Cutaneous vasculitidis: histology and immunofluorescence.

Cutaneous vasculitis comprises a wide spectrum of diseases that involve predominantly the blood vessels and surrounding tissues of the skin. Few vasculitic syndromes have pathognomonic clinical, radiographic and/or laboratory findings; thus, confident and accurate diagnosis of vasculitis requires histological confirmation. Skin biopsy should be done, optimally within 24 to 48 hours after vasculitic lesions appear. Deep excision biopsy must be preferred. Direct immunofluorescence of lesional skin is helpful in the diagnosis of vasculitides in the light of a proper clinico-pathological setting and diagnostic in some peculiarly forms. Cutaneous histological patterns can be used to generate relevant clinical differential diagnoses, and, when coupled with patient's history, clinical and laboratory data, allow more precise and accurate diagnosis of vasculitic syndromes. This review will focus on histopathological and immunologic pattern of the more common cutaneous vasculitis syndromes, based on the 2012 Revised International CHCC.

[Severe drug hypersensitivity syndrome due to sulphasalazine in patient with rheumatoid arthritis]. / Grave sindrome da ipersensibilità a farmaci indotta da sulfasalazina in paziente con artrite reumatoide.

Drug Hypersensitivity Syndrome, also known as Drug Rash with Eosinophilia and Systemic Symptoms is a severe adverse reaction characterized by clinical manifestations including fever, skin eruption, lymphoadenopathy, associated with eosinophilia, leukocytosis and multiple visceral involvement, with 10% of mortality due to development of multiple organ failure. This reaction usually occurs between two and six-eight weeks after the beginning of the treatment and may not resolve with interruption of the suspected drug. Sulfonamides, anticonvulsant, allopurinol are the most frequently involved molecules, but recently cases have been described also with gabapentin and strontium ranelate. In the present report we describe a case of a patient with rheumatoid arthritis who presented severe drug hypersensitivity syndrome, with liver and kidney involvement due to sulphasalazine.

Dermatoscopic features of cutaneous atypical fibroxanthoma: three cases.

Atypical fibroxanthoma (AFX) is an uncommon, low-grade, malignant, spindle-cell tumour of fibrohistiocytic histogenesis, which can mimic other malignant skin tumours, such as basal and squamous cell carcinoma (CC), melanoma, and Merkel cell carcinoma (MCC). Three cases of AFX were examined by dermatoscopy, which revealed white areas and an atypical polymorphous vascular pattern characterized by the concurrence of different structures: linear, dotted, hairpin, arborescent and highly tortuous vessels, irregularly distributed over the surface. Seborrhoeic elements and photoageing may be accompanying features depending on the anatomical location of the AFX. AFX may be added to the list of slightly pigmented, reddish, malignant cutaneous tumours, such as SCC, MCC, amelanotic/hypomelanotic melanoma and eccrine porocarcinoma, which display prominent and chaotic dermatoscopic neoangiogenetic features in more advanced stages of proliferation.

Opposed bilateral transposition flap: a simple and effective way to close large defects, especially of the limbs.

BACKGROUND: Excision of large tumours, particularly of the limbs, can be challenging because of problems related to wound repair. This is especially true of the lower legs, where skin is often tight and difficult to mobilize. Closure by flap, which would represent the first choice for defects usually between 12-15 mm to 38-40 mm diameter, is at risk of developing complications, such as end-flap necrosis or dehiscence due to skin tension. For larger defects, usually more than 40 to 45 mm diameter, grafting still remains the only realistic option in the majority of cases, with all the various problems associated with this procedure, such as lengthy healing times and the risk of developing leg ulcers, above all in elderly patients with impaired blood circulation. Second intention healing implies extraordinarily long healing times with often unacceptable delays in normal ambulation and activity. OBJECTIVE: To find an alternative to the usual repair techniques and to try to reduce the risk of complications. CONCLUSIONS: We developed a relatively simple but effective technique for the closure of large wounds resulting from the excision of tumours. Our technique consists of two longitudinal, parallel, transposition flaps obtained from two opposite sides of the wound, with major axes orientated in the cephalic-caudal direction. The two flaps are then rotated around two fulcra placed at two extremes of the wound by approximately 90 degrees . This relatively simple technique has never caused any of the ordinarily associated problems in terms of necrosis or ulcer development. In addition, dehiscence of sutures never occurred, given the fact that suture tension is minimal. Quick healing has resulted in the majority of cases, avoiding all the problems associated with grafting or other traditional flap techniques.

Dermoscopy of lichen planus-like keratosis: a model of inflammatory regression.

BACKGROUND: Lichen planus-like keratosis (LPLK) or benign lichenoid keratosis is an involuting cutaneous entity where regressing features are the histologic hallmark. Most authors consider LPLK as an heterogeneous spectrum of intraepithelial epidermal or melanocytic lesions, mainly pigmented, involuting by inflammatory regression. OBJECTIVE: The authors review the clinico-histologic definition and correlate with the dermoscopic features of LPLK. METHODS: Sixteen LPLK were clinically distributed into three types: plaque-like (PL), flat erythematous (FE) and flat pigmented (FP) type and evaluated with conventional dermoscopy. Dermoscopic features of regression were recorded as the presence of blue-white structures and vascular structures. The predominant distribution, size and colour of pigmented granules were also recorded. All cases were excised and submitted to histopathologic examination and subdivided into three groups according to the early, classic and atrophic subtypes. RESULTS: The FP (44%) and the FE (37%) types are diagnosed more frequently than the PL type (19%). PL type correlates better with the classic type. FE correlates mainly with early/atrophic types, while the FP nearly exclusively with the late atrophic type. Regressive features are present in all but one case with a predominance of blue areas (94%). Localized (55%) and diffuse (37.5%) granular pattern are presenting in all but one case. The diffuse granular pattern correlates with the FP type (5/6 cases), while the localized granular pattern is mainly present (6/9 cases) in the FE type. Vascular structures can be found in half of the cases and white scar-like depigmentation is just present in four cases. BWS and vascular structures present together are observed in four cases (25%). CONCLUSIONS: Our results show a large correlation among clinical, histologic and dermoscopic aspects of LPLK may be interpreted as a spectrum of cutaneous lesions going into inflammatory regression, showing different clinical and dermoscopic patterns according to the involuting stage. The early type of LPLK (FE) shows a localized granular pattern where regression is at the very early stage. The classic dermoscopic features of regressing lesion for LPLK (pigmented granular pattern) apply to the most frequent encountered pigmented atrophic flat type or classic pigmented type, where sometimes regression is advanced or almost complete and no clear diagnosis of a previous benign/malignant - epithelial or melanocytic lesion can often be given. Regressive dermoscopic features must be evaluated in the context of global and clinical pattern of the lesion. Nonetheless dermoscopy can close correlate with clinical incipient or complete regression and must prompt the need for eventual prophylactic surgical removal.

Thysanoptera dermatitis.

Thysanoptera dermatitis is caused by the bite of small (1-2 mm) insects (generally thrips). Thrips usually feed on the juices of vegetables but if they reach human skin they can suck the epidermal lymph after biting. The cutaneous lesions formed are small pink and itchy papules localized mainly on the trunk and the arms. Diagnosis is only possible by demonstrating that the insect is present inside one of the lesions of the skin. Thysanoptera dermatitis is often misdiagnosed as mosquito bites. Although self-resolving in a few days, Thysanoptera dermatitis should be known not only for the cultural and scientific training of the dermatologist but also to add more detailed diagnostic information to the generic diagnosis of 'entomodermatosis' and to confirm the benign evolution of the bites.

Old fashioned sodium bicarbonate baths for the treatment of psoriasis in the era of futuristic biologics: an old ally to be rescued.

BACKGROUND: For centuries, medicated baths have been one of the first lines of treatment for psoriasis. Even today, with sophisticated immunosuppressive treatments available, Dead Sea salts and spa waters are recognized to be beneficial in the management of psoriatic patients. OBJECTIVE: To assess statistically the efficacy of sodium bicarbonate (NaHCO3) baths in psoriasis patients. METHODS: Thirty-one patients with mild-moderate psoriasis were admitted to this study; Nineteen patients were treated with sodium bicarbonate baths and compared with twelve patients who were administered a placebo. Assessments were made on days 0 and 21. RESULTS: Almost all patients who used NaHCO3 reported a statistically valuable improvement. NaHCO3 baths reduced itchiness and irritation; in general, the patients themselves recognized a beneficial impact on their psoriasis, so much so that they have continued to bathe in NaHCO3 even after the end of the study. CONCLUSION: We maintain that even with sophisticated immunosuppressive and highly specific anti-cytokine and anti-chemokines treatments available for the treatment of psoriasis, an older and often forgotten treatment can still play a role.

Dermoscopic observation of Bowen's disease.

BACKGROUND: In the literature no specific dermoscopic criteria have been described for the diagnosis of Bowen's disease (BD). OBJECTIVE/AIM: To assess the morphological findings of BD seen under dermoscopic observation. METHODS: Clinical and dermoscopic images of 14 patients affected by BD with various amount of pigmentation were obtained by means of Heine Dermaphot. Dermoscopic images were analysed by experienced observers applying the modified pattern analysis. RESULTS: The most frequently occurring dermoscopic features were found to be: multicomponent pattern (100%); atypical vascular structures (86.6%); absence of pigmented network (64.3%) or presence of pseudo-network (35.7%); irregular diffuse pigmentation or blotches of pigment (64.2%); irregularly distributed dots and globules (64.2%); focal/multifocal hypopigmentation (78.5%), scaly surface (64.2%) and haemorrages (26.6%). CONCLUSIONS: Dermoscopically, BD is mainly characterized by a multicomponent global pattern associated with a prominent vascular pattern (mainly dotted vessels) and a scaly surface. Although no specific dermoscopic criteria can be given for BD, epiluminescence can be a valuable aid in the diagnosis of such a mimicker lesion.

Diffuse scleroderma occurring after the use of paclitaxel for ovarian cancer.

Acase of diffuse scleroderma in a 56-year-old woman who received paclitaxel for the treatment of a metastatic ovarian cancer is presented. The clinical cutaneous alterations, as well as the capillaroscopic and histological findings, were indistinguishable from those encountered in definite systemic sclerosis (SSc). In contrast to SSc, Raynaud's phenomenon and cutaneous calcinosis were absent and antinuclear antibodies were negative. The temporal relationship between the onset of skin involvement and administration of the drug may indicate an effect of paclitaxel.

Systemic lupus erythematosus induced by Epstein-Barr virus infection.

We report a 22-year-old woman who developed systemic lupus erythematosus (SLE) immediately after an Epstein-Barr virus (EBV)-induced mononucleosis infection. The link between these two conditions has long been suspected. The close temporal relationship, the course of the pathological events and the development of immunological changes in this case provide further evidence supporting the hypothesis that EBV infection could work as a trigger in some cases of SLE, particularly if the patient is genetically susceptible.

Concordance between telepathologic diagnosis and conventional histopathologic diagnosis: a multiobserver store-and-forward study on 20 skin specimens.

OBJECTIVE: To study the validity and feasibility of transferring images of cutaneous biopsy specimens via e-mail to remote physicians active in dermatopathology for teleconsultation. DESIGN: Twenty skin specimens previously diagnosed at the Department of Dermatology, University of Graz, Austria, were subsequently sent for teleconsultation using the store-and-forward method. For each case, 3 or 4 images at different magnifications were sent by e-mail to 16 colleagues (11 dermatopathologists and 5 pathologists) in 15 centers in 6 different countries. Six weeks later each observer received the hematoxylin-eosin-stained specimens to render a conventional diagnosis. SETTING: Dermatopathology and pathology units within institutional and private settings. MATERIAL: Twenty small skin biopsy specimens of cutaneous diseases were selected randomly from a study set of 80. MAIN OUTCOME MEASURE: Concordance between telepathologic diagnoses and conventional histopathologic diagnoses of 20 skin specimens. RESULTS: On average, 78% of the telediagnoses were correct (range, 60%-95%), whereas 85% of the conventional diagnoses were correct (range, 60%-95%). A perfect diagnostic concordance was obtained in 7 (35%) of 20 cases, and a significant difference was identified in only 1 case. CONCLUSIONS: Results suggest that telepathology performed by physicians active in dermatopathology may serve as a reliable technique for the diagnosis of cutaneous diseases when experts in dermatopathology are not available locally. Furthermore, teledermatopathology is attractive because it provides an opportunity to obtain timely consultation on difficult cases.

Cutaneous carcinomas and preinvasive neoplastic lesions. Role of MMP-2 and MMP-9 metalloproteinases in neoplastic invasion and their relationship with proliferative activity and p53 expression.

BACKGROUND: Metalloproteinases (MMPs) are thought to be involved in the process of destruction of basement membranes and stromal invasion by neoplastic epithelial cells. AIMS: In order to investigate the role of MMPs in cutaneous oncogenesis we studied the expression of MMP-2 and MMP-9 in 34 cases of epidermal preinvasive neoplastic lesions and invasive carcinomas. We also studied their relationship with the expression of tissue inhibitors of MMPs and with proliferative activity and p53 expression in neoplastic epithelial cells. RESULTS: MMP-9 was found to be focally expressed by neoplastic epithelial cells at the infiltrative edges in microinvasive carcinomas and in dyskeratotic foci in Bowen's disease and widely invasive carcinomas. Gradation of Mib-1 positivity and p53 expression was found with increasing abnormality in the spectrum of malignancy. CONCLUSIONS: Our results seem to suggest the involvement of MMPs in microinvasive carcinomas, which show also low proliferative activity and p53 expression, whether other factors seem to be more important in widely invasive carcinomas.