICIPANTS/MATERIALS, SETTING, METHODS All subjects underwent, in our outpatient clinic, a complete physical, endocrine, scrotal and transrectal US evaluation and semen analysis (including sIL-8) on the same day. Of the 699 males of infertile couples, 181 (age 38.6 ± 6.6 years) had an assessable MAR test, whereas the test was assessable in all 109 fertile men (age 36.6 ± 5.2 years). The associations among MAR test positivity and the other studied parameters were investigated on a caseload of 290 men (patients + fertile men) and in the two cohorts of males of infertile and fertile couples. MAIN RESULTS AND THE ROLE OF CHANCE Of the 181 men of infertile couples studied, 20 (11%) had a positive MAR test, including 12 (6.6%) who had a MAR test ≥ 50%, which is considered as a pathological threshold according to the WHO. Of the 109 fertile men, four (3.7%) had a positive MAR test, of which one (0.9%) had a MAR test ≥ 50%. MAR test positivity was therefore found more often in men of infertile couples (P < 0.05). In the entire caseload (n = 290) of males of both infertile and fertile couples, no correlations between MAR test positivity and seminal characteristics were observed. A positive MAR test was associated with epididymal US abnormalities, particularly with the mean size of the epididymal body and tail (both P < 0.0001), and in infertile men, a positive MAR test was also associated with an abnormal epididymal echotexture. In addition, subjects with a positive MAR test more frequently showed a history of epididymitis and high sIL-8 levels. Considering endocrine parameters, only a positive correlation between MAR test positivity and LH levels was observed, even after adjusting for age and life-style factors (adj. r = 0.232, P < 0.0001), while no associations with testosterone and FSH levels were found. LIMITATIONS, REASONS FOR CAUTION Antisperm antibodies (ASA) were detected in this study by using the SpermMAR test IgG, but other tests are available. In addition, for technical reasons, the MAR test is not assessable in subjects with severe oligo-astheno-zoospermia and, therefore, this test may lead to an intrinsic selection bias. Finally, owing to the cross-sectional nature of the study, neither a causality hypothesis nor mechanistic models can be inferred. WIDER IMPLICATIONS OF THE FINDINGS First, our results indicate that MAR test positivity is associated with clinical and US signs suggestive of chronic epididymal inflammation and not testicular damage. Hence, when investigating a subject with a positive MAR test, the epididymis and not just the testis should be evaluated. Furthermore, MAR test positivity was more often detected in males of infertile couples than in fertile men, but it was not associated with conventional semen parameter values. Our data support a role of ASA in couple infertility, regardless of the conventional sperm analysis. How ASA affects couple fertility needs to be addressed by further studies. STUDY FUNDING/COMPETING INTEREST(S) Grants were received from the Ministry of University and Scientific Research (SIR project to F.L., protocol number: RBSI14LFMQ). There are no conflicts of interest. TRIAL REGISTRATION NUMBER N/A.

Repair of a large lateral foot defect with a combination of keystone island flap and V-Y plasty

Reconstruction of foot defects, not possible with primary closure, is often challenging, because the skin at this level is tight and difficult to mobilize. Traditional random pattern cutaneous flaps also have a limited role for the restoration of small and middle-sized wounds, because of the high risk of complications, such as flap necrosis and dehiscence. Skin grafts are widely used to cover large losses in non-weight-bearing sites, although they tend to heal slowly and result in poor outcomes [1]. [...]

The helix flap in the reconstruction of circular skin defects

ejd.2012.1791 Auteur(s) : Roberto Cecchi r.cecchi@usl3.toscana.it, Laura Fancelli, Laura Bartoli, Luigi Brunetti, Michela Troiano, Mario Pavesi U.O. Dermatologia, Ospedale di Pistoia, V. Matteotti 1, 51100 Pistoia, Italy Surgical removal of skin tumours generally originates circular defects, which may be challenging whenever they are not amenable to primary closure. Flap procedures, such as advancement, rotation, interpolation, transposition, skin grafting and combinations thereof can be utilized [...]

Ferris Smith technique for full-thickness oral commissure defect

Auteur(s) : Roberto Cecchi, Laura Bartoli, Luigi Brunetti, Mario Pavesi UO Dermatologia, Ospedale di Pistoia, V. Matteotti 1, 51100 Pistoia, Italy Satisfactory reconstruction of defects affecting the lip commissure is always challenging. Several reconstructive procedures, with the use of both local flaps and more complex distant free flaps, have been reported, with variable results [1, 3]. Here, we present an elderly patient with a squamous cell carcinoma (SCC) of the lip commissure, subjected [...]