Rosaria Palazzo

Skin pathology findings in a cohort of 1500 adult and elderly subjects

Background No extensive studies are available in the literature on the eventual skin pathology induced by neurologic or systemic diseases in elderly individuals. Other factors, such as health and hygiene, socioeconomic status, and climate can also play an important role.

Chronic heat-induced skin lesions (erythema ab Igne): ultrastructural studies.

Erythema ab igne (EI) is an uncommon skin lesion caused by mild and repeated exposure to infrared sources. The aim of this study was to investigate the ultrastructural alterations in this condition. The ultrastructural study was carried out on 5-outpatients who presented typical EI of their exposed sites. Skin punch biopsies were processed for standard electron microscopy. The epidermis was hyperpigmented, with focal regressive changes of basal keratinocytes. An apparent functional activation of melanocytes with numerical increase of dendritic processes was also observed. The dermis showed abundant melanophages and occasional elastic fiber alterations similar to actinic elastosis. No alterations consistent with preneoplastic skin conditions were observed. The ultrastructural findings associated with EI seem to be nonspecific and consistent with moderate regressive changes of keratinocytes as well as a consensual melanocytic activation and elastic fiber modifications. Similar alterations can be observed in chronic actinic skin damage. This condition is presumably more benign than the ultraviolet exposure.The association of EI and premalignant skin lesions, though occasionally described, seems relatively infrequent.

Failure of fluoxetine to modify the skin‐picking behaviour of Prader‐Willi syndrome

Prader-Willi Syndrome (PWS) is a Multiple Congenital Anomalies/Mental Retardation (MCA/MR) syndrome usually caused by a deletion of paternally derived DNA within the proximal part of the long arm of chromosome 15. Holm et al. summarized a scoring system for the diagnosis of PWS, which included both major and minor malformations, separated by their specificity and frequency. Among the behavioural abnormalities peculiar to PWS, the so-called skin-picking (SP) has been reported in the majority of PWS patients and it appears throughout life constantly or occasionally. We have already reported on this feature, highlighting its pre-eminent position between the dermatological signs in PWS. Behavioural dermatitis in PWS has been successfully treated with fluoxetine. Fluoxetine is a serotonin uptake inhibitor and should also be effective against bulimia and other compulsive–obsessive disorders presented by PWS patients. The average effective dose has been assessed within the 60–80 mg/day range. Our unsatisfactory experience on two adolescents with PWS syndrome is subsequently reported.

CHRONIC CUTANEOUS LEISHMANIASIS MIMICKING SEBOPSORIASIS

Sir, Histological examination of the affected skin showed a granuloma consisting of lymphocytes, plasmacytes and, mostly, A 68-year-old man, on pharmacological substitution therapy for 10 years for the removal of a large pituitary adenoma with histiocytes. The routine blood work-up and the lymphocytic subpopulation assays resulted as normal. asymmetric expansion above the cella turcica, presented with chronic dermatitis of the scalp and face with onset referred 1 The patient was in poor physical condition and was therefore treated intra-lesionally only, with a weekly administration of year earlier. Dermatologists had previously diagnosed it variously as psoriasis, seborrhoeic dermatitis and sebopsoriasis, 1–1.5 ml megumine antemoniate distributed in the areas clinically affected. After six sessions of treatment the patient was but the patient claimed no improvement from the various topical and systemic therapies scrupulously followed. clinically healed. After 2 years of total well-being, he returned to our observaDuring examination, the patient presented diffused scalp erythema and sparse whitish squamous crusts, especially on tion, presenting a clinical symptomatology similar to the one already described, but less severe. Histological slides, prepared the sides. The right ear lobe appeared congested, desquamating and sore, with serous secretion from the retroauricular groove. with the same technique as previously, revealed the presence of parasites outside the macrophages. A subsequent eightThe face was erythematous-edematous, and the skin of the nose was desquamating. A thin, irregular squamous crust session cycle of meglumine antimoniate infiltration therapy resulted in a complete clinical resolution of the lesions. In the adhering to the underlying tissue was observed on the left ala nasi (Fig. 1). Its removal uncovered a serous-producing surlast 6 months, the patient has not had any relapses, but has developed some typical nummular psoriatic lesions on the face, while thin cone-like extensions emerged from the inferior surface of the squamous crust. Tiny pieces of tissue were taken elbows and lower limbs presently treated with topical therapy and heliotherapy. from the borders of the oozing lesion, and May-Grumwald coloured slides were prepared. At the same time, a 3 mm It is well known that focal cutaneous leishmaniasis may manifest itself with different clinical expressions from the diameter tissue sample was punch-removed from the affected right mastoidal area. classical ‘‘oriental sore’’ (1). Recently, some authors have emphasized the rise in sporotrichoid forms with hard, mobile Microscopic examination of the slides revealed the presence of numerous leishmania inside and mostly outside the macrosubcutaneous nodules which appear about a month later than the primary lesion as an indication of parasitic diffusion along phages. For this reason, no culture testing was performed. the lymphatics (2). We believe that our patient can be defined as being affected by ‘‘non-healing’’ (chronic) cutaneous leishmaniasis mimicking sebopsoriasis, a term used to define the presence of welldemarcated scalp plaques with clinical and histopathological characteristics found across psoriasis and seborrhoeic dermatitis. We cannot exclude that the clinical aspect is influenced by an isomorphic type reaction in a patient predisposed to psoriasis. A case of visceral leishmaniasis presenting as a psorasiform eruption in a young male patient affected by AIDS has been reported recently; however, neither the lymphocytic subpopulation assay nor HIV investigation was abnormal in our patient (3).

Failure of colchicine in the treatment of severe acne vulgaris.

Sir, We read with great interest the recent letter by Sadjadi & Moshir (1) concerning the treatment of acne vulgaris with colchicine. The authors reported an improvement in all 22 selected patients after 2 months of administration of a daily dose of 1 mg of colchicine. The effectiveness of the drug was more evident in the patients with severe acne vulgaris. They recommended this drug as a possible replacement for antibiotic therapy of acne. For this reason, in December 1998 we started a similar study on 12 out-patients (10 females, 2 males, age range 14 ± 27 years) affected by severe forms of acne (conglobata and nodular cystic type) and who for various reasons refused oral retinoids. Informed consent was obtained from all the subjects. Before starting the trial, a complete blood work-up was carried out. Colchicine therapy (1 mg/day) was started and maintained for 2 months. At the end of therapy, evaluation showed no improvement in any of the patients and the treatment was stopped. No clinical side-effects (e.g. nausea, pain, vomiting, diarrhoea) were reported and no haematological manifestations were seen. Colchicine is an alkaloid that binds to, and depolymerizes, the microtubular system of cells. Moreover, colchicine inhibits cellular migration (2). The ef®cacy of colchicine is well documented in Behcets disease (3) and its use has recently been suggested for other cutaneous conditions (4 ± 6). Based on our unsatisfactory results, we are of the opinion that the treatment of acne vulgaris with colchicine should be considered very cautiously, although further studies are needed to clarify this matter.

The papulokeratotic type of solitary benign lichenoid keratosis

A 67‐year‐old housewife was referred to us for a papulonodular keratotic lesion on the left side of the left eyebrow ( Fig. 1 ). The lesion had started to develop 6 months earlier and had gradually reached a size of 2 cm in diameter. It was firm, nonitching, and painless on pressure.

Cockayne syndrome and lichen actinicus

The authors describe the case of a young woman aged 22 years admitted to our Institute with a diagnosis of Cockayne syndrome. On admission she presented with a photoexposed dermatitis diagnosed, on the basis of clinical and histological aspects, as lichen planus actinicus. Cockayne Syndrome is characterized by precocious aging and other important signs such as dwarfism, mental retardation, photosensitivity, retinal atrophy and progressive neurological deterioration. The syndrome is autosomal recessive with normal infancy and onset of the first signs of deterioration within the first years of life. Lichen planus actinicus is a typical papular dermatitis of the photoexposed parts found in tropical and Mediterranean regions, which may be conditioned by racial factors. This is the first description in literature of a case of lichen planus actinicus in Cockayne syndrome.