Mohs micrographic surgery for nail unit tumours: an update and a critical review of the literature

Mohs micrographic surgery (MMS) is a good treatment option for epithelial neoplasms, especially when localized in areas where tissue conservation is crucial, such as the nail unit (NU). MMS is a method of radical excision offering high cure rates due to the margin control and functional preservation. Our aim is to provide a review on the use of MMS for the treatment of the most common nail tumours. We revised the current literature on the use of MMS to treat malignant neoplasms (Bowen's disease, squamous cell carcinoma, melanoma, basal cell carcinoma, keratoacanthoma, carcinoma cuniculatum) and benign neoplasms (onychomatricoma and glomus tumour). MMS represents a successful surgical option for nail tumours, firstly in terms of tissue conservation: the NU anatomy is complex and the preservation of the component structures is imperative for its functionality. Secondly, due to the surgical radicality, which is essential not only for the clearing of malignant tumours, but also for benign cases, in order to reduce recurrences. Although a conservative treatment of NU melanoma with MMS has been proposed, in our experience, the conservative approach with functional surgery is a good option for the treatment of non-invasive melanoma (in situ and Ia).

Safety profile of chronic leg ulcer biopsy: a monocentric retrospective series

BACKGROUND

Skin biopsy is an important tool for various skin conditions. However, in the case of leg ulcers, some Authors still consider it highly risky and mandatory only in selected cases.

METHODS

The aim of this study was to evaluate the rate of adverse events after leg ulcers biopsy in 866 consecutive patients referring to our Wound Care Unit in Bologna from January 2008 to December 2016. Two biopsies were performed (from the border and the centre) by the same dermatologist following a standardized structured protocol.

RESULTS

A total of 329 males and 537 females (ratio of 1:1.6), mean age 72 years (range 50-97 years) underwent a skin biopsy. Up to 70% of all analyses revealed a vascular ulcer (614 patients; 70.9%) while other conditions (252 patients; 29.1%) included inflammatory dermatitis, vasculitis, ulcerated neoplasms, infective lesions, post-traumatic and pressure sores, erosive pustular, dermatitis and pyoderma gangrenosum. Adverse events occurred in 322 patients (38.43% of all biopsies), mostly a dull pain (320 patients, 37%) that resolved within some hours. Five patients with vasculitis (0.6%) experienced a worsening of the lesion and another five patients (0.6%) developed erysipelas. Only two patients, on double antithrombotic therapy (0.23%), had intraoperative bleeding. No allergic reactions were detected.

CONCLUSIONS

According to our experience, skin biopsy should be mandatory for non-healing wounds. It is safe and involves only a low rate of adverse events.

Masson's Intravascular Vegetant Hemangioendothelioma

Eleven cases of Masson's hemangioendothelioma are reported. This benign condition must be distinguished histologically from numerous malignant endothelial lesions. Two different papillary structures were observed; one defined as « inflammatory papilla » was constantly associated with a thrombus; the other, defined as «fibrous papilla» was observed in 4 cases where no thrombus could be found. It is postulated that the inflammatory papillae are an exuberant endothelial growth during the normal organisation of a thrombus; fibrous papillae, it is suggested, might be reactive to blood or lymph stasis.

Cicatricial alopecia

Cicatricial alopecias (CAs) are clinical pathological conditions that result in the complete destruction of hair follicles, which are replaced by fibrotic structures. Clinically they are characterized by different inflammatory conditions resulting in the end stage in the complete disappearance of hair follicle and follicular ostia. CAs are classified in primary cicatricial alopecia (PCA) and secondary cicatricial alopecia (SCA). PCA include multiple inflammatory diseases with distinctive clinical and histopathologic features that primarily affect and destroy the hair follicle. On the other way, diseases classified as SCA include inflammatory and neoplastic conditions and physical traumas usually primarily affecting the dermis and causing secondary follicular destruction.

Diagnostic Efficacy of Digital Dermoscopy and Clinical Findings in Thin Melanoma of the Lower Limbs

The introduction of dermoscopy has improved the accuracy of diagnosis of melanoma. However, early stage melanoma can be difficult to diagnose. Eighty-nine cases of thin melanoma with a Breslow thickness ≤1 mm located on the lower limb and diagnosed between 2008 and 2016 were assessed using 4 dermoscopic algorithms: (i) modified pattern analysis; (ii) ABCD rule of dermoscopy; (iii) 7-point checklist; and (iv) Menzies' method. Two groups of early stage melanomas of the legs were identified: "difficult to diagnose melanomas" (DDM) and "non-difficult to diagnose melanomas" (NDDM). In our series the dermoscopic features of DDM were difficult to differentiate from melanocytic naevi, and the reticular pattern was the most frequently observed. "Depigmentation" was the only specific criterion associated with DDM. The sensitivity of diagnostic systems for thin melanomas of the lower limbs was lower than in previous studies. This result could be related to the lower mean Breslow thickness of the invasive melanomas in our sample and the high number of melanomas in situ. In conclusion, early stage melanoma of the legs may be difficult to detect at clinical examination or with dermoscopic examination alone. Focusing on depigmentation in dermoscopy associated with anamnestic features could be a useful tool to detect difficult thin melanomas. In addition, sequential dermoscopy is recommended for high-risk patients with previous melanomas or atypical mole syndrome.

The epidemic spreading of basal cell carcinoma: incidence trend, demographic features, characteristics and risk factors in a retrospective study of 8557 lesions in Bologna. A 25-year analysis in a Dermatology referral center

BACKGROUND

The aim of this study was to retrospectively analyze all the cases of BCC histologically diagnosed in the Cutaneous Tumor Center of Dermatology of Bologna University, in a period between 1990 and 2014.

METHODS

All the consecutive histopathologically diagnosed BCCs at the Dermatology of the Bologna University from 1990 to 2014 were retrospectively reviewed. We evaluated the absolute number of basal cell carcinoma (BCCs), the demographic features of patients and the characteristics of BCCs with statistically significant correlations.

RESULTS

During the investigated 25 years, 8557 BCCs were collected in 7297 patients. We observed that the incidence of this cancer, after stabilizing around a plateau of 400 cases/year in 2005, progressively increased onwards reaching a maximum of cases (821) in 2014 (+105.25%), with an 8.32% mean increase per year in those last 9 years. Moreover, we found a significant correlation (P<0.01%) between gender and the onset of BCC, between the anatomic location and the occurrence of the tumor, between the onset of recurrent or new BCCs and sun exposure.

CONCLUSIONS

The present study collects the largest series in the Italian literature focused on demographic features and characteristics of BCC, highlights its higher increasing incidence in Bologna and the need to improve preventive strategies to stem the epidemic diagnosis of BCC.

Melanoma and melanocytic nevi in pediatric patients: a single institution experience

BACKGROUND

Melanoma is an infrequent neoplasm in children and adolescents. The number of consultancies for melanocytic nevi control in the pediatric population is increased by the major anxiety of parents and pediatricians.

METHODS

A retrospective chart review was performed in order to evaluate the incidence rate of melanoma, Spitz nevi, congenital and acquired melanocytic nevi in patients aged 14 years or less and referred to our institution from April 2010 to September 2015.

RESULTS

A total of 32,755 dermatologic pediatric consultancies were performed in the considered 66 months period, including 4260 patients referred for mole control (13%). During the same period, a total of 5193 excisions of melanocytic lesions were performed (adults and pediatric patients), 259 of which were performed in 250 patients aged 14 years or less (4.98%). Only 1 in situ melanoma of the nail matrix was detected in a 12-year-old female patient (0.38% of surgical excisions). The number needed to excise (NNE) in our pediatric population, calculated by comparing the total number of excised lesions and the number of melanomas found, was 259.

CONCLUSIONS

Our data leads to 3 major observations: 1) the rarity of melanoma in patients with 14 years of age or less is confirmed; 2) the number of excisions performed in this pediatric population is extremely high; 3) neither the cases of melanoma and atypical Spitz neoplasm (ASN) nor the majority of Spitz nevi were referred to us for a generic mole control. Mole controls in the pediatric population should be properly addressed, incrementing the attention on specific suspicious cutaneous lesions.

Sequential monitoring of pigmented lesions during dabrafenib treatment: a prospective study and a literature overview

BACKGROUND

Targeted therapies in melanoma have shown clinical benefit in incrementing the overall survival of metastatic patients. However, cutaneous adverse events have been frequently associated with these drugs.

METHODS

We report our experience in the management of patients treated with dabrafenib for metastatic melanoma, focusing on the monitoring of pigmented lesions. Dermatologic evaluation was performed during the first visit, at the start of each treatment and subsequently after every four weeks. Global nevi count, videodermoscopy of suspected lesions, and surgical excisions when necessary were performed at the beginning of the treatment and every fourth week. All other cutaneous adverse events (cAEs) were noted and documented. Eleven patients were included.

RESULTS

The most important cAEs included palmo-plantar hyperkeratosis, diffuse xerosis and pigmented lesion changes. Regarding the latter, in 6 patients, especially in the first months of treatment, we observed hyperpigmentation and hyperkeratosis of the nevi, of the pigmented mucosae and, in one patient, hyperkeratotic changes on a cutaneous metastasis. Histopathology of the excised lesions showed one ex novo melanoma occurrence and benign changes to pre-existing nevi.

CONCLUSIONS

The awareness of the importance of sequential monitoring of pigmented lesions, with particular attention to the lesions of new onset, is crucial for the best management of these complex patients.

Management and treatment of nail melanoma

BACKGROUND

An early and prompt nail apparatus melanoma (NAM) diagnosis is associated with less invasive surgical procedures and a better patient's prognosis. The diagnostic delay may be related both to the clinical misinterpretations and to errors in the diagnosing process. Biopsy techniques have been adequately described by nail experts, but the two main problems in the correct choice of the biopsy are probably related to the difficulty in performing surgery in the nail unit and the risk of permanent nail dystrophy.

METHODS

We retrospectively investigated anamnestic data and diagnostic procedures that all NAM patients referred from 1992 to January 2014, with the following objectives: 1) to evaluate the initial misdiagnoses and quantify the diagnostic delay; 2) to correlate the type of the initial biopsy with the achievement of the correct diagnosis.

RESULTS

In our cases it was easier for a non-dermatologist to misdiagnose NAM for a benign inflammatory disease. Dermatologist instead were easier to refer patients to a tertiary center for nail diseases.

CONCLUSIONS

In the presence of a NAM clinical and dermoscopic suspicion, longitudinal biopsy is recommended in all cases of nail pigmentation (lateral or median), that is estimated in its width as 3-6 mm, or larger than 6 mm. Regarding therapeutic surgery in our experience disarticulation compared to "functional surgical excision" did not correlate with a better prognosis.

Management and treatment of mucosal melanoma of the genital tract

The melanoma of the genital mucosa is a rare melanocytic neoplasm that affects both sexes. The diagnosis is often delayed; videodermatoscopy may represent a useful diagnostic tool. The treatment is complex and multidisciplinary. We report the main diagnostic features and therapeutic approaches for mucosal melanoma of the genital tract.

A single institute's experience on melanoma prognosis: a long-term follow-up

BACKGROUND

The prognosis of cutaneous melanoma is correlated to histopathologic parameters such as Breslow thickness, the presence of mitosis, ulceration and lymphatic involvement at the moment of the diagnosis. On the other hand, the prognostic value of parameters such as age, sex, and tumor localization are still a matter of debate. We evaluated herein the prognostic factors in melanoma patients during a long-term follow-up (60 months).

METHODS

Melanoma patients presenting stage IB-III at diagnosis were included. Breslow thickness, ulceration, lymphatic involvement, patients' age, sex and tumor localization were correlated to patients' prognosis. Univariate Cox regressions and multivariate Cox proportional-hazards regression were performed. Successively, Kaplan-Meier was used for variables significantly associated with overall melanoma survival.

RESULTS

A total of 115 melanoma patients were included in this study. During follow-up 82 (72.17%) patients survived and 33 (28.7%) died. In our dataset, Breslow thickness >2 mm (P=0.0007), patients age >50 years (P=0.005) and positive sentinel lymph node (P=0.0003) seem to be the most important variables correlated with the presence of metastases at 5 years follow-up. However distant metastases were also observed during follow-up in 14/26 patients presenting negative sentinel lymph node at diagnosis.

CONCLUSIONS

Given the vital importance of target drugs and the newly introduced immunotherapies in cutaneous melanoma management, we would suggest that mutational analyses should also be extended to the subgroup of patients presenting microstaging parameters related to a poor prognosis in a long-term follow-up of 60 months.

Risk of skin cancer development in 672 patients affected by actinic keratosis

BACKGROUND

Actinic keratoses (AKs) are the most common type of keratinocytic lesions worldwide. The skin areas affected by the so-called "field cancerization" harbor mutagenetic risks for the development of squamous cell carcinoma (SCC).

METHODS

We retrospectively investigated the histopathological reports and clinical charts of 672 patients affected by multiple AKs, presenting at least 5 years of follow-up. The frequency of non-melanoma skin cancers (NMSC, namely SCC and basal cell carcinoma [BCC]) and malignant melanomas (MMs) in patients affected by multiple AKs were analyzed.

RESULTS

More than 40% of patients with a previous diagnosis of multiple AKs developed an NMSC (SCC or BCC), or an MM, during a follow-up period of 5 to 11 years. The risk of developing another skin malignancy appeared to be higher in the age range between 61 and 80 years. The relative risk of developing a BCC and/or an MM in patients with a previous AK diagnosis was found to be 4.52.

CONCLUSIONS

The presence of multiple AKs and "field cancerization" seems to be associated with a high risk not only of NMSC such as SCC and BCC, but also of MM. An adequate follow-up is required in these groups of patients.

Pain evaluation in patients affected by cutaneous squamous cell carcinoma and actinic keratosis: an observational study

BACKGROUND

Pain is a frequent symptom in cancer patients. The aim of our study was to evaluate the presence of pain in histopathologically-diagnosed hypertrophic actinic keratosis (AK) or cutaneous squamous cell carcinoma (SCC).

METHODS

An observational study evaluating pain presence and intensity in skin cancer was performed, including patients affected either by SCC or by hypertrophic AK. Pain intensity was assessed using the 11-point Numeric Rating Scale, ranging from 0 (absence of pain) to 10 (most intense pain). Both spontaneous pain and pressure-related pain intensity, due to local digital pressure, were evaluated.

RESULTS

In patients with SCC, spontaneous pain was present in 57.5% of the cases, while pressure-related pain was revealed in 80.0% of the cases. In hypertrophic AK patients, spontaneous pain was detected only in 15.0% of the cases, while pressure-related pain was present in 25.0% of the cases. A statistically significant difference between the 2 groups was found in the evaluation of spontaneous and pressure-related pain values, these values being significantly higher in the SCC group. No significant correlations between the degree of inflammation, the histotype or invasiveness of SCCs, and the intensity of pain were found.

CONCLUSIONS

The recognition of pain as a symptom, more frequently associated with SCC, might prove useful in the clinical practice. Further research is needed, in order to better understand and characterize pain associated with different skin neoplasms.

Nail apparatus melanoma: is trauma a coincidence? Is this peculiar tumor a real acral melanoma?

Nail Apparatus Melanoma (NAM) is rare, particularly in Caucasians. Understanding its pathogenesis and collecting epidemiologic data may be difficult due to its location and the exiguity of the case series of this cancer. Cutaneous melanoma has been thought related to UV radiation, and NAM is considered an acral variant of melanoma, even if the nail presents a specific anatomy. Little is reported about pathogenesis, except reports suggesting traumatic injuries as a causal factor. UV exposure is debated in nail melanoma because of its structure. The nail is, in fact, a unique structure with sun-exposed and non exposed melanocytes. NAM arises from the nail melanocytes, located in the nail matrix, which is the germinative part of the nail and composed of a proximal and distal portion. The proximal nail matrix lays under the proximal nail fold that covers it and is non-sun exposed, while the distant nail matrix, clinically visible as the lunula, is sun-exposed, though lying underneath the nail plate. According to these anatomical data, NAM is a distinct melanoma type, and studies need to classify it as acral melanoma or as a particular type of melanoma with its own pathogenesis and prognostic criteria. This study investigates potential risk factors of NAM, emphasizing (i) trauma and (ii) UV exposure among our NAM patients.

Association between dietary vitamin C and risk of cutaneous melanoma in a population of Northern Italy

Cutaneous melanoma incidence has been increasing during the last few years, and diet has been suggested as one of the lifestyle factors responsible for this increase. Since antioxidant nutrients such as ascorbic acid might prevent skin carcinogenesis, we investigated the risk of cutaneous melanoma related to vitamin C intake in a population-based case-control study in Northern Italy based on 380 melanoma patients and 719 matched controls, to whom we administered a semiquantitative food-frequency questionnaire. After adjusting for potential confounders, odds ratio of melanoma were 0.86 (95 % confidence interval 0.65 - 1.15) and 0.59 (95 % confidence interval 0.37 - 0.94) in the intermediate and highest categories of vitamin C dietary intake respectively, compared with the bottom one. The association between vitamin C and decreased risk persisted after adjustment for some potential confounders. In age- and gender-stratified analyses, this association was seen in young females (< 60 years old), and was found to be enhanced in subjects with phototypes II and III. These results suggest a possible protective activity of vitamin C intake against cutaneous melanoma in specific subgroups of this population of Northern Italy.

Evaluation of incidental thyroid nodules in patients with primary melanoma

AIM

Literature data have suggested an increase of incidental thyroid nodules in patients with malignancies, including melanoma.

METHODS

The ultrasound findings of 168 consecutive melanoma patients were revisited in order to evaluate the presence of incidental thyroid nodules and the results were compared with clinical features, Breslow thickness and the rate of malignancy of incidental thyroid nodules.

RESULTS

We observed that: 1) incidental thyroid nodules are more frequent in patients affected by melanoma (60.6%) than in the healthy population; 2) no statistically significant difference were found in thyroid involvement on the basis of gender and age; 3) incidental thyroid nodules frequency is increased in patients with thinner melanoma and this increase is more evident if we consider melanoma in situ and female patients; 4) it was not detected malignant incidental thyroid nodules.

CONCLUSION

The data revealed a high frequency of incidental thyroid nodules in patients with melanoma, suggesting that it is necessary to study this association in a larger group of patients, also including age/gender matched controls.

Superficial acral fibromyxoma: a clinicopathological and immunohistochemical analysis of 12 cases of a distinctive soft tissue tumor with a predilection for the fingers and toes

AIM

Superficial acral fibromyxoma (SAFM) is a rare soft tissue tumor, recently delineated and documentated as a separate entity. We report 12 cases of SAFM observed in our department from June 2004 to June 2010 and highlight pathological features and differential diagnosis.

METHODS

Radiographic examination of the affected digit was performed in all patients. All the tumors were surgically excised under local anesthesia. Follow-up was made every 6-8 months for a maximum period of five years.

RESULTS

The patients consisted of 8 men and 4 women, age range 28-76 years (mean 51), presenting with a solitary mass or nodule located in the toes and fingers. Histologically the lesions were well circumscribed dermal nodules composed of stellate and spindle cells, arranged in a myxoid matrix. Very low grade atypia and a few mitotic figures were found in only one case. Neoplastic cells showed immunoreactivity for CD34 (12 patients). In contrast focally positive or negative staining was shown for the epithelial membrane antigen (EMA) and CD 99. Actin, S100 protein, HMB45 and cytokeratin were negative. In three cases marked hyperkeratosis and acanthosis of the epidermis was present. Pathological analysis confirmed the diagnosis of superficial acral fibromyxoma. No recurrences were observed even in a long term, 2-5 year follow-up.

CONCLUSION

Complete surgical excision of the tumors and a careful follow-up is suggested, despite the benign course previously reported.

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.

METHODS

Eleven dermatopathologists, from nine Italian Institutions, collected the specimens of melanocytic lesions from the breast and other body sites, excluding the acral, genital, and flexural areas, as controls. Cases and controls were matched for sex and age. All nevi were observed 'blindly' and simultaneously by all participants. For each lesion, 10 histological parameters were analyzed: asymmetry, absence of lateral demarcation of melanocytes, lentiginous proliferation, nested and dyshesive pattern, intraepidermal melanocytes above the basal layer, involvement of the hair follicle, absence of maturation of dermal melanocytes, melanocytic atypia, fibroplasia of the papillary dermis, and lymphocytic dermal infiltrate. Each parameter was scored 2 when present and 1 when absent or not valuable. A total score was calculated for each lesion. Results were statistically analyzed by the chi-square test and the Mann-Whitney U-test.

RESULTS

One hundred and one nevi came from the breast area and 97 from elsewhere. Breast nevi exhibited significantly more atypical features than nevi from other sites. In particular, breast nevi with intraepidermal melanocytes, melanocytic atypia, and dermal fibroplasia were significantly more numerous. We did not find any sexual difference.

CONCLUSIONS

To avoid undue concerns, dermatopathologists should be aware that melanocytic nevi of the breast may show a high degree of atypical features.

Granular parakeratosis: four paediatric cases

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.

Necrobiotic xanthogranuloma without periorbital involvement: an ultrastructural investigation

A case of necrobiotic xanthogranuloma without typical periorbital involvement is described at the ultrastructural level. The patient, a 58-year-old Italian man, presented in 1995 with a brief history of nodulo-papular lesions commencing on the lower limbs, and mild paraproteinemia. During 6 years of follow-up, anemia, neutropenia with marked lymphopenia, and increased ESR were found, while serum cholesterol and triglyceride levels decreased from hyper to hypo values. Systemic diseases, such as diabetes, malignancy, or extracutaneous lesions, often associated with NXG, have not developed. Conventional histology was distinctive for NXG, and immunohistochemistry confirmed that dermal histiocytes were not of Langerhans cell lineage. At ultrastructure, regeneration and degeneration ("regen-degen") features were observed in some individual deep dermal histiocytes, which have not been previously documented in the literature. Identification of giant histiocytes showing 'regen-degen'' aspects might prove to be a useful ultrastructural diagnostic marker for NXG.

Onychomatricoma: report of three cases, including the first recognized in a colored man

Onychomatricoma is an uncommon benign tumor of the nail matrix with typical clinical features. We report here 3 cases of onychomatricoma, including the first case in a black patient. In all three patients a presumptive diagnosis of onychomatricoma was made by clinical examination. The affected nails were thickened and showed a marked overcurvature of the nail plate. Frontal view of the nail revealed the presence of small woodworm-like cavities within the nail plate. In all cases the pathology showed multiple fibroepithelial projections that extended into the thickened nail plate. The tumor epithelium was identical to that of the normal nail matrix and keratinized without a granular layer.

Psoriasiform acral dermatitis: a peculiar clinical presentation of psoriasis in children

Recently an unusual chronic dermatosis, considered a new clinical entity and closely resembling psoriasis, has been described in the literature under the term psoriasiform acral dermatitis (PAD). It is characterized by cutaneous involvement of the digits without nail dystrophy. We describe three young patients, ages 6 to 8 years, in whom this condition was associated with psoriasis. Two children were affected by psoriasis vulgaris, while the third had a palmoplantar psoriasis. All laboratory investigations performed were within normal limits. Skin biopsy specimens taken from the fingers of two patients revealed the pathologic features of subacute spongiotic dermatitis. Histologic examination of a biopsy specimen taken from an erythematous squamous patch confirmed the clinical diagnosis of psoriasis in two patients. The dermatitis showed a fluctuating course in all three patients, with only a moderate to strong improvement with therapy with calcipotriol ointment (50 microg/g). During follow-up, two patients experienced marked spontaneous, persistent improvement, while the disease slightly worsened in the third. The children had features similar to those described in PAD, but were also suffering from psoriasis. Whether PAD is a distinctive entity or just a clinical manifestation of psoriasis in children is still an open question. We strongly believe this latter hypothesis, although further studies are needed to confirm it.

Psoriatic scarring alopecia: observations in four patients

BACKGROUND AND DESIGN

Although acute or chronic hair loss in psoriasis of the scalp can be a symptom of the disease, until now there has been no agreement as to whether or not it is only restricted to erythrodermic, generalized pustular and scalp plaque psoriasis. The purpose of this study was to evaluate patients with chronic scalp psoriasis and alopecia and to determine if the alopecia was of the scarring type.

RESULTS

We report four cases of psoriatic scarring alopecia and describe the clinical and histologic features of these patients. The diagnosis was made by scalp biopsies (vertical and transverse sections) and other causes of scarring alopecia were excluded.

CONCLUSIONS

Psoriasis can cause scarring alopecia.

Storiform collagenoma of the nail

The term circumscribed storiform collagenoma was coined by Maize et al in 1989 to describe four dermal fibromas with pathologic features resembling the sclerotic fibromas associated with Cowden's disease. We report a subungual nodule with the pathologic features of circumscribed storiform collagenoma in a patient without Cowden's disease.

"Endonyx" onychomycosis: a new modality of nail invasion by dermatophytes

Three patients with onychomycosis due to Trichophyton soudanense with an "endonyx" type of nail invasion are presented. Endonyx onychomycosis is clinically characterized by a diffuse milky-white discolouration of the affected nail, in the absence of nail bed hyperkeratosis or onycholysis. Nail plate surface and nail thickness are normal. The pathology shows a contrast between the great number of fungal hyphae visible in the nail plate and the absence of fungal elements in the nail bed. The nail bed does not show inflammatory changes or hyperkeratosis and adheres strictly to the lowermost layers of the nail plate. The hyponychium is normal and does not contain hyphae. The endonyx pattern of nail infection appears to be specific to T. soudanense nail invasion and may possibly reflect the high affinity of T. soudanense to hard keratins.