Sanja Javor

Erosive pustular dermatosis of the scalp induced by ingenol mebutate

most clinicians are unfamiliar with its use in children. Recently, a 14-year-old adolescent male with psoriasis was reported to improve on ustekinumab, almost completely clearing psoriasis by week 16. Of the 12 to 18-year-olds given ustekinumab for psoriasis in a randomized, phase 3 study, 78.4% on half-standard dosage and 80.6% on standard dosage achieved PASI-75 at 12 weeks. Our 2-year-old patient is the youngest we know of to be treated with ustekinumab. Due to the rapid clinical resolution of her psoriasis, we propose ustekinumab as a successful therapy for young patients with severe, refractory psoriasis. Though large clinical trials will need to be conducted, our report highlights the effectiveness and safety of ustekinumab in this population. Overall, ustekinumab is a promising biologic agent that warrants further investigation in the paediatric population affected by psoriasis.

Atypical exanthems associated with Parvovirus B19 (B19V) infection in children and adults

Parvovirus B19 (B19V) infection may differently manifest in various age groups. Erythema infectiosum (‘fifth disease’) is the most common B19V manifestations in children. Arthralgias and arthritis, with or without rash, are common manifestations of B19V infection in adults. Pruritus is usually present in adults and children. However, other cutaneous manifestations and atypical exanthems have been occasionally reported during B19V infection. To investigate the putative role of B19V infection in atypical exanthems, a total of 390 consecutive patients with atypical exanthems were analysed for B19V infection by determining B19V IgG and IgM antibodies titres in acute and convalescent phase as well as B19V DNA detection in serum by polymerase chain reaction (PCR). Atypical exanthems resulted related to B19V infection in 6 of the 120 pediatric (5%) and 14 of the 270 adult patients (5.2%). In conclusion this study reveals that atypical exanthems related to B19V infection are possible both in children and in adults, with a similar prevalence. J. Med. Virol. 87:1981–1984, 2015.

Endothelin-1 Levels in Scleroderma Patients: A Pilot Study

Endothelin-1 (ET-1) is a potent endogenous vasoconstrictor, which mediates vascular wall cells proliferation, fibrosis, and inflammation through two types of ET-1 receptors (ET-A and ET-B). In our retrospective study the serum levels of ET-1 in 18 systemic sclerosis (SSc) patients with and without digital ulcers (DUs) were assessed to observe possible correlation between the levels of ET-1, the evolution of SSc, and the therapy with an ET-1 antagonist (bosentan). In all our patients, the levels of ET-1 were found higher than normal range and correlate with the severity of the disease. Furthermore we also observed that in patients without DUs the levels of ET-1 were higher and did not correlate with new DUs development. In conclusion, the levels of ET-1 in our studied patients do not correlate with the possible development of DUs. The reduction of ET-1 levels in DUs patients in therapy with bosentan confirms the efficacy of this molecule both for treatment and prevention of digital ulcers. The inhibition of ET-A receptor by its antagonist may activate the opposite ET-B receptors, with well-known function ET-1 degradation and reducing of ET-1 serum level as confirmed in our pilot study.

Vaccine-induced pityriasis rosea and pityriasis rosea-like eruptions: a review of the literature.

References 1 Fein H, Steth AP, Mutasim DF. Cutaneous arteritis presenting with hyperpigmented macules: Macular arteritis. J Am Acad Dermatol 2003; 49: 519–522. 2 Lee JS, Kossard S, McGrath MA. Lymphocytic thrombophilic arteritis, a newly described medium-sized vessel arteritis of the skin. Arch Dermatol 2008; 144: 1175–1182. 3 Sadahira C, Yoshida T, Matsuoka Y, Takai I, Noda M, Kubota Y. Macular arteritis in Japanese patients. J Am Acad Dermatol 2005; 52: 364–366. 4 Saleh Z, Mutasim DF. Macular lymphocytic arteritis: a unique benign cutaneous arteritis, mediated by lymphocytes and appearing as macules. J Cutan Pathol 2009; 36: 1269–1274. 5 Shen S, Williams RA, Kelly RI. Neuropathy in a patient with lymphocytic thrombophilic arteritis. Australas J Dermatol 2013; 54: e28–e32. 6 Llamas-Velasco M, Sanchez-Perez J, Fraga J, Garcia-Diez A. Reply: macular lymphocytic arteritis: letter to the Editor. J Cutan Pathol 2014; 41: 481–481. 7 Al-Daraji W, Gregory AN, Carlson JA. Macular arteritis: a latent form of cutaneous polyarteritis nodosa? Am J Dermatopathol 2008; 30: 145–149. 8 Macarenco RS, Galan A, Simoni PM et al. Cutaneous lymphocytic thrombophilic (Macular) arteritis: a distinct entity or an indolent (reparative) stage of cutaneous polyarteritis nodosa ? Report of 2 cases of cutaneous arteritis and review of the literature. Am J Dermatopathol 2013; 35: 213–219. 9 Kossard S, Lee JS, McGrath MA. Macular lymphocytic arteritis. J Cutan Pathol 2010; 37: 1114–1115.

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.

Localized exanthem due to echovirus 9

Francesco Drago, Giulia Ciccarese,* Francesco Broccolo, Antonio Toniolo, Sanja Javor, and Aurora Parodi Department of Dermatology, IRCCS A.O.U. San Martino-IST, DISSAL, Largo Rosanna Benzi, 1

Pityriasis rosea in a hepatitis b-positive patient treated with pegylated interferon α2a: Report of a case and review of the literature

Pityriasis rosea (PR) is an acute, self-limiting exanthematous disease caused by the endogenous reactivation of human herpesvirus (HHV)-6 and/or HHV-7 infection in conditions of altered immunity. In addition, many drugs have been incriminated as possible triggers of PR-like eruptions, characterized by clinical, morphological and histopathological features that differ from typical PR. Here, we report a case of PR in a patient with chronic hepatitis B, receiving pegylated interferon α2a (PEG-IFN-α2a). PR, arising after the second administration of the PEG-IFN-α2a, might be considered a clinical expression of the patients altered immune condition as reported in the immune reconstitution inflammatory syndrome affecting patients with human immunodeficiency virus infection after high-dose antiretroviral therapy.

Gianotti-Crosti syndrome as presenting sign of cytomegalovirus infection: A case report and a critical appraisal of its possible cytomegalovirus etiology

Gianotti-Crosti syndrome (GCS) is a self-limiting exanthem of acute onset with a characteristic acral distribution, usually occurring in children. It is characterized by symmetric pink to red-brown papular or papulovesicular lesions that are a few millimetres in diameter, distributed on the face, buttocks and limbs. It may be accompanied by low-grade fever, hepato-splenomegaly and lymphadenopathy. GCS is considered a unique cutaneous response to viral infection, mostly associated with hepatitis B virus and Epstein-Barr virus (EBV), but other viruses, bacterial infections and recent immunizations may be inciting factors. We report a case of a 3-year-old girl presenting generalized, pruritic, papulovesicular eruption on the face and extremities for one month. In our case, GCS was related to cytomegalovirus (CMV) primary infection and may be considered the presenting sign of the infection.

Subacute cutaneous lupus erythematosus induced by lansoprazole

A 48-year-old woman presented us with multiple annular erythematous-squamous plaques over trunk and limbs appeared 3 weeks before. There was no mucosal involvement. Her medical history included systemic lupus erythematosus (LES), diagnosed 3 years before and currently no longer treated, and gastroesophageal reflux for which she was in therapy with lansoprazole (30mg/daily) from 2months.Microscopy in 10 % potassium hydroxide and culture for mycoses was negative. Routine laboratory investigations were normal, antinuclear antibodies (ANA) negative, and anti-Ro/SSA antibodies positive (titer 1/80). Histology of an annular lesion showed atrophy of the epidermis, hydropic degeneration of the basal layer, edema in the upper dermis, and perivascular and periadnexial lymphohistiocytic infiltrate, consistent with subacute cutaneous lupus erythematosus (SCLE). A direct immunofluorescence test was negative. The patient received oral methylprednisolone (0.5 mg/kg/daily), topical steroids, and continued lansoprazolewith improvement but without complete resolution of the lesions. Therefore, lansoprazole was suspected to be responsible of the eruption and replaced by alginate and bicarbonate sodium with complete remission in a few days. Hence, diagnosis of drug-induced SCLE (DI-SCLE) was made. SCLE is a subtype of cutaneous lupus erythematosus that usually manifests as annular, psoriasiform lesions with limited systemic involvement and typically associated with positive ANA, anti-Ro/SSA, and anti-La/SSB antibodies. It may also be induced or exacerbated by drugs, including thiazide diuretics, calcium channel blockers, and also proton pump inhibitors (PPI) [1]. DI-SCLE does not differ clinically, histopathologically, or immunologically from idiopathic SCLE even though some authors have emphasized that DI-SCLE presented more disseminated cutaneous manifestations (as in our patient) and more frequent occurrence of malar rash and bullous, targetoid, and vasculitic lesions [1]. Patients with autoimmune diseases are more prone to druginduced or exacerbated SCLE [1], but the pathogenesis of DISCLE is not completely understood. However, it may be correlated to antimicrobial peptides (AMPs), small effector molecules of the innate immune system with well-known antimicrobial activity [2, 3]. In fact, several AMPs are increased in CLE at both gene and protein levels. In particular, AMPs were found to be significantly more highly induced in subacute CLE as compared with discoid LE and LE tumidus [2]. This might also explain the low prevalence of skin infections in CLE [2]. The selectivity of AMPs to bacterial cells relies on their cationic structures that are crucial for the interaction with negatively charged bacterial membranes [3]. Cathelicidins are a family of evolutionarily conserved AMPs, and hCAP-18 is the only cathelicidin in humans. Proteolytic cleavage of this preprotein releases a 37-residue known as LL-37 that is secreted by bone marrow cells, circulating leukocytes, and numerous types of epithelial tissues, such as skin. LL-37 could mediate innate immunity through regulating chemotaxis of leukocytes and production of cytokines at sites of infection/ inflammation as well as promoting re-epithelization during wound healing. LL-37 orients near the surface of phospholipid bilayers and forms oligomeric structures possessing the ability to disrupt cell membrane [3]. Depending on cellular context, autophagy may serve as a pro-death either pro-survival mechanism through p53 activation [3]. Human LL-37 and its derivatives may contribute to the control of immune-mediated inflammatory diseases through the regulation of proand antiinflammatory cytokines [4]. * Sanja Javor javor.med@gmail.com

A Case of Complete Adult-Onset Kawasaki Disease: A Review of Pathogenesis and Classification

Kawasaki disease (KD) is an acute systemic vasculitis that occurs primarily in children and rarely in adults, possibly after bacterial or viral infections in genetically susceptible hosts. KD may frequently be undiagnosed especially in adult patients without the presence of all the classical clinical criteria (incomplete or atypical KD). In addition, many differential diagnoses could be considered. Here, we report a case of KD in an adult patient with clinical features characteristic of the classical form. KD requires a long-term management in both paediatric and adult patients, in order to avoid complications that could follow both the acute and retrospective diagnoses of KD.