Epidemiological and clinical analysis of exposure-related factors in non-melanoma skin cancer: A retrospective cohort study

BACKGROUND

The incidence of non-melanoma skin cancers (NMSCs) increased over last decades, probably due to environmental concerns or to the increase of frail patients with age related comorbidities. Currently, the relationship of increasing global skin cancer rates with increased ultraviolet radiations (UVRs) resulting from stratospheric ozone depletion, global warming, and air pollution from fossil-fuel combustion.

AIMS

We conducted a retrospective epidemiological study including 546 NMSC patients managed at the Dermatology Unit of the Tor Vergata Hospital to highlight different trends of sun exposure or different comorbidities.

METHODS

Descriptive and inferential statistical analyses were performed to evidence differences between continous variable and Spearman rank test for dicotomical variables. Charlson Comorbidity Index was calculated to obtain the 10-years survival rate in order to identify the mean comorbidity burden of our patients.

RESULTS

Considering patients with comorbidities (73.81%), actinic keratoses (AKs) was the most frequent lesion. In patients with a history of previous melanoma, basal cell carcinoma (BCC) was predominant (ANOVA test, p < 0.05) with a statistically significant correlation (rho = 0.453; p < 0.01). Squamous cell carcinoma (SCC) showed a higher rate in arterial hypertension patients, followed by the chronic heart failure and hematologic neoplasms (60%, 29.7% and 32.1%, respectively) groups. Men were more affected than women, representing 61.54% of patients. Chronic sun exposure is directly correlated with SCC rho = 0.561; p < 0.01), whereas BCC correlated with a history of sunburns (rho = 0.312; p < 0.05).

CONCLUSIONS

History of photo-exposition had an important role on NMSC development especially for work or recreational reasons. Sex, age, and presence of comorbidities influenced different NMSC types. BCC was more frequent in younger patients, associated with melanoma and sunburns. The presence of SCC is associated with older patients and the hypertension group. AKs were diagnosed predominantly in oldest men, with a chronic sun-exposure history, and hematologic neoplasms group.

Stenotrophomonas maltophilia skin infection in an immunocompetent patient: Primary cutaneous CD30+ T-cell lymphoproliferative disorder or pseudolymphoma?

Cutaneous pseudolymphomas are a wide group of diseases mimicking cutaneous lymphoma. They comprise several skin conditions with different etiopathogenesis, clinical-pathological features, and prognosis, which may occur in the absence of an identifiable trigger factor or after administration of medications or vaccinations, tattoos, infections, or arthropod bites. They present with different manifestations: from solitary to regionally clustered lesions, up to generalized distribution and, in rare cases, erythroderma. They persist variably, from weeks to years, and resolve spontaneously or after antibiotics, but may recur in some cases. CD30+ T-cell pseudolymphomas are characterized by the presence of large, activated lymphoid cells, generally in response to viral infections, arthropod assault reactions, and drug eruptions. Stenotrophomonas maltophilia is a ubiquitous Gram-negative bacillus responsible for opportunistic infections in immunocompromised patients. Infection of intact skin in immunocompetent patients is particularly rare. Here, we report a case of a man presenting an isolated nodule histopathologically mimicking a primary cutaneous CD30+ T-cell lymphoproliferative disorder.

Increased Occurrence of Cutaneous Leiomyomas and Dermatofibromas in Patients with Uterine Leiomyomas without Fumarate Hydratase Gene Mutations

Leiomyomas are smooth muscle-derived benign neoplasms that can affect all organs, most frequently in the uterus. Fumarate hydratase gene (FH) mutation is characterised by an autosomal dominant disease with increased occurrence of renal tumours, but also by cutaneous (CLs) and uterine leiomyomas (ULs). So far, an increased occurrence of skin tumours in non-mutated patients with ULs has not been verified. To this aim, a case-group of women who were FH non-mutated patients surgically treated for ULs (n = 34) was compared with a control-group (n = 37) of consecutive age-matched healthy women. The occurrence of skin neoplasms, including CLs and dermatofibromas (DFs), was evaluated. Moreover, the microscopic features of FH non-mutated skin tumours were compared with those of an age-matched population group (n = 70) who presented, in their clinical history, only one type of skin tumour and no ULs. Immunohistochemical and in vitro studies analysed TGFβ and vitamin D receptor expression. FH non-mutated patients with ULs displayed a higher occurrence of CLs and DFs (p < 0.03 and p < 0.001), but not of other types of skin tumours. Immunohistochemistry revealed a lower vitamin D receptor (VDR) expression in CLs and DFs from the ULs group compared with those from the population group (p < 0.01), but a similar distribution of TGFβ-receptors and SMAD3. In vitro studies documented that TGFβ-1 treatment and vitamin D3 have opposite effects on α-SMA, TGFβR2 and VDR expression on dermal fibroblast and leiomyoma cell cultures. This unreported increased occurrence of CLs and DFs in FH non-mutated patients with symptomatic ULs with vitamin D deficiency suggests a potential pathogenetic role of vitamin D bioavailability also for CLs and DFs.

Topical Treatment of Actinic Keratosis and Metalloproteinase Expression: A Clinico-Pathological Retrospective Study

Actinic keratosis is an intraepithelial proliferation of atypical keratinocytes that could progress into invasive squamous cell carcinoma. Most evidence suggests an important role of the dermal matrix metalloproteinases in the progression of atypical skin epithelial lesions. We evaluated the clinical efficacy of three different therapeutic modalities (a medical device containing 0.8% piroxicam cream and 50+ sunscreen, photodynamic therapy, and ingenol mebutate gel) to treat suspicious actinic keratoses, which were biopsied for histopathological examination and then analyzed for the expression of matrix metalloproteinases by immunohistochemistry. Clinical, dermoscopic, and reflectance confocal microscopy evaluations revealed a gradual decrease in all standard scores validated for actinic keratosis assessment at the end of the treatments. From a histopathological point of view, we documented the substantial restoration of normal skin architecture, while the immunohistochemical evaluation of matrix metalloproteinases showed a reduction in expression in the treated skin lesions compared to the baseline. As actinic keratoses are considered the precursors of squamous cell carcinoma, their treatment is crucial to prevent the development of a more aggressive disease. Our study monitored the evolution of actinic keratoses subjected to three different topical therapies, with the value of correlating clinical and histopathological findings. Moreover, as the matrix metalloproteinases are largely recognized factors involved in the pathogenesis and evolution of actinic keratosis to squamous cell carcinoma, the demonstration by immunohistochemistry of a reduction in their expression after the treatments adds new valuable concern to the field.

Early clinical response to 5-fluorouracil 0.5% and salicylic acid 10% topical solution in the treatment of actinic keratoses of the head: an observational study

BACKGROUND

Actinic keratosis is one of the most common dermatological disorders. A new topical solution, constituted by 0.5% 5-fluorouracil and 10% salicylic acid (Actikerall, Almirall) has been introduced in the treatment pipeline of non-hyperkeratotic actinic keratoses of the head and neck.

PATIENTS AND METHODS

We analyzed in an observational prospective clinical study the short-term treatment effectiveness of 5-fluorouracil and salicylic acid on face and scalp actinic keratoses of grade 1 and 2 of forty patients. Efficacy assessment was performed by clinical dermatological examination, collecting color photographs, calculating AKASI score, and by means of dermoscopy for each target lesion at every visit.

RESULTS

AKASI score decreased from an initial score of 3.3 to a final score of 0.9. At week 4, we were able to record a complete clearance of 50% of the treated lesions and a partial clearance of 28%. At the end of 12 weeks, 84% of the total lesions showed complete clearance, while 8% had partial clearance.

CONCLUSIONS

5-fluorouracil and salicylic acid topical solution is effective in the treatment of mild to moderate actinic keratoses. In the future, further studies are needed to evaluate the chance of adjusting drug dosage according to patients' and actinic keratoses features.

The Role of Glutathione-S Transferase in Psoriasis and Associated Comorbidities and the Effect of Dimethyl Fumarate in This Pathway

Psoriasis vulgaris is a chronic inflammatory skin disease characterized by well-demarcated scaly plaques. Oxidative stress plays a crucial role in the psoriasis pathogenesis and is associated with the disease severity. Dimethyl fumarate modulates the activity of the pro-inflammatory transcription factors. This is responsible for the downregulation of inflammatory cytokines and an overall shift from a pro-inflammatory to an anti-inflammatory/regulatory response. Both steps are necessary for the amelioration of psoriatic inflammation, although additional mechanisms have been proposed. Several studies reported a long-term effectiveness and safety of dimethyl fumarate monotherapy in patients with moderate-to-severe psoriasis. Furthermore, psoriasis is a chronic disease often associated to metabolic comorbidities, as obesity, diabetes, and cardiovascular diseases, in which glutathione-S transferase deregulation is present. Glutathione-S transferase is involved in the antioxidant system. An increase of its activity in psoriatic epidermis in comparison with the uninvolved and normal epidermal biopsies has been reported. Dimethyl fumarate depletes glutathione-S transferase by formation of covalently linked conjugates. This review investigates the anti-inflammatory role of dimethyl fumarate in oxidative stress and its effect by reducing oxidative stress. The glutathione-S transferase regulation is helpful in treating psoriasis, with an anti-inflammatory effect on the keratinocytes hyperproliferation, and in modulation of metabolic comorbidities.

Experimental Pharmacological Management of Psoriasis

Psoriasis is a chronic, relapsing, immune-mediated systemic disease. Its pathogenesis is complex and not fully understood yet. Genetic and epigenetic factors interact with molecular pathways involving TNF-α, IL-23/IL-17 axis, and peculiar cytokines, as IL-36 or phosphodiesterase 4. This review discusses the mechanisms involved in the development of the disease, as well as the therapeutic options proposed following the investigation of the inflammatory psoriatic pathways. We performed a comprehensive search using the words “psoriasis” and the newest molecules currently under investigation and approval. From these data, a new scenario in psoriasis is occurring to personalize the therapies - especially systemic ones and those using small molecules – and avoid topical and injectable drugs. We reported the newest therapeutic opportunities, including the inhibitors of Janus kinase/tyrosine kinase 2, phosphodiesterase-4 and IL-36 receptor. Today, more than 20 molecules are under investigation for the treatment of cutaneous psoriasis. Most of them are constituted by small molecules or biologic therapies. This underlines how psoriasis needs systemic therapies, due to its complex pathogenesis and multisystemic involvement.

Effectiveness of a cosmetic device containing a combination of alpha- and beta-hydroxy acids, urea, and thuja for the treatment of seborrheic keratoses

BACKGROUND

Seborrheic keratosis is a benign epidermal tumor of cosmetic concern-as it progressively increases in size, thickness, and pigmentation-on which topical treatments are poorly effective. Considering its keratotic component, effective products may include active principles with keratolytic action.

AIMS

Evaluate the efficacy and tolerability of a topical cosmetic product with urea and hydroxy acids, in the treatment of seborrheic keratoses.

PATIENTS AND METHODS

Twenty patients were enrolled in an observational, prospective, open-label study. The topical device was applied on seborrheic keratoses twice daily for 30 days. We evaluated the progression of the treatment by clinical examination-using Daily Life Quality Index-and epiluminescence microscopy at baseline and day 30.

RESULTS

After 30 days of treatment, we documented a significant reduction in seborrheic keratosis thickness and number, which was confirmed also by epiluminescence microscopy. On day 30, global Daily Life Quality Index improved by 99.95%. The tolerability of the cosmetic device was considered excellent, according to 19/20 subjects (95%).

CONCLUSIONS

The results of our study showed the efficacy and tolerability of this cosmetic device. Its active compounds favor gradual removal of seborrheic keratoses, even in case of pigmented variants. This non-invasive treatment represents an alternative to surgical procedures, mainly for fragile patients and delicate skin areas. It is possible to speculate its usefulness in the topical treatment of circumscribed hyperkeratosis, palmoplantar keratoderma, and thick psoriatic plaques.

Trifarotene: A Current Review and Perspectives in Dermatology

Retinoids have numerous applications in inflammatory, dyskeratotic, and oncohematology diseases. Retinoids have now reached the fourth generation, progressively reducing toxicity whilst increasing their efficacy. Trifarotene is a new fourth-generation retinoid with a selective action on RAR-γ. In this review, we reported the trials—both concluded and in progress—including the use of trifarotene in dermatological diseases. Studies were identified by searching electronic databases (MEDLINE, EMBASE, PubMed, Cochrane, Trials.gov) from 2012 to today and reference lists of respective articles. Only articles published in English language were included. Randomized trials evaluating trifarotene tolerability, safety, and efficacy in congenital ichthyosis and acne have demonstrated great results and mild side effects, leading to the approval by the FDA of trifarotene for the treatment of lamellar ichthyosis in 2014, and of acne vulgaris in October 2019. No high-quality randomized clinical trials have evaluated the treatment of primary cutaneous lymphomas with trifarotene. Finally, we are hypothesizing future perspectives in the treatment of non-melanoma skin cancers, fungal infections, photoaging, and hand-foot skin reactions with trifarotene.

Cutaneous mastocytosis: A dermatological perspective

Mastocytosis is a rare disease characterised by expansion and collection of clonal mast cells in various organs including the skin, bone marrow, spleen, lymph nodes and gastrointestinal tract. The prevalence of mastocytosis has been estimated to be one in 10 000, while the estimated incidence is one per 100 000 people per year. Cutaneous mastocytosis is classified into (i) maculopapular cutaneous mastocytosis, also known as urticaria pigmentosa; (ii) diffuse cutaneous mastocytosis; and (iii) mastocytoma of the skin. In adults, cutaneous lesions are usually associated with indolent systemic mastocytosis and have a chronic evolution. Paediatric patients, on the contrary, have often cutaneous manifestations without systemic involvement and usually experience a spontaneous regression. Diagnosis of cutaneous mastocytosis may be challenging due to the rarity of the disease and the overlap of cutaneous manifestations. This short review describes pathogenesis and clinical aspects of cutaneous mastocytosis with a focus on diagnosis and currently available therapies.

Omalizumab and adalimumab: a winning couple

Introduction: We report a case of a young female patient, previously affected by psoriatic arthritis, and treated with adalimumab, who developed a chronic spontaneous urticaria and started a concomitant therapy with omalizumab. Methods & results: A 50% reduction of the Dermatology Life Quality Index (from 7 at baseline to 4 in weeks 12 and 24) and a complete reset of the Urticaria Activity Score for 7 days (from 27 at baseline to 0 in weeks 12 and 24) were recorded. During all treatment with omalizumab, administering of adalimumab was continued. Due to complete control of urticaria symptoms, the patient stopped treatment with omalizumab after 24 weeks. Conclusion: The combination of adalimumab and omalizumab could offer a favorable efficacy and safety profile. The synergistic action of the two biological drugs in reducing systemic inflammation could be responsible for a shorter time to obtain clinical response.

Clear cell hidradenoma of the hand: A case report in an 83-year old patient

INTRODUCTION

Clear cell hidradenoma (CCH) is a superficial adnexal tumor of the sweat glands. It generally appears on the trunk or scalp and is uncommon on the upper and lower limbs; it is extremely rare on the hand. CCH tend to be benign, with low malignancy risk. Treatment is based on complete surgical excision. We report a rare case of a CCH of the palm of the hand in an 83-year old patient.

PRESENTATION OF CASE

An 83-year old male patient presented with a small mass on the palmar surface of his left hand, which was progressively increasing over 5 years. The tumor was surgically excised after sonography and sent for histologic examination, based on which diagnosis of CCH was made. Three months after surgery, the patient had no recurrence and was symptom free.

DISCUSSION

CCH is a rare tumor of the distal extremities and to the best of our knowledge, only one case of this tumor on the hand has been reported. Our case represents a rare CCH located at the palm of the hand, which was successfully surgical excised without recurrence. Therefore, CCH needs to be considered in the differential diagnosis when encountering masses on the distal extremities. Hidradenocarcinoma is the malignant variant that arises from the same cells.

CONCLUSION

We report the second case of CCH on the palmar surface of the hand. Treatment of choice is surgical excision, followed by histological analysis and close follow-up for recurrence.

A rare case of vulvar superficial myofibroblastoma associated with ambigous and unusual differential diagnosis

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Superficial myofibroblastoma of the Labia Majora.

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Differential diagnosis between vulvar superficial myofibroblastoma and cyst/hydrocele of Nuck duct.

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Differential diagnosis between vulvar superficial myofibroblastoma and inguinal/crural hernia.

Efficacy of Vismodegib in pigmented basal cell carcinoma: Appearances are deceiving

Basal cell carcinoma (BCC) is the most common skin cancer in humans. Pigmented basal cell carcinoma (pBCC) is a rare variant of BCC. Vismodegib, was the first drug to be approved for the treatment of locally advanced (laBCCs) or metastatic basal cell carcinoma. The aim of this study was to evaluate the efficacy of Vismodegib in patients with pBCCs. We retrospectively analyzed patients receiving Vismodegib as treatment for laBCCs presenting also various pBCCs. After 6 months of treatment, we performed excisional biopsies of pBCCs, that apparently at clinical and dermoscopic assessment did not respond to therapy. A total of nine patients were assessed. After 6 months of treatment, locally advanced target BCCs showed complete remission in four out of nine patients (44.4%), four patients (44.4%) were considered in partial remission and one patient (11%) showed no response to treatment. On the contrary, all the pBCCs showed both clinically and dermoscopically resistance to treatment. Therefore, clinically persistent pBCCs were surgically removed in three patients. Histology showed a complete elimination of the neoplastic cells together with features of previous regression. Our findings indicate that the efficacy of Vismodegib is higher than that documented by clinical or even dermatoscopic observation alone.

High-Risk Recurrence Basal Cell Carcinoma: Focus on Hedgehog Pathway Inhibitors and Review of the Literature

Basal cell carcinoma is the most common skin tumour, with the majority of the cases occurring on the head and neck district, where cosmetic and functional results are crucial. It can be locally destructive if not diagnosed early and treated appropriately. Surgery is the treatment of choice for most lesions, but aggressive, recurrent, or unresectable tumours can be challenging to manage. Advanced basal cell carcinoma includes high recurrence risk subtypes, in which standard therapies demonstrate lack of efficacy. This led to a need for investigating more deeply the pathogenesis of the disease and to the discovery of the implication of the hedgehog pathway. The development of systemic inhibitors of this pathway provides new treatment options for patients with advanced disease, resulting in survival improvement. Food and Drug Administration, before, and European Medicines Agency later approved 2 Hedgehog pathway inhibitors for the treatment of advanced basal cell carcinomas, vismodegib and sonidegib. Here, we present a review of the current English language literature trying to analyze differences in the 2 drugs as a head-to-head comparison between them has not already been documented in a randomized controlled clinical trial. Although vismodegib and sonidegib showed similar efficacy and safety profiles, in an indirect comparison scenario, sonidegib has shown slightly better outcomes in locally advanced basal cell carcinoma than vismodegib. They present different molecular structures, as they bind different residues on their targets and develop resistance for different mutations. In a future scenario, clinical trials comparing the 2 drugs are needed, as well as expanding data on discontinuation of therapy and/or consequential administration of them, with the aim to improve our clinical practise.

Dermoscopy and Reflectance Confocal Microscopy in the Diagnosis and Management of Nail Fold Squamous Cell Carcinoma

The management and prognosis of squamous cell carcinoma largely depend on its invasiveness and grade of differentiation. Pigmented nail fold squamous cell carcinoma represents a therapeutic challenge, needing careful treatment to preserve nail function. Here, we report the use of dermoscopy and Reflectance Confocal Microscopy to monitor nail fold squamous cell carcinoma in situ and its response to treatment with topical imiquimod.

Arsenic Trioxide, Itraconazole, All-Trans Retinoic Acid and Nicotinamide: A Proof of Concept for Combined Treatments with Hedgehog Inhibitors in Advanced Basal Cell Carcinoma

The treatment of advanced basal cell carcinoma has seen a progressive evolution in recent years following the introduction of Hedgehog pathway inhibitors. However, given the burden of mutations in the tumor microenvironment and lack of knowledge for the follow-up of advanced basal cell carcinoma, we are proposing a possible synergistic therapeutic application. Our aim is to underline the use of arsenic trioxide, itraconazole, all-trans-retinoic acid and nicotinamide as possible adjuvant therapies either in advanced not responding basal cell carcinoma or during follow-up based on Hedgehog pathway. We have analyzed the rational use of these drugs as a pivotal point to block neoplasm progression, modulate epigenetic modification and prevent recurrences.

Reflectance Confocal Microscopy of Pigmented Bowen's Disease: A Case Series of Difficult to Diagnose Lesions

Pigmented Bowen's disease is a rare variant of in situ squamous skin cell carcinoma. It mainly affects patients between 60 and 70 years of age. Its clinical features include well-demarcated, pigmented plaque arising in photo-exposed areas of the body. The best-characterized feature of the disease by histological examination is the presence of atypical keratinocytes, hyperpigmentation of the epidermis with trans-epidermal elimination of melanin and dermal melanophages. Precise diagnosis is often difficult, both clinically and dermoscopically, as Bowen's disease is often mistaken with keratinocyte tumors such as solar lentigines, seborrheic keratosis, Bowenoid papulosis, pigmented basal cell carcinoma, pigmented actinic keratosis; or even melanocytic lesions such as melanocytic nevus, pigmented epithelioid melanocytoma, and melanoma. Precise diagnosis often requires biopsy and histopathological examination of the tissue. Reflectance confocal microscopy is a noninvasive technique to diagnose pigmented skin lesions. To date, not much data are available regarding its use in the diagnosis of pigmented Bowen's disease. Herein, we report a well-represented case series of pigmented Bowen's disease imaged using dermoscopy and reflectance confocal microscopy.

Lichenoid Keratosis: A Clinical Trap without Secrets for Reflectance Confocal Microscopy

Lichenoid keratosis, also defined as benign lichenoid keratosis, was reclassified as lichen planus-like keratosis by Shapiro and Ackerman. Clinical and dermoscopic features of lichen planus-like keratosis can vary, often not providing useful and necessary information to perform an accurate diagnosis without performing a biopsy or histological examination. We describe 2 difficult to detect lichen planus-like keratosis cases in which we performed reflectance confocal microscopy. We underline the usefulness of this noninvasive diagnostic tool in the unclear cases of lichen planus-like keratosis.

Adenosquamous carcinoma of the right colon with diffuse signet-ring mucinous component

Colorectal carcinoma is one of the most frequent human malignant neoplasms. Besides the most common histological types, colorectal adenosquamous carcinoma is very rare, being microscopically constituted by tumoural glandular and squamous components. The diagnosis of primary colon adenosquamous carcinoma requires the exclusion of a metastatic squamous cell carcinoma and the extension of a primary squamous cell carcinoma from the anal-rectum junction. We report a case of primary adenosquamous carcinoma of the ascending colon in a 62-year-old Caucasian man affected by long-standing ulcerative colitis. Peritumoural lymph nodes and distant metastasis were present. We reported also a diffuse signet-ring mucinous component, which has not been previously observed. Moreover, we investigated microsatellite and all-RAS/B-RAF status, p16 and p53 protein expression, and the molecular presence of human papillomavirus DNA in all the morphologically distinct components, in order to suggest pathogenetic factors influencing the aggressive prognosis of colon adenosquamous carcinoma.

Uterine Leiomyoma with Massive Lymphoid Infiltrate in a Patient with History of Assisted In-Vitro Fertilization

Uterine leiomyomas are the most common benign tumors of the gynecological tract. Massive lymphocytic infiltration has been reported rarely in uterine leiomyomas and it has been described as a pathogenetic correlation with gonadotropin-releasing hormone agonists. Uterine leiomyomas with massive lymphoid infiltration have to be differentiated from non-Hodgkin lymphomas. We report a case of a woman without a history of gonadotropin-releasing hormone agonist treatment, who presented with a uterine leiomyoma that increased in size after the procedure of assisted in-vitro fertilization, and associated with massive nodular lymphoid infiltrate simulating, morphologically, a non-Hodgkin lymphoma. Uterine leiomyoma with massive lymphocytic infiltration is a very rare entity, probably of reactive significance, which has to be differentiated from diseases that need a systemic therapeutic approach.

Glandular Schwannoma: An Uncommon Variant of Schwannoma with Controversial Histogenesis

Schwannomas are benign, encapsulated nerve sheath tumors arising from Schwann cells; several histologic variants of schwannoma have been described, including the exceedingly rare glandular schwannoma (GS). The histogenesis of the glands in GS (as well as in other peripheral nerve sheath tumors with a glandular component) remains unclear; no consensus exists as to whether glands should be interpreted as metaplastic elements or entrapped reactive glands. We report a case of GS with detailed immunohistochemical analysis of the epithelial component. We believe that our findings raise further questions regarding the histogenesis of glands in GS, casting doubts on the traditional distinction between true metaplasia and glandular entrapment. Further research is warranted in this regard.

New local treatment for photoaging using a formulation containing piroxicam 0.8% and sunscreen

Objective

Skin aging is a complex process influenced by several factors that cause DNA damage and alter the extracellular matrix. The anti-inflammatory drug piroxicam can counteract photocarcinogenesis and photoaging by blocking cyclooxygenases-1 and 2, matrix metalloproteinases, and ornithine decarboxylase, and inducing apoptosis.

Methods

We conducted an open observational study in 50 adults with moderate to severe signs of photoaging treated with a new local formulation of piroxicam 0.8% plus sunscreen for 16 weeks. Photoaging was assessed using a validated dermoscopic photoaging scale. Each patient’s own perception of their skin quality was assessed using a graphic scale.

Results

The new formulation demonstrated a reliable effect on photoaging after 16 weeks, based on improved median dermoscopic photoaging and skin-quality scores. No patients experienced any adverse effects.

Conclusions

To the best of our knowledge, this study provides the first evidence for the safe and effective use of a local piroxicam formulation for the treatment of moderate to severe photoaging.

Sofosbuvir induced leucocytoclasic vasculitis: a case report

Background

We describe a case of leucocytoclasic vasculitis induced by Sofosbuvir and its disappearence after the end of the therapy. The hepatitis C virus, firstly described in 1989, is a major global health problem, with high morbidity and mortality. We observed a temporal relationship between the treatment and the onset of vasculitis. We emphasize the multidisciplinary approach to the patients with liver disease to improve the quality of life of these patients.

Case presentation

A 53-year-old Caucasian man with a history of hepatitis C virus genotype 1 infection was examined at our Department of Dermatology for the occurrence of palpable purpura. The patient referred that the first appearance of the dermatoses was about one month after initiation of therapy with Sofosbuvir for hepatitis C.

Conclusions

Vasculitis appeared after the beginning of Sofosbuvir and, even though it was treated with different medications proved to be effective, it disappeared only after the conclusion of the therapy, giving a strong evidence to be a drug eruption.

Current developments in pharmacotherapy for actinic keratosis

INTRODUCTION

Actinic keratosis (AK) is a superficial squamous cell carcinoma (SCC) where chronic sun exposure playing central role in its pathogenesis. UVB causes direct damage to DNA, producing pyrimidine dimers, and suppressing the protective role of p53. The stepwise progression of AK, with increased expression of anti-apoptotic Bcl-2, favors progression to SCC. Moreover, the dermal response characterized by inflammation and mediated by prostaglandins is a critical component of tumorigenesis that promotes tumor growth, tissue invasion, angiogenesis and metastasis. Other risk factors are represented by age, gender, phototype and drugs.

AREAS COVERED

In this review, the authors document the recent developments of different therapies used to treat AK and provide their perspectives on current and future treatment strategies.

EXPERT OPINION

The usefulness of long-term treatment with piroxicam and sun filters or diclofenac targeting the inflammation phases of skin tumorigenesis favors AK's healing and provides greater control of the cancerization field. Nonsteroidal anti-inflammatory drugs can be safely used in patients who use photosensitizing drugs and, therefore, are more at risk of developing skin tumors. Immunomodulatory therapies, which require shorter treatment, are characterized by more common local side effects, and need more attention by the dermatologist in the concern of patient education, resulting essential to improve adherence and outcomes.

Tacrolimus 0.03% ointment for treatment of paediatric lichen sclerosus: a case series and literature review

Objectives

This study aimed to investigate the usefulness and tolerability of topical tacrolimus in paediatric vulvar lichen sclerosus (LS). We examined whether there was improvement of the most problematic symptoms, such as itching, pain, and vulvar constipation.

Methods

Ten girls, aged from 4 to 9 years old who were affected by vulvar LS, were enrolled in an open clinical study to confirm the efficacy of tacrolimus 0.03% ointment to treat LS. Tacrolimus was applied twice a day for 6 weeks and then stopped during the follow-up period. The study duration included 6 weeks of treatment and 6 weeks of follow-up. A literature search of the PubMed (MEDLINE) database was conducted of reports published since 1 January, 2004.

Results

Our study and previous studies indicated the potential effectiveness of tacrolimus in LS. Treatment with topical tacrolimus was well tolerated with significant improvement of itching, pain, and constipation.

Conclusion

Tacrolimus may be a safe and effective alternative treatment, without the risk of corticosteroid-related vulvar atrophy, for paediatric vulvar LS. LS could become a further indication of topical tacrolimus therapy if these promising results are confirmed in the future.

Cutaneous features of myotonic dystrophy types 1 and 2: Implication of premature aging and vitamin D homeostasis

Skin changes have been described in myotonic dystrophy type 1 (DM1). However, whether and in which way skin is a target of specific disease alterations in DM1 and DM2 has not been yet clarified. This study aims to explore cutaneous features of DM1 and DM2 patients. Skin examination was performed in 60 DM1, 15 DM2, and 103 control, unselected patients by means of dermoscopy. It revealed quantitative and qualitative abnormalities of nevi and typical signs of premature aging in both DM1 and DM2 patients, with a significantly higher frequency of dysplastic nevi, alopecia, xerosis and seborrheic dermatitis. Twenty-eight nevi were excised in DM patients and none showed histological features of melanoma, although 12 of them were diagnosed as dysplastic and the remaining 16 presented histological irregularity in melanin distribution. In DM1 patients, the number of nevi correlated with CTG expansion size, whereas the presence of dysplastic nevi and xerosis inversely correlated with vitamin D levels. DM1 and DM2 patients display a high frequency of skin abnormalities, the most common of which correlate with genotype severity and serum vitamin D levels. Skin examination is highly informative in these patients and reveals features suggestive of premature aging and impaired vitamin D homeostasis.

Efficacy of ingenol mebutate gel for actinic keratosis in patients treated by thiazide diuretics

Actinic keratosis (AK) is considered as superficial squamous cell carcinoma. Chronic sun exposure plays a central role in its pathogenesis. In particular, ultraviolet B radiation causes direct damage to the DNA, producing pyrimidine dimers that suppress the protective role of p53. Other risk factors include advanced age, male sex, and fair skin type. Even some drugs used for treating blood hypertension, such as thiazide diuretics, can increase the risk of developing AK. Their photosensitizing action seems to be connected with reactive oxygen species production. We report our experience with ten patients affected by multiple AK, in therapy with thiazide diuretics, treated by ingenol mebutate gel. AK was clinically and dermoscopically evaluated at baseline and after 30 days from the beginning of the treatment. Moreover, patients were screened for vitamin D₃ values and reported a general hypovitaminosis status. To our knowledge, we report for the first time the efficacy of ingenol mebutate gel in this group of patients, particularly at risk of developing AK.

Long-term use of a new topical formulation containing piroxicam 0.8% and sunscreen: efficacy and tolerability on actinic keratosis. A proof of concept study

INTRODUCTION

Cyclooxygenase (COX) 1 and 2 enzyme up-regulation is involved in the pathogenetic process of actinic keratosis (A.K.) and non-melanoma skin cancers. Diclofenac, a non-steroidal anti-inflammatory (N.S.A.I.D.) drug, is used as topical treatment of A.K. Piroxicam is a N.S.A.I.D. characterized by a high COX-1 inhibition activity.

STUDY AIM

We conducted an 18 month exploratory open-label study on A.K., to assess the efficacy and tolerability of a new topical formulation of piroxicam and sunscreen in A.K.

PATIENTS

Enrolled subjects applied a galenic formulation of piroxicam 0.8%, vehiculated in a topical product containing sun filters with high (50+) and broad spectrum (UVA) actions, twice a day for 6 months. Subjects were then followed up for additional 12 months. Thirty-eight subjects with a total of 69 A.K. lesions participated in the trial. The primary outcome was the evolution of the Actinic Keratosis Erythema Scale Atrophy (A.K.E.S.A) score assessing erythema, scale, and atrophy of a target A.K. lesion. Secondary outcomes were the percentage of treated lesions with complete (100%) or partial (≥75%) clearance and the evaluation skin tolerability.

RESULTS

A.K.E.S.A. mean (S.D.) score at baseline was 7.5 (1.2). After 6 months of treatment, A.K.E.S.A. score decreased to 0.9 (1.1), a -88% reduction versus baseline. At the end of follow-up, A.K.E.S.A. score was 0.8 (1.2). A complete response was achieved in 38 of the 69 lesions (55%, 95% C.I.: 43% to 66%) and clearance was maintained 1 year post-treatment. A partial clearance was observed in 57 of 69 treated lesions (83%, 95% C.I.: 73% to 91%). Adverse events were limited to mild local irritation.

CONCLUSION

Our experience suggests that 6 month topical piroxicam 0.8% is efficacious and well tolerated in A.K. Clinical efficacy is maintained 1 year post-treatment. The main limitation of our study is that it was an open label non-controlled trial. Future controlled trials are warranted in order to compare the efficacy and tolerability of this topical piroxicam preparation with standard treatments in the management of A.K.

Lack of efficacy of imiquimod in patients with basal cell carcinoma previously treated with rituximab for B cell lymphoma: two case reports

Background

Non-Hodgkin lymphomas are a heterogeneous group, which involve either B or T lymphocytes. The most used treatment is a chemotherapy regimen, which includes cyclophosphamide, hydroxydaunorubicin, oncovin and prednisone combined with rituximab - a monoclonal antibody specific for CD20 - an antigen expressed on B lymphocyte membrane. Nonmelanoma skin cancers are the most common forms in patients who have lymphomas.

Case presentation

We reported the cases of two Caucasian men affected by non-Hodgkin disease, treated with chemotherapy and rituximab. After treatment, they both presented superficial basal cell carcinoma and we prescribed imiquimod 5 % cream. Unfortunately, the drug was not effective in either patient and the tumors were excised.

Conclusions

We speculated about the effect of rituximab on B lymphocytes, on a particular population of T cells and on antigen-presenting dendritic cells that may have determined a lower expression of some surface antigens involved in antigen presentation. These cells are the specific targets of imiquimod to promote skin cancer cells apoptosis. A lack of action by imiquimod on skin cancer after treatment with rituximab is likely due to its transitory inhibitory effects on lymphocytes and Langherans cells. Further studies could be useful to understand the mechanism behind the lack of response.