Expression of cytokines, chemokines and other effector molecules in two prototypic autoinflammatory skin diseases, pyoderma gangrenosum and Sweet's syndrome.

Pyoderma gangrenosum (PG) and Sweet's syndrome (SS) are two inflammatory skin diseases presenting with painful ulcers and erythematous plaques, respectively; both disorders have a debilitating clinical behaviour and PG is potentially life-threatening. Recently, PG and SS have been included among the autoinflammatory diseases, which are characterized by recurrent episodes of sterile inflammation, without circulating autoantibodies and autoreactive T cells. However, an autoinflammatory pattern clearly supporting this inclusion has never been demonstrated. We studied 16 patients with PG, six with SS and six controls, evaluating, using a sandwich-based protein antibody array method, the expression profile of inflammatory effector molecules in PG, SS and normal skin. The expressions of interleukin (IL)-1 beta and its receptor I were significantly higher in PG (P = 0·0001 for both) and SS (P = 0·004-0·040) than in controls. In PG, chemokines such as IL-8 (P = 0·0001), chemokine (C-X-C motif) ligand (CXCL) 1/2/3 (P = 0·002), CXCL 16 (P = 0·003) and regulated upon activation normal T cell expressed and secreted (RANTES) (P = 0·005) were over-expressed. In SS, IL-8 (P = 0·018), CXCL 1/2/3 (P = 0·006) and CXCL 16 (P = 0·036) but not RANTES were over-expressed, suggesting that chemokine-mediated signals are lower than in PG. Fas/Fas ligand and CD40/CD40 ligand systems were over-expressed in PG (P = 0·0001 for Fas, P = 0·009 for Fas ligand, P = 0·012 for CD40, P = 0·0001 for CD40 ligand), contributing to tissue damage and inflammation, while their role seems to be less significant in SS. Over-expression of cytokines/chemokines and molecules amplifying the inflammatory network supports the view that PG and SS are autoinflammatory diseases. The differences in expression profile of inflammatory effectors between these two disorders may explain the stronger local aggressiveness in PG than SS.

Drug-induced lupus erythematosus.

Drug-induced lupus erythematosus (DI-LE) is defined as an entity characterized by clinical manifestations and immunopathological serum findings similar to those of idiopathic lupus but which is temporally related to drug exposure and resolves after withdrawal of the implicated drug. Similarly to idiopathic lupus, DI-LE can be divided into systemic LE, subacute cutaneous LE (SCLE), chronic cutaneous LE (CCLE) and cutaneous LE tumidus. DI-SCLE is the most frequent variant of drug-induced cutaneous LE and presents mainly with annular-polycyclic lesions; the clinical picture is often widespread, with involvement of the lower legs that are usually spared in idiopathic SCLE. ANA and anti-Ro/SSA antibodies are typically present, whereas antihistone antibodies are uncommonly found. We have recently addressed the question whether DI-SCLE differs significantly from its idiopathic counterpart by virtue of clinical features and, based on our findings, we have suggested that the frequent occurrence of malar rash and bullous, erythema multiforme-like and vasculitic manifestations can be regarded as the hallmark of DI-SCLE. In contrast, the histology is not a useful diagnostic criterion for DI-SCLE, considering that the typical pattern of lichenoid interface dermatitis is seen only in the early stage of disease and tissue eosinophilia does not represent a differentiating histopathological feature. DI-CCLE and DI-LE tumidus, albeit possibly misdiagnosed, are rarely observed and are characterized by classic discoid lesions and erythematous-oedematous plaques on sun exposed areas, respectively. Management of DI-LE is based on the discontinuation of the offending drug; topical and/or systemic corticosteroids and other immunomodulating/immunosuppressive agents should be reserved for resistant cases.

Neutrophilic dermatoses and inflammatory bowel diseases.

Pyoderma gangrenosum (PG) and Sweet's Syndrome (SS) are inflammatory skin diseases caused by the accumulation of neutrophils in the skin and, rarely, in internal organs, which led to coining the term of neutrophilic dermatoses (ND) to define these conditions. Recently, ND have been included among the autoinflammatory diseases, which are forms due to mutations of genes regulating the innate immune responses. Both PG and SS are frequently associated with inflammatory bowel diseases (IBD), a group of chronic intestinal disorders which comprises ulcerative colitis and Crohn's disease and whose pathogenesis involves both the innate and adaptive immunity in genetically prone individuals. Patients with IBD develop PG in 1-3% of cases, while SS is rarer. PG presents with deep erythematous-to-violaceous painful ulcers with undermined borders, but bullous, pustular, and vegetative variants can also occur. SS, also known as acute febrile neutrophilic dermatosis, is characterized by the abrupt onset of fever, peripheral neutrophilia, tender erythematous skin lesions and a diffuse neutrophilic dermal infiltrate. In this review that will be focused on PG and SS, we will describe also the aseptic abscesses syndrome, a new entity within the spectrum of ND which frequently occurs in association with IBD and is characterized by deep abscesses mainly involving the spleen and skin and by polymorphic cutaneous manifestations including PG- and SS-like lesions.

Diagnosis and disease severity assessment of epidermolysis bullosa acquisita by ELISA for anti-type VII collagen autoantibodies: an Italian multicentre study.

BACKGROUND: Epidermolysis bullosa acquisita (EBA) is a rare autoimmune mucocutaneous bullous disease caused by autoantibodies against type VII collagen, a component of anchoring fibrils that stabilizes dermoepidermal adherence. Type VII collagen is composed of a collagenous domain linked by the noncollagenous (NC)1 and NC2 domains. OBJECTIVES: To assess the repeatability, sensitivity and specificity of a recently developed enzyme-linked immunosorbent assay (ELISA) for detection of anti-type VII collagen autoantibodies, and to ascertain whether they may be a marker of disease activity in EBA. METHODS: Using this ELISA, which was able to recognize autoantibodies against the NC1 and NC2 epitopes of type VII collagen, we tested 14 EBA sera, 30 healthy control sera and 113 disease control sera. RESULTS: In the EBA sera group, 12 out of the 14 samples were positive in ELISA, with autoantibody titres varying from 7·2 to 127·9UmL(-1) (cutoff value <6), the sensitivity of the method being 86%. Among the controls, only two bullous pemphigoid sera tested positive, the specificity being 98·6%. A good correlation was found between EBA disease severity, expressed as autoimmune bullous skin disorder intensity score, and the serum levels of anti-collagen VII autoantibodies, measured by ELISA (n =14; r=0·965; P=0·0001). The intra- and interassay coefficients of variation of the ELISA method ranged from 6·3% to 18·3%. CONCLUSIONS: This NC1+NC2 ELISA can be a practical assay for the diagnosis of EBA. The correlation between autoantibody titres and disease severity suggests its usefulness as a marker of disease activity in EBA However, this should be confirmed by studies on larger series of patients.

Prothrombotic state and impaired fibrinolysis in bullous pemphigoid, the most frequent autoimmune blistering disease.

Bullous pemphigoid (BP) is a potentially life-threatening autoimmune blistering disease that is burdened with an increased risk of cardiovascular events. In BP, there is an interplay between inflammation and coagulation both locally, which contributes to skin damage, and systemically, which leads to a prothrombotic state. Fibrinolysis is an important defence mechanism against thrombosis, but has only been studied locally in BP and no systemic data are available. The aim of this observational study was to evaluate systemic fibrinolysis and coagulation activation in patients with BP. We measured parameters of fibrinolysis and coagulation by immunoenzymatic methods in plasma from 20 patients with BP in an active phase and during remission after corticosteroid treatment. The controls were 20 age- and sex-matched healthy subjects. Plasma levels of plasminogen activator inhibitor type 1 (PAI-1) antigen, PAI-1 activity and tissue plasminogen activator (t-PA) antigen were significantly higher in the BP patients with active disease than in healthy controls (P = 0·0001 for all), as were the plasma levels of the fibrin fragment d-dimer and prothrombin fragment F1+2 (P = 0·0001 for both). During remission after treatment, levels of PAI-1 antigen and PAI-1 activity decreased significantly (P = 0·008 and P = 0·006, respectively), and there was also a significant decrease in plasma levels of d-dimer (P = 0·0001) and F1+2 (P = 0·0001). Fibrinolysis is inhibited in patients with active BP, due mainly to an increase in plasma levels of PAI-1. Corticosteroids not only induce the regression of BP lesions, but also reduce the inhibition of fibrinolysis, which may contribute to decreasing thrombotic risk.

Evidence for vitamin D deficiency and increased prevalence of fractures in autoimmune bullous skin diseases.

BACKGROUND: Vitamin D deficiency plays a role in autoimmune diseases and risk of fractures. No data are available on vitamin D levels and vertebral fractures in autoimmune bullous skin diseases. OBJECTIVES: To assess serum vitamin D levels and the prevalence of vertebral fractures in patients with pemphigus vulgaris (PV) and bullous pemphigoid (BP), potentially fatal autoimmune bullous disorders. METHODS: We studied 13 consecutive inpatients with untreated active PV (six men and seven women, mean ± SD age 53·5 ± 14·3 years), 15 with BP (seven men and eight women, mean ± SD age 76·9 ± 12·4 years) and 28 age-, body mass index- and sex-matched controls. The 25-hydroxyvitamin D (25-OHD) levels and presence of vertebral fractures on spinal X-ray were assessed in all subjects. RESULTS: In patients with PV, 25-OHD levels were lower (mean ± SD 12 ± 4·4 ng mL(-1) ) and prevalence of severe hypovitaminosis D higher (62%) than in controls (mean ± SD 22·2 ± 11·7 ng mL(-1) , P = 0·012; 23%, P = 0·0047, respectively). The prevalence of fractures was 54% and 31% in patients with PV and controls, respectively. Patients with BP showed lower 25-OHD levels (mean ± SD 9·6 ± 7·2 ng mL(-1) ) and higher prevalence of severe hypovitaminosis D (73%) than controls (mean ± SD 22·6 ± 18·7 ng mL(-1) , P = 0·022; 27%, P = 0·01, respectively). The prevalence of fractures tended to be higher in patients with BP than in controls (67% vs. 33%, respectively, P = 0·068). CONCLUSIONS: The low 25-OHD levels found in PV and BP may suggest a role for this agent in their pathogenesis. The increased prevalence of fractures should be taken into consideration in patients who must be given corticosteroids.

Margin involvement and clinical pattern of basal cell carcinoma with mixed histology.

BACKGROUND: Mixed basal cell carcinoma (BCC) has not been sufficiently and specifically studied. OBJECTIVE: The aim of this study was to estimate in adults the prevalence of mixed cases observed among primary BCCs and to compare clinical and anatomical features of mixed vs. single BCCs, with focus on the incomplete excision. PATIENTS AND METHODS: A total of 3636 histologically confirmed primary BCCs were examined. Data on gender, age, histological subtype, anatomical location and margin involvement were collected. Mixed type was defined as a combination of two or more single subtypes. RESULTS: Prevalence of single and mixed BCCs was 82.2% and 17.8% respectively. Prevalence of BCCs on the upper limbs was higher in mixed than single cases (8.8% vs. 4.0%; P<0.001) while prevalence on the back was lower (16.9% vs. 23.7%; P<0.001). Tumour was aggressive in 59.1% of mixed vs. 16.0% of single BCCs (P<0.001). Margin involvement was more prevalent in mixed than in single BCCs (16.7% vs. 9.6%; P<0.0001). At multivariate analysis being mixed vs. single BCC was associated with aggressiveness of tumour (OR=8.5, 95% CI, 6.9-10.4), lateral margin involvement (OR=1.98, 95% CI, 1.42-2.76) and subject being man (OR=1.31, 95% CI, 1.10-1.60) but not with deep involvement of margin or anatomical location. CONCLUSION: Among BCCs, the mixed type may be observed in adults with relatively high rate and may represent a complex and individual subset of BCCs with potential aggressive behaviour.

Localized Wegener's granulomatosis.

BACKGROUND: Wegener's granulomatosis (WG) is a rare granulomatous necrotizing vasculitis of small and medium vessels which has predilection for upper airways, lungs and kidney. However, any other organ, including the skin and oral cavity, can be involved. Although mucocutaneous lesions are relatively common, they have only rarely been reported as localized manifestation of the disease. OBJECTIVES: Our aim was to evaluate the type and sites of skin and mucosal lesions, clinical course and response to treatment, histologic features and laboratory findings in localized WG. METHODS: The medical records of three patients (two women and one man) with localized WG followed up at our hospitals for a mean time of 10 years were studied. RESULTS: All patients presented with facial plaques infiltrating the nasal and palatal mucosae and cartilages and, in one case, perforating the palatal bone. Anti-neutrophil cytoplasmic antibodies, which are the marker for multisystem WG, were negative. The disease, refractory to various immunosuppressants, responded well, albeit incompletely, to prednisone plus cyclophosphamide. LIMITATIONS: The limited number of patients is counterbalanced by the rarity of the disease. CONCLUSIONS: Our cases may represent a rare distinctive subset of WG limited to the facial region and upper airway mucosa but showing a locally aggressive behaviour leading to cartilage and bony destruction.

Circumscribed palmar or plantar hypokeratosis: report of an italian case.

Circumscribed palmar or plantar hypokeratosis is a rare benign epidermal malformation of the skin. Clinically it shows asymptomatic, well-circumscribed, and depressed erythema persisting for many years on the palms or soles. Its main histopathologic feature shows a characteristic epidermal depression with an abrupt decrement in the thickness of the stratum corneum, with a sharp stair between normal and involved skin. We describe a case of a 68-year-old woman who presented with an erythematous, asymptomatic, well-circumscribed, depressed patch, on the right thenar eminence which had been present for years.

Inflammatory cells, cytokines and matrix metalloproteinases in amicrobial pustulosis of the folds and other neutrophilic dermatoses.

Amicrobial pustulosis of the folds (APF) is a rare cutaneous disease characterized by relapsing sterile pustules frequently associated with autoimmune disorders. Although APF pathophysiology is still undefined, scattered reports suggest involvement of neutrophils. The aim of the present study is to evaluate the role of the skin inflammatory infiltrate, selected multifunctional cytokines and effectors of tissue damage in APF and other neutrophilic dermatoses. We studied, by immunohistochemical methods, inflammatory cell markers (CD3, CD163, myeloperoxidase), cytokines (TNF-alpha, IL-8, IL-17), metalloproteinases (MMP-2, MMP-9) and vascular-endothelial-growth-factor (VEGF) in lesional skin from six patients with APF, 11 with pyoderma gangrenosum (PG), 7 with Sweet's syndrome, and in 20 normal skin samples. Immunoreactivities of CD3, CD163, myeloperoxidase, TNF-alpha, IL-8, IL-17, MMP-2, MMP-9 and VEGF were significantly higher in APF, PG and Sweet's syndrome than in controls (p=0.0001). IL-8 was more expressed in PG than in APF (P=0.002) and Sweet's syndrome (p=0.001). In APF, MMP-9 reactivity was higher than in Sweet's syndrome (p=0.035), but less intense than in PG (p=0.020). Our study supports the role of proinflammatory cytokines/chemokines and MMPs as important effectors for the tissue damage in APF similarly to classic neutrophilic dermatoses.

Axillary basal cell carcinoma: additional 25 patients and considerations.

BACKGROUND: Axillary basal cell carcinoma represents a rarely described occurrence in world literature. OBJECTIVE: To report our 14 years' experience of axillary basal cell carcinomas. METHODS: A review of Pathology department database is given. RESULTS: Twenty-five further patients with axillary basal cell carcinomas of 7367 basal cell carcinomas diagnosed are reported. These represent a percentage of 0.33%.The average age of patients was 64.96 years, not significantly different from the average age of patients with overall basal cell carcinomas. No patient had had previous radiant or immunosuppressive treatment or axillary sunburn. No patient had basal cell naevus syndrome. The subtypes involved were superficial and nodular. No patient of 17 patients followed up had recurrences or metastasis after 5 years of follow-up. CONCLUSION: Axillary Basal cell carcinomas are rare. No particular predisposing or risk factor is recorded. They do not seem to be significantly more aggressive than other basal cell carcinomas.

Drug-induced subacute cutaneous lupus erythematosus: evidence for differences from its idiopathic counterpart.

BACKGROUND: Drug-induced subacute cutaneous lupus erythematosus (DI-SCLE) is a lupus variant with predominant skin involvement temporally related to drug exposure and resolving after drug discontinuation. It usually presents with annular polycyclic or papulosquamous eruptions on sun-exposed skin and shows serum anti-Ro/SSA antibodies. OBJECTIVES: To address the question whether DI-SCLE differs significantly from idiopathic SCLE by virtue of clinical features. METHODS: Ninety patients with SCLE seen in our departments from 2001 to 2010 were reviewed. Eleven of them diagnosed as having DI-SCLE were evaluated for type of skin lesions, systemic involvement, clinical course, and histopathological, direct immunofluorescence and laboratory findings. The cutaneous features were compared with those of the 79 patients with idiopathic SCLE. RESULTS: The cutaneous picture was widespread in 82% of patients with DI-SCLE and in 6% of those with idiopathic SCLE [odds ratio (OR) 66·6, 95% confidence interval (CI) 11·2-394·9; P = 0·0001]. Bullous and erythema multiforme (EM)-like lesions were present in 45% of patients with DI-SCLE and in 1% of those with idiopathic SCLE (OR 65·0, 95% CI 6·5-649·6; P = 0·0001). Vasculitic lesions were observed in 45% of patients with DI-SCLE and in 3% of those with idiopathic SCLE (OR 32·1, 95% CI 5·1-201·7; P = 0·0001). Malar rash occurred in 45% of patients with DI-SCLE and in 6% of those with idiopathic SCLE (OR 12·3, 95% CI 2·8-54·9; P = 0·001). Visceral manifestations were excluded in all patients with DI-SCLE. Anti-Ro/SSA antibodies were found in all but one patient with DI-SCLE and disappeared after resolution in 73% of cases. CONCLUSIONS: DI-SCLE differs from idiopathic SCLE by virtue of distinctive cutaneous features, particularly the widespread presentation and the frequent occurrence of malar rash and bullous, EM-like and vasculitic manifestations.

Spindle and/or epithelioid cells nevi in pediatric age: are they different from those of adults? A clinical review of 187 cases.

AIM: Spindle and/or epithelioid cells nevi represent the spectrum of a clinico-pathologic entity with different characteristics. Aim of the study is to provide information about the differences in characteristics of these nevi for different groups of age. METHODS: Two different groups are considered: younger than 15 years and older than 15 years. An analysis of 187 spindle and/or epithelioid cells nevi was performed. Forty-five pediatric patients (24 males and 21 females) and 142 adult patients (44 males and 98 females) were examined. Age, sex, type of nevus, location, clinical characteristics were evaluated. RESULTS: Spindle and epithelioid cells nevi were observed in 53% of the pediatric and in 45% of adult patients. Female more frequently presented with spindle nevus cell both in pediatric (56%) and in adult (70%) cases. In pediatric patients, the anatomical distribution was prevalent in the areas of the head and neck. Pigmentation was not a distinctive feature of pediatric cases and only interested the spindle and epithelioid cells nevi. The regularity of borders was not a distinctive character for neither of the groups of patients. Uniformity in color occurred more frequently in pediatric patients. CONCLUSION: Spindle and/or epithelioid nevi belong to the same spectrum of pathologies, they behave differently in the different groups of age thus permitting a certain degree of clinical distinction in different age groups.

Activation of coagulation in bullous pemphigoid and other eosinophil-related inflammatory skin diseases.

Bullous pemphigoid (BP) is a skin disease caused by autoantibodies to hemidesmosomal proteins BP180 and BP230, with eosinophils participating in blister formation. Tissue factor (TF), the initiator of coagulation, is embodied within the eosinophil granules and exposed upon activation. We evaluated the coagulation activation in patients with BP (63), chronic urticaria (CU; 20), atopic dermatitis (AD; 14), cutaneous drug reactions (CDRs; six), psoriasis (20), dermatitis herpetiformis (DH; four) and primary cutaneous T cell lymphoma (CTCL; five), and in 40 healthy controls. Prothrombin fragment F1+2 and d-dimer (coagulation markers) were measured by enzyme-linked immunosorbent assay (ELISA) in all plasma samples and BP blister fluid. Skin TF expression was evaluated immunohistochemically in the patients and 20 controls. F1+2 and d-dimer levels were higher in BP plasma than in control plasma (P = 0·0001 for both), and dramatically high in blister fluid; both correlated positively with disease severity, esinophil counts and anti-BP180 antibodies (P = 0·006-0·0001). Plasma F1+2 and d-dimer levels were higher in the CU, AD and CDR patients than in controls (P = 0·0001 for all), but normal in the psoriasis, DH and CTCL patients. Skin TF was expressed in the BP (P = 0·0001), CU (P = 0·0001), AD (P = 0·001) and CDR patients (P = 0·01), but not in the psoriasis, DH or CTCL patients. Co-localization confocal microscopy studies confirmed eosinophils as the source of TF in 10 BP patients. The coagulation cascade is activated in BP and other eosinophil-mediated skin disorders, but not in non-eosinophil driven conditions. This hypercoagulability may contribute to inflammation, tissue damage and, possibly, thrombotic risk.

New monoclonal antibodies against B-cell antigens: possible new strategies for diagnosis of primary cutaneous B-cell lymphomas.

Reactivities of the monoclonal antibodies (mAbs) of the 9th Human Leukocyte Differentiation Antigen Workshop, in order to define specific antigenic expression of the primary cutaneous B-cell lymphomas (PC-BCL), were analyzed by immunohistology on human tonsil and on PC-BCL, such as follicular centre B-cell lymphomas (FCL), marginal zone lymphomas (MZL) and diffuse large B-cells lymphomas leg-type (DLBL-LT). We identified some subgroups of mAbs that were exclusively or preferentially positive in one lymphoma cell type: the PC-FCL subgroup of mAbs includes PD1/CD279, GCET-1, hFCRL1/CD307a, FCRL2/CD307b, CXCR5/CD185, B7-DC/CD273, MRC/CD200, CD130, CXCR4/CD184, Siglec-5/14, CD150, on the other hand subgroup of mAbs in PC-MZL includes BTLA/CD272, BLIMP-1, hCD38. No specific subgroup of mAbs was found to label PC-DLBCL. This study may be useful to better define specific antigen profile of different PC-BCL entities leading to a correct diagnosis.

Role of inflammatory cells, cytokines and matrix metalloproteinases in neutrophil-mediated skin diseases.

Pyoderma gangrenosum (PG) is a rare, immune-mediated inflammatory skin disease presenting with painful ulcers having undermined edges. Less commonly, bullous and vegetative variants exist. Histology consists of a neutrophil-rich dermal infiltrate. We characterized immunohistochemically the infiltrate in different variants of PG and in another neutrophilic dermatosis as Sweet's syndrome. We studied 21 patients with PG, eight with Sweet's syndrome and 20 controls, evaluating skin immunoreactivity for inflammatory cell markers (CD3, CD163 and myeloperoxidase), cytokines [tumour necrosis factor (TNF)-α, interleukin (IL)-8 and IL-17], metalloproteinases (MMP-2 and MMP-9) and vascular endothelial growth factor (VEGF). Immunoreactivities of CD3, CD163, myeloperoxidase, TNF-α, IL-8, IL-17, MMP-2, MMP-9 and VEGF were significantly higher in both PG and Sweet's syndrome than in controls (P=0·0001). Myeloperoxidase (neutrophil marker), IL-8 (cytokine chemotactic for neutrophils) and MMP-9 (proteinase-mediating tissue damage) were expressed more significantly in both ulcerative and bullous PG than in vegetative PG as well as in Sweet's syndrome (P=0·008-P=0·0001). In ulcerative PG, the expression of CD3 (panT cell marker) and CD163 (macrophage marker) were significantly higher in wound edge than wound bed (P=0·0001). In contrast, the neutrophil marker myeloperoxidase was expressed more significantly in wound bed than wound edge (P=0·0001). Our study identifies PG as a paradigm of neutrophil-mediated inflammation, with proinflammatory cytokines/chemokines and MMPs acting as important effectors for the tissue damage, particularly in ulcerative and bullous PG where damage is stronger. In ulcerative PG, the wound bed is the site of neutrophil-recruitment, whereas in the wound edge activated T lymphocytes and macrophages pave the way to ulcer formation.

Herpes simplex virus infection and pemphigus.

Pemphigus is a group of autoimmune blistering diseases of the skin and/or mucous membranes caused by the presence of antibodies against adhesion molecules on the cell surface of keratinocytes. In genetically predisposed patients, several factors, including drugs, physical agents, neoplasms, hormones, and viruses, notably herpes simplex virus (HSV), have been hypothesized to trigger or exacerbate the disorder. To clarify whether HSV infection represents an aetiopathogenetic factor for pemphigus or a consequence of the immunosuppressive treatment, skin and/or mucosal swabs from 35 patients with pemphigus vulgaris or pemphigus foliaceus were tested for HSV by polymerase chain reaction. Twenty-three of these patients were newly diagnosed, while the remaining 12 had had a previous diagnosis and were under treatment with low-dosage oral corticosteroids. Repeat swabs were taken two weeks after starting intensive immunosuppressive therapy in 8 HSV-negative patients. All skin swabs (n=27) resulted negative for both HSV-1/2, while oral swabs (n=30) were positive for HSV-1 in 5 out of the 12 patients who were being treated with oral corticosteroids, but in none (n=19) of the non-treated group (p=0.0067, X2 test). Five out of the 8 patients with repeat swabs became positive for HSV-1, prompting us to start antiviral therapy. In conclusion, HSV is unlikely to be a triggering factor for pemphigus, but its presence in pemphigus lesions seems to be a frequent and early complication of immunosuppression.

Drug-induced lupus: an update on its dermatologic aspects.

Drug-induced lupus erythematosus (DILE) is defined as an entity characterized by clinical manifestations and immunopathological serum findings similar to those of idiopathic lupus but which is temporally related to continuous drug exposure and resolves after discontinuation of the offending drug. Similar to idiopathic lupus, DILE can be divided into systemic lupus erythematosus (SLE), subacute cutaneous lupus erythematosus (SCLE) and chronic cutaneous lupus erythematosus (CCLE). Based on the literature review and retrospective analysis of our case series, we focused on the dermatological aspects of DILE. The cutaneous features of drug-induced SLE are protean, including particularly purpura, erythema nodosum and photosensitivity as well as the skin lesions characterizing both urticarial and necrotizing vasculitis. The typical laboratory profile of systemic DILE consists of positive antinuclear antibodies (ANA) and antihistone antibodies, the latter being regarded as the serum marker of this subset. The drugs most frequently implicated in the development of systemic DILE are hydralazine, procainamide, isoniazid and minocycline. Drug-induced SCLE usually presents with annular polycyclic or papulosquamous cutaneous manifestations as in the idiopathic form, but blisters or targetoid lesions mimicking erythema multiforme cannot rarely be associated. The clinical presentation is often generalized, with involvement of the lower legs that are usually spared in idiopathic SCLE. ANA and anti-Ro/SSA antibodies are usually present, whereas antihistone antibodies are uncommonly found. Drugs associated with SCLE include particularly calcium channel blockers, angiotensin-converting enzyme inhibitors, thiazide diuretics, terbinafine and the recently reported tumour necrosis factor (TNF)-alpha antagonists. Drug-induced CCLE is very rarely described in the literature and usually refers to fluorouracile agents or TNF-alpha antagonists. The picture is characterized by the occurrence of classic discoid lesions, but aspects of lupus tumidus can occasionally develop. ANA are demonstrated in around two-thirds of the cases. Management of DILE is based on the withdrawal of the offending drug. Topical and/or systemic corticosteroids and other immunosuppressive agents should be reserved for resistant cases.

Coagulation activation in autoimmune bullous diseases.

The main autoimmune blistering skin disorders are pemphigus vulgaris (PV) and bullous pemphigoid (BP). They differ in the inflammatory infiltrate, which is more intense in BP. Inflammation is known to activate coagulation in several disorders. Local and systemic activation of coagulation was evaluated in BP and PV. We studied 20 BP patients (10 active and 10 remittent), 23 PV patients (13 active and 10 remittent) and 10 healthy subjects. The coagulation markers prothrombin fragment F1+2 and D-dimer were measured by enzyme-immunoassays in plasma. The presence of tissue factor (TF), the main initiator of blood coagulation, was evaluated immunohistochemically in skin specimens from 10 patients with active PV, 10 patients with active BP and 10 controls. Plasma F1+2 and D-dimer levels were significantly high in active BP (P = 0.001), whereas in active PV the levels were normal. During remission, F1+2 and D-dimer plasma levels were normal in both BP and PV. TF immunoreactivity was found in active BP but neither in active PV nor in normal skin. TF reactivity scores were higher in active BP than in controls or active PV (P = 0.0001). No difference in TF scores was found between active PV and controls. BP is associated with coagulation activation, which is lacking in PV. This suggests that BP but not PV patients have an increased thrombotic risk. The observation that thrombotic complications occur more frequently in BP than in PV further supports this view.

Clinical features of 36 cases of amelanotic melanomas and considerations about the relationship between histologic subtypes and diagnostic delay.

BACKGROUND: Amelanotic melanomas (AM) are a difficult diagnostic challenge for clinicians. OBJECTIVE: To consider the clinical presentation of AM, the histologic subtypes involved, the relationship with the diagnostic delay and the possible involvement in overall prognosis. PATIENTS/METHODS: Patients who were observed in our department to be affected by cutaneous melanomas were recorded. Sex, age, the clinical features, the site of presentation, the suspected diagnosis, the clinical course, the histological type, the Clark level and the Breslow thickness were recorded. AM were divided in three main clinical types: an erythematous macule or patch on sun-exposed skin, a dermal plaque or nodule without a particular epidermal change, an exophytic nodule. Only pure AM were considered. Histological subtypes considered were superficial spreading melanoma, nodular melanoma, and lentigo maligna melanoma. Diagnostic delay considered from when the patients first noticed the lesion on the site where the melanoma was diagnosed and when the physician or the patient first proposed the removal was recorded. The chi-squared test was used for statistical evaluation with P < 0.05 as level of significance. RESULTS: Thirty-six cases of AM out of a total of 500 melanomas (7.2%) were collected. The most frequent morphology of clinical presentation was the papulo-nodular form, followed by the plaque form. Mean Breslow thickness of AM was 1.72 mm compared to 0.61 mm of pigmented cases. Nodular histotype was highly represented in AM (30.5% of cases) with respect to pigmented nodular melanomas (2.9%). The diagnostic delay did not differ between amelanotic and pigmented melanomas, nor between nodular AM and nodular pigmented melanomas. CONCLUSION: The great prevalence of clinical and histological nodular cases, the higher mean Breslow thickness (considered as the most important factor of prognosis) of AM compared with a not significant greater diagnostic delay may point out that a good percentage of AM have an intrinsic faster speed of growth with a worse prognosis irrespectively of the diagnostic performance. The importance of educational campaign for patient and physicians is stressed.