P.A. Fanti

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

Idiopathic trachyonychia (twenty‐nail dystrophy): a pathological study of 23 patients

We report the clinical features and pathological findings in 23 patients with idiopathic trachyonychia (twenty‐nail dystrophy). Clinically, the nail changes in the majority of patients consisted of the typical ‘sandapered’ appearance, with a rough, Iustreless nail plate. In some, however, the nail plate abnormality was less severe, with numerous small, superficial pits, which imparted a shiny appearance to the surface of the nail. Histology of nail biopsy specimens showed spongiotic changes in 19 patients, psoriasiform features in three, and features of lichen planus in one patient. The mean follow‐up of these patients was 2 years, during which time none developed alopecia areata or mucocutaneous lesions.

Melanocytic nevi of the breast: a histologic case‐control study

Background:  Melanocytic nevi in the genital, acral, and flexural sites often display clinical and histologic features that may simulate melanoma. We verified whether this is the case also for nevi of the breast.

Granular parakeratosis: four paediatric cases.

Summary Axillary granular parakeratosis (GP) was first described in 1991 as a peculiar eruption presenting with erythematous hyperpigmented and hyperkeratotic papules and plaques of the cutaneous folds frequently associated with pruritus. Histopathology shows a characteristic picture with a conspicuous granular appearance of the parakeratotic horny layer. Until now, only 24 adults, mainly women aged over 40 years, have been reported with GP. We demonstrate that this condition can also occur in young children. Four children aged between 10 and 24 months had asymptomatic hyperpigmented scaling papules 2–3 mm in diameter located on the groin, lower back, buttocks and flanks. In all cases the mothers reported the habit of frequent washing followed by application of many topical products. Biopsy revealed the same features in all four patients: the epidermis showed a thickened horny layer with a unique compact parakeratosis with maintenance of the stratum granulosum and marked retention of keratohyaline granules throughout the stratum corneum.

Telogen Effluvium due to Recombinant Interferon α-2b

Five of 10 patients receiving long-term recombinant interferon α-2b therapy complained of considerable hair loss. The pull test and the trichogram showed a telogen count consistent with a telogen effl

Carcinoma cuniculatum of the Nail Apparatus: Report of Three Cases

Three patients affected by carcinoma cuniculatum involving the nail apparatus are reported. The toes were affected in 2 cases, the thumb in 1 case. In the first patient the tumour developed in the subungual area and resulted in loss of the toe-nail. In the second patient the tumour originated on the dorsum of the toe and subsequently involved the proximal nail fold. In the third patient the tumour developed in the nail bed resulting in loss of the lateral part of the nail plate. The pathology showed in all cases invaginating strands of well-differentiated keratinocytes, some of which had central crypts containing keratinous debris. Radical excision of the tumour required disarticulation of the digit in 2 cases, whereas Mohs micrographic surgery was performed in the third case.

Nail Changes as the First Sign of Systemic Amyloidosis

A 68-year-old man had had for 3 years a severe onychodystrophy involving all fingers and toes which clinically mimicked nail lichen planus. The nail biopsy showed amyloid deposits in the superficial dermis of the nail matrix. Physical, pathological and laboratory examinations confirmed the diagnosis of primary systemic amyloidosis. At the time of the diagnosis the patient did not present any other cutaneous sign of systemic amyloidosis.

Cutaneous Necrosis and Calcinosis Following Electroencephalography

The authors report 2 children who developed circumscribed dystrophic calcifications at the site of electrode placement after electroencephalographic examination. Deep cutaneous necrosis was a prominent clinical feature. A biopsy showed focal dermal calcification confirmed by a diffractometer analysis of a calcific granule. Cutaneous calcinosis is a possible risk of the usage of an electrode paste containing calcium chloride. Prolonged exposure and damaged skin seem to be prerequisites for this uncommon but harmful condition.

Histopathologic features of alopecia areata incognito: a review of 46 cases.

Background: Alopecia areata (AA) incognito represents a variant of AA characterized by acute diffuse hair thinning. Dermoscopy shows yellow dots and short regrowing hairs. The differential diagnosis with telogen effluvium (TE) and androgenetic alopecia may be difficult.

Atrichia and papular lesions: report of a case.

We report a case of atrichia with papular lesions in a 4-year-old girl. The scalp was completely hairless since birth, except for dark, shiny, coarse hair on the frontoparietal region. Eyelashes and eyebrows were sparse. Numerous papular lesions developed on the hairless scalp, cheeks and neck during the second year of life. Teeth and sweating function were normal. The family history was negative. Histologic examination of a papular lesion showed the presence of a keratin-filled cyst in contact with the overlying epidermis. The pathology of the bald scalp showed the presence of tubular epithelial structures devoid of hair bulbs extending from the epidermis to the deep dermis and the superficial hypodermis. Sebaceous and outer root sheath differentiation was evident in most of the tubular structures that also frequently contained small ducts surrounded by two or three layers of flat epithelial cells. The superficial dermis contained horny cysts, similar to those present on the cheeks.