Elongated linear vessels simulating branching vessels and diffuse structureless orange areas as prominent dermoscopic features of diffuse flat facial and extrafacial granuloma faciale: A case series

Dermoscopy can be an important help for the diagnosis of skin cancers and inflammatory cutaneous diseases. The list of the dermoscopic features reported in granuloma faciale is wide and includes vascular and non-vascular features. We report here three cases of diffuse flat facial and extrafacial granuloma faciale that exhibited elongated linear vessels simulating branching vessels and diffuse structureless orange areas. The differential diagnosis between flat-type granuloma faciale, basal cell carcinoma and cutaneous sarcoidosis can be extremely difficult, making histology mandatory before any treatment.

Fetal aortic isthmus Doppler assessment to predict the adverse perinatal outcomes associated with fetal growth restriction: systematic review and meta-analysis

PURPOSE

Fetal growth restriction (FGR) management and delivery planning is based on a multimodal approach. This meta-analysis aimed to evaluate the prognostic accuracies of the aortic isthmus Doppler to predict adverse perinatal outcomes in singleton pregnancies with FGR.

METHODS

PubMed, EMBASE, the Cochrane Library, ClinicalTrials.gov and Google scholar were searched from inception to May 2021, for studies on the prognostic accuracy of anterograde aortic isthmus flow compared with retrograde aortic isthmus flow in singleton pregnancy with FGR. The meta-analysis was registered on PROSPERO and was assessed according to PRISMA and Newcastle-Ottawa Scale. DerSimonian and Laird's random-effect model was used for relative risks, Freeman-Tukey Double Arcsine for pooled estimates and exact method to stabilize variances and CIs. Heterogeneity was quantified using I2 statistics.

RESULTS

A total of 2933 articles were identified through the electronic search, of which 6 studies (involving 240 women) were included. The quality evaluation of studies revealed an overall acceptable score for study group selection and comparability and substantial heterogeneity. The risk of perinatal death was significantly greater in fetuses with retrograde Aortic Isthmus blood flow, with a RR of 5.17 (p value 0.00001). Similarly, the stillbirth rate was found to have a RR of 5.39 (p value 0.00001). Respiratory distress syndrome had a RR of 2.64 (p value = 0.03) in the group of fetuses with retrograde Aortic Isthmus blood flow.

CONCLUSION

Aortic Isthmus Doppler study may add information for FGR management. However, additional clinical trial are required to assess its applicability in clinical practice.

A retrospective observational study on cutaneous adverse events induced by immune checkpoint inhibitors

BACKGROUND

Cutaneous adverse events (CAEs) related to oncological therapies are a common scenario in daily clinical practice.

METHODS

This is a retrospective observational study collecting the data regarding CAEs of patients treated with immune checkpoints inhibitors (ICIs) in four different Italian centers.

RESULTS

Of 323 patients included, 305 were evaluable for this analysis; 182 patients (59.7%) had metastatic cutaneous melanoma (CM), 99 (32.5%) non-small cell lung cancer (NSCLC) and 24 (7.8%) renal cell carcinoma (RCC). The most frequent CAEs that we found, considering all the 305 patients, were pruriginous maculopapular rash (10.2% of the patients), vitiligo-like areas (7.2% of the patients), psoriasiform rash (6.2% of the patients), asymptomatic maculopapular rash (4.6% of the patients), and lichenoid rash (4.3% of the patients). Vitiligo-like areas occurred more frequently in patients with CM, while a lichenoid rash was more frequently observed in patients with RCC. Treatment interruption was related to drug-induced CAEs in 15.4% of melanoma patients and 0.0% of lung and kidney patients. Patients developing a cutaneous adverse event had better overall response rate and higher progression free survival and overall survival than the patients without CAEs.

CONCLUSIONS

Our study brings new information on the characteristics of CAEs related to ICIs treatment in three different types of cancers, CM, NSCLC and RCC.

Stardust Pattern as Evolution of Pigmented Spitz Nevi During Childhood

INTRODUCTION

Spitz nevi (SN) are benign melanocytic proliferations frequently occurring in children. Some pigmented SN with a starburst pattern evolve into the "stardust" one, which is characterized by a central, black to gray, hyperpigmented area and remnants of a brown network at the periphery. These dermoscopy changes are often the first alert to induce excision.

OBJECTIVES

The aim of this study is to enlarge the case series of stardust SN in children, in order to increase confidence with this new dermoscopic pattern and reduce unnecessary excisions.

METHODS

This retrospective observational study was conducted with SN cases received from IDS members. The inclusion criteria were: clinical and/or histopathologic diagnosis of Spitz naevus with starburst appearance in children <12 years old, availability of a dermoscopic image at baseline and after follow-up of at least 1 year, availability of patient data. The dermoscopic images and their changes over time were assessed by three evaluators in consensus.

RESULTS

38 SN were enrolled, with a median age of 7 years and a median FUP duration of 15,5 months. Comparing the evolution with time of FUP, no significant differences were found between growing and involuting lesions in terms of patient age and sex, location and palpability of lesions.

CONCLUSIONS

The long follow-up reported in our study could really support the concept of benignity of changing SN. A conservative approach is acceptable for nevi showing the stardust pattern, because it may be considered a physiological evolution of pigmented Spitz nevus, and urgent surgeries could be avoided.

Pediatric emergency care admissions for somatic symptom disorders during the COVID-19 pandemic

During the COVID-19 pandemic, children and adolescents with psychiatric disorders experienced an exacerbation of their symptoms with more access to the emergency department (ED). However, little is known about the experience of somatic symptom disorders (SSDs) during the COVID-19 pandemic in children. Therefore, we aimed to compare the rates of pediatric ED admissions for SSDs before and during the COVID-19 pandemic and to understand whether the relative risk of ED admissions for SSDs changed between the two periods. We retrospectively enrolled all children between 4 and 14 years admitted for SSDs in the pediatric ED of Santobono-Pausilipon Hospital, Naples, Italy, from March 11th, 2020, to March 11th, 2021 (pandemic period), and in the same time period of the previous year (pre-pandemic period). We identified 205/95,743 (0,21%) children with SSDs presenting in ED in the pre-pandemic year and 160/40,165 (0,39%) in the pandemic year (p < 0.05). Considering the accesses for age, we observed a relative decrease of the accesses for SSDs over 12 years old (IRR 0,59; CI 0,39-0,88), while we found no differences under 12 years old (IRR 0,87; CI 0,68-1,10).   Conclusion: In this study, we found that despite the massive decrease in pediatric admissions due to the COVID-19 pandemic, somatic symptom disorders' admissions to the pediatric ED increased, suggesting an impact of the pandemic also on pediatric psychiatric disorders. What is Known: • During the COVID -19 pandemic, children and adolescents with a psychiatric disorder experienced exacerbation of their symptoms with more accesses in Emergency Department. What is New: • We found that despite the massive decrease of the pediatric admissions due to the COVID-19 pandemic, somatic symptom disorders admissions in healthy children to the pediatric Emergency Department increased ,suggesting an impact of the pandemic also on the pediatric psychiatric disorders.

Subungual Metastasis from Ovarian Cancer: Case Report and Brief Review of the Literature

Introduction

Visceral solid cancers can metastasize in almost any organ, including the skin and its appendages.

Case Presentation

We report here the case of a 19-year-old Caucasian girl carrying a diagnosis of malignant germ cell tumor of the ovary, with pulmonary and brain metastases, that developed a painful red-violaceous subungual papule of the 4th finger of the left hand, associated with an over-curvature of the nail plate. Dermoscopy was characterized initially by different shades of pink and red, while after few weeks, it showed black pigmentation due to subcorneal hematomas, hemorrhagic crusts, and a rainbow pattern. Histology confirmed a diagnosis of a metastasis from a poorly differentiated carcinoma of ovarian origin.

Discussion and Conclusion

A brief review on the diagnosis and treatment of subungual metastases is reported.

Eruptive Non-melanoma Skin Cancers/Squamous Atypia Following Skin Surgery. Report of Two New Cases, Concise Review of the Literature With Special Emphasis on Treatment Options

INTRODUCTION

Eruptive cutaneous squamous cell carcinomas (ESCC), eruptive squamous atypia (ESA) and eruptive keratoacanthomas (EKA) are different terms used to describe the occurrence of multiple cutaneous squamous neoplasms after skin surgery, laser treatment, traumas, such as tattoos, and local or systemic medical treatments. ESCC have been reported to arise at the sites of skin surgery, including the area affected by the primary tumor and split thickness skin graft (STSG) donor and recipient sites.

OBJECTIVES

The aim of this study is to report 2 additional cases of ESCC after skin surgery and make a critical revision of the literature, analyzing the clinical, histological features and outcomes of ESCC after cutaneous surgery.

METHODS

Up to August 2021, according to our systematic review of the literature, we have collected 19 published articles and a total of 34 patients, including our 2 cases.

RESULTS

The results of this review highlight five red flags that clinicians should consider: (i) lower and upper limbs represent the cutaneous site with the highest risk, representing 83,78% of the cases in the literature; (ii) the median time to onset of ESCC is approximately 6 weeks; (iii) primary cutaneous squamous cell carcinomas were completely excised with free margins on histologic examination in the totality of the cases of the literature, and therefore ESCC should not be considered recurrences; (iv) any surgical technique involves a risk to promote ESCC; (v) treatment of ESCC includes medical treatment, surgery or combined surgical and medical treatment.

CONCLUSIONS

This review highlights 5 red flags which could support clinicians in the diagnosis and management of ESCC after skin surgery.

Drug Intake and Actinic Keratosis: A Case-Control Study

Background

Actinic keratosis (AK) is a form of premalignant keratinocyte dysplasia. Recently, the role of photosensitizing drugs in the development of AK has been postulated.

Objective

This study evaluated a possible association between the use of photosensitizing drugs and the development of AK. A secondary aim was to identify a possible association between any medication other than those primarily examined and AK.

Methods

A single-center, case-control study assessed the cumulative drug exposure of 90 patients with AK and 90 controls visiting a dermatology service for other skin ailments. Before the visit, patients were interviewed to collect data on daily therapy and the lag-time of discontinued drugs within the last 2 years, and to record the drug's active ingredient, dosage, and duration of therapy. In addition, sociodemographic characteristics including age, sex, educational level, skin phototype, and cumulative sun exposure habits were gathered.

Results

By logistic regression, exposures to angiotensin II receptor blockers (ARBs) and antiplatelet agents were identified as independent risk factors for the development of AK. ARB intake was associated with AK only at high exposure (OR = 13.6; 95% CI, 2.0-93.8). The use of antiplatelet drugs was borderline, yet not significant, at low exposure (OR = 3.31; 95% CI, 0.86-12.7), but increased in a dose-dependent manner. The strongest correlation was found at the highest cumulative dose (>1100 dose unit-years (OR = 4.38; 95% CI, 1.16-16.6).

Conclusions

High exposure to ARBs and antiplatelet agents may promote AK carcinogenesis in at-risk patients.

Terra firma-forme dermatosis: a systematic review

Terra firma-forme dermatosis (TFFD) is an acquired pigmentation disorder that promptly regresses after applying isopropyl alcohol 70%. The clinical presentation ranges from patches of brownish discoloration to velvety hyperkeratotic plaques. Critical analyses of current data are lacking, so etiologies, pathogenesis, and disease associations are still debated in the literature. A literature search was done in the PubMed and Google Scholar databases to identify the published papers reporting clinical cases of TFFD. Of 102 papers screened, 64 met the including criteria. Overall, the records of 256 patients presenting a mean age of 18.34 years and a female:male ratio of 1:37 were reviewed. The present article aims to provide a key point-summary regarding the clinical outcome, associated comorbidities, pathogenesis, histopathology, dermoscopy, and therapeutic modalities of TFFD.

High dose brachytherapy with non sealed 188Re (rhenium) resin in patients with non-melanoma skin cancers (NMSCs): single center preliminary results

Background and aim

High dose brachytherapy using a non sealed ¹⁸⁸Re-resin (Rhenium-SCT®, Oncobeta® GmbH, Munich, Germany) is a treatment option for non-melanoma skin cancer (NMSC). The aim of this prospective study was to assess the efficacy and the safety of a single application of Rhenium-SCT® in NMSC.

Materials and method

Fifty consecutive patients (15F, 35 M, range of age 56–97, mean 81) showing 60 histologically proven NMSCs were enrolled and treated with the Rhenium-SCT® between October 2017 and January 2020. Lesions were located on the face, ears, nose or scalp (n = 46), extremities (n = 9), and trunk (n = 5). Mean surface areas were 7.0 cm² (1–36 cm²), mean thickness invasion was 1.1 mm (0.2–2.5 mm), and mean treatment time was 79 min (21–85 min). Superficial, mean, and target absorbed dose were 185 Gy, 63 Gy, and 31 Gy respectively. Patients were followed-up at 14, 30, 60, 90, and 180 days posttreatment, when dermoscopy and biopsy were performed. Mean follow-up was 20 months (range 3–33 months). Early skin toxicity was classified according to Common Terminology Criteria for Adverse Events (CTCAE). Cosmetic results were evaluated after at least 12 months according to Radiation Therapy Oncology Group (RTOG) scale.

Results

At 6 months follow-up, histology and dermoscopy were available for 54/60 lesions, of which 53/54 (98%) completely responded. One patient showed a 1-cm² residual lesion that was subsequently surgically excised. Twelve months after treatment, 41/41 evaluable lesions were free from relapse. Twenty four months after treatment, 23/24 evaluable lesions were free of relapse. In 56/60 lesions early side effects, resolving within 32 days were classified as grades 1–2 (CTCAE). In the remaining 4/60 lesions, these findings were classified as grade 3 (CTCAE) and lasted up to 8–12 weeks but all resolved within 90 days. After at least 12 months (12–33 months), cosmetic results were excellent (30 lesions) or good (11 lesions).

Conclusion

High dose brachytherapy with Rhenium-SCT® is a noninvasive, reasonably safe, easy to perform, effective and well-tolerated approach to treat NMSCs, and it seems to be a useful alternative option when surgery or radiation therapy are difficult to perform or not recommended. In our population 98% of the treated lesions resolved completely after a single application and only one relapsed after 2 years. Larger patients’ population and longer follow-up are needed to confirm these preliminary data and to find the optimal dose to administer in order to achieve complete response without significant side effects.

Terra firma-forme dermatosis

Terra firma-forme dermatosis is an underreported acquired pigmentation disorder caused by keratinocyte retention that is not mentioned in many textbooks. It is characterized by the onset of asymptomatic hyperpigmented patches or velvety plaques potentially involving any part of the body, including the trunk, extremities, and the skin folds such as neck, axilla, inguinal region, and umbilical folds. It affects both sexes equally and all age groups, although it seems more prevalent in children with a mean age of 10.4 years. The prompt regression after rubbing with an alcohol-soaked gauze is diagnostic and curative. The cause of this affection remains unknown, although less rigorous hygiene or an atopic background is contributory.

Cauliflower-like exophytic mass on the skin: polypoid melanoma. Clinical, dermoscopic, and histologic features

Polypoid melanoma is a variant of nodular melanoma, whose poor prognosis depends on its thickness and the presence of ulceration at the time of diagnosis. The authors report two cases of polypoid melanoma, presenting as broad, cauliflower-like, polypoid masses. Dermoscopy was characterized by a multicolored pattern, atypical polymorphic vessels, and the fiber sign. Clinical and dermoscopic features can help to diagnose polypoid melanoma and exclude other possible differential diagnoses. However, histology remains mandatory to confirm the diagnostic suspicion.

Scalp hair whorl patterns in patients affected by Neurofibromatosis Type 1: A case-control study

Background

The hair whorl denotes the spiral disposition of hairs around an axis, which is determined by the follicle growing direction. Atypical variants of scalp hair patterns, identified by abnormally placed or multiple whorls, have been associated with early brain developmental disorders and several dysmorphic syndromes.

Materials and Methods

A 6-month case-control, prospective monocentric study included an overall number of 557 children. A logistic regression analysis was performed to evaluate the relationship between localization, the number of scalp hair whorls, and their association with neurofibromatosis type 1 (NF1).

Results

NF1 positively correlates with a frontal localization, whereas a negative association was found with a parietal whorl pattern (P < 0.001).

Conclusion

Evaluation of scalp whorls gains importance in the neonatal settings and may contribute to suspect the early diagnosis of NF1, as the related National Institutes of Health diagnostic criteria cannot be usually observed at an early age.

Sonographic features of vaccination granulomas in children with delayed-type hypersensitivity to aluminum

In this article, we report the sonographic features of vaccination granulomas in three children sensitized to aluminum. Although the recognition of the vaccination granuloma relies on the clinical examination, misdiagnosis is frequent, leading to distressful procedures or prolonged antibiotic administration. In all our cases, sonography revealed a teardrop-shaped echogenic central structure, suggesting the deposition of aluminum crystals along the route of administration with consequent subcutaneous degenerative changes, and a surrounding hypoechoic cap, which reflects the changeable inflammatory reaction and the granuloma formation.

Disseminate Recurrent Folliculitis and Hidradenitis Suppurativa Are Associated Conditions: Results From a Retrospective Study of 131 Patients With Down Syndrome and a Cohort of 12,351 Pediatric Controls

Background

Hidradenitis suppurativa (HS) is a chronic, inflammatory, recurrent skin disease of the pilosebaceous unit characterized by protean manifestations. Several studies have found an increased incidence and earlier presentation of this disease in patients carrying trisomy 21. Patients with Down syndrome (DS) have a higher risk of developing a wide range of cutaneous manifestations, including HS and chronic folliculitis. Recently, disseminate recurrent folliculitis (DRF) has been reported as an atypical monosymptomatic feature of HS at its onset.

Objective

To assess the prevalence of HS and DRF by comparing a cohort of patients carrying trisomy 21 vs pediatric controls.

Methods

A retrospective 2-year monocentric clinical study was performed by collecting clinical data of 131 patients with DS, aged 4-36 years, followed at the Dermatology Unit and Down Syndrome Regional Center of Bologna University. Data were matched with those coming from 12,351 pediatric controls.

Results

In DS patients, DRF and HS showed a prevalence of, respectively, 6.8% and 24.4%, while 5.3% of patients presented both diseases. In the control group the prevalence for HS+ and DRF+ was 0.5% and 1.2%, respectively, with a 0.14% of overlap cases. The association between HS and DRF proved to be statistically significant in both groups (P < 0.05). In the DS cohort the mean age of symptoms onset was 15.67 (SD: 2.29) years for HS and 13.11 (SD: 4.93) years for DRF. Buttocks were the most frequently affected body area for DRF followed by the inguinocrural area, while in HS buttocks were less frequently involved than groins and upper thighs.

Conclusions

Because of the later onset of HS, patients with DRF at an early age should be monitored for the possible onset of HS in the apocrine-bearing areas.

Dermoscopy of subungual red comets associated with tuberous sclerosis complex

We report here our experience on the use of dermoscopy for the detection of subungual red comets, which are sometimes present in the nails of patients affected by tuberous sclerosis complex. Dermoscopy allowed us to visualize, with better resolution than the naked eye, very tortuous capillaries surrounded by a whitish halo and close parallel binary tortuous capillaries. In some cases, subungual red comets are associated with the presence of periungual or subungual fibromas, but their exact pathogenesis remains unknown.