A different approach for identifying hypomelanotic macules in tuberous sclerosis complex.

AIM: Tuberous sclerosis complex is a neurocutaneous syndrome with an autosomal dominant pattern of inheritance and a high percentage of sporadic cases. One of the most interesting thing about tuberous sclerosis complex is the earliest skin manifestation represented by the hypomelanotic patches. These lesions may be difficult to diagnose. In our article we provide a different diagnostic tool in order to increase the likely of right identification of these lesions. METHODS: We used a modified starch-iodine, applied on the hypomelanotic patches of the patient and on the normal skin. It allowed to show a decreased sweat production by eccrine glands in hypomelanotic macules in TSC. This test has not been standardized yet, but it is simple and inexpensive. RESULTS: Three patients of pediatric age and 1 adult patient affected by tuberous sclerosis complex were enrolled. The test put in evidence a decreased activity of the sweat glands. CONCLUSION: The hypomelanotic patches are very common in tuberous sclerosis complex, and sometimes are the only earliest sign with few elements of this syndrome. There are different diagnostic tools like skin biopsies, but they are invasive and not always easy to perform. The opportunity of a simple and unexpensive test for helping in the right diagnosis of this syndrome should be considered.

Adnexal polyp in a newborn baby.

Birthmarks can frequently be seen in newborn babies, but their etiopathogenesis is often unclear. These lesions can be divided into three groups: vascular birthmarks, pigmented birthmarks, and birthmarks resulting in abnormal development. Some birthmarks may require further analysis and clinical follow-up in order to rule out underlying defects, malignant potential, or correlation with syndromic diseases. Presented here is the case of a newborn baby with two simultaneous birthmarks: an adnexal polyp and a nevus anemicus. Adnexal polyps are considered an uncommon clinical observation

Angles and geometric shapes, but not lines, in melanocytic lesions may be helpful in the clinical diagnosis of melanoma.

BACKGROUND: Geometric shapes have been suggested to be found in malignant melanomas. We have observed a number of melanomas presenting with linear and incomplete angulated figures. OBJECTIVE: To verify the assumption that geometric shapes, a linear border and/or incomplete angulated figures may indicate a potential melanoma. METHODS: Patients with surgically removed melanocytic lesions were admitted to the study. We evaluated the presence of a sharp linear demarcation, the presence of contiguous lines resulting in the formation of angle/s and the presence of complete geometric figure. We distinguished the obtained results into melanoma and benign melanocytic naevi. RESULTS: A total of 471 melanomas and 1979 melanocytic naevi were collected. Linear borders, angles and geometric figures were observed in 42 melanomas and in 75 benign melanocytic naevi. Angles with incomplete geometric configuration were observed in 21 melanomas and in 37 benign naevi (21/471 vs. 37/1979, 4.24% vs. 1.87%; P < 0.0016); complete even if irregular geometrical figures in 12 melanomas and 17 naevi (12/471 vs. 17/1979, 2.54% vs. 0.85%; P < 0.005). The presence of line(s) did not significantly differed in the two considered groups. CONCLUSIONS: Melanocytic lesions with angulated shapes and complete geometrical configurations might indicate a suspect melanoma. Only sharp linear demarcation of the lesion do not seem to be significantly associated with melanoma suspicion.

Clinically and/or histologically pigmented poromas in Caucasian patients.

AIM: Pigmented poromas are rarely reported and considered to be more common in non-white people and on non-acral sites. Objective of the present study was to report our cases of pigmented poromas with particular attention to the presence of clinical and/or microscopic evidence of pigmentation, their characteristics and the diagnostic pitfall with other pathologies. METHODS: All the histologically confirmed poromas observed from January 1994 to July 2012 were considered. Clinic-epidemiological data were collected. The presence of clinical pigmentation was recorded as well as the presence of melanin pigmentation or melanocytes in the histologic specimens. RESULTS: One hundred and one patients with poromas were collected. All the patients were Caucasians. All the lesions were solitary. Only three patients had a clinically visible pigmented poromas. In eight cases the presence of melanin and melanocytes did not produce a clinically visible pigmentation. All the poromas with pigmentation did not occur on palmo-plantar surfaces. CONCLUSION: Pigmented poromas may be observed even in Caucasian patients and their clinical aspect mimic basal cell carcinoma and/or melanoma. The presence of pigment visible at the histology may not be observed in the clinical expression. The absence of pigmentation on palmo-plantar location is confirmed in all the reported cases.

Observational study on the mitotic rate and other prognostic factors in cutaneous primary melanoma arising from naevi and from melanoma de novo.

BACKGROUND: Melanomas can arise from naevi or appear de novo. The frequency or the effect of their origin on prognosis is still debated. Mitotic rate (MR) and ulceration of melanomas have been proposed as further new prognostic indexes. AIM: To determine the different prognostic factors in melanomas de novo and melanomas from pre-existing naevi and whether these two melanoma groups have different MR or presence of ulceration. METHODS: All patients with confirmed primary melanomas observed in our clinic from 1996 to July 2013 were included. The distinction between the two groups of melanomas was histologically based. We compared Breslow's thickness, the number of mitosis/mm(2) and the presence of ulceration between the naevus-associated melanoma and de novo melanoma group. RESULTS: Of the 873 melanomas, 626 (71.8%) have a de novo melanoma, 247 (28.2%) a naevus-associated melanoma. Breslow's thickness was not significantly different in the two groups (0.77 ± 1.47 mm vs. 0.59 ± 1.35 mm). The number of patients with presence of ulceration and MR ≥1 mitosis/mm(2) was not significantly different in the two groups (19.6% vs. 16.3%). In thicker melanomas (Breslow's thickness ≥ 1 mm), the number of patients with ≥6 mitosis/mm(2) was significantly higher (26.6% vs. 7.9%; P < 0.05) in the de novo melanoma group. CONCLUSIONS: When mitosis ≥ 1 mm/mm(2) , the results obtained do not show a better or worse prognosis based on Breslow's thickness, ulceration and MR in melanomas associated with naevus vs. melanomas de novo. When ≥6 mitosis/mm(2) are considered, the number of patients in the de novo melanoma group with thick melanoma is highly more represented. The debate about the cut-off value of mitosis ≥1 mm(2) is open.

Unusual sites for poromas are not very unusual: a survey of 101 cases.

BACKGROUND: Poromas are benign adnexal tumours generally believed to be of eccrine origin, which usually develop on palmoplantar sites. However, it is thought that a percentage of poromas develop on non-palmoplantar or 'unusual' sites. AIM: To review cases of poromas with reference to their clinicoepidemiological characteristics, paying particular attention to the those located on sites other than the palms and soles. METHODS: All histologically confirmed poromas seen at our department between 1994 to 2012 were reviewed. The clinicoepidemiological data recorded included age at diagnosis, gender, location, size, colour, and preoperative and pathological diagnoses. RESULTS: In total, 101 poromas were reviewed, corresponding to 0.0058% of all the epithelial skin tumours biopsied in our department. The mean age was 65.05 years (range 30-100 years), and the male to female ratio was 1.52. All the lesions were solitary and asymptomatic, with no sign of bleeding. The most common presentation was a red or reddish lesion, particularly at palmoplantar sites, where 33 (32.7%) of the 101 poromas were located, Poromas found at other affected sites were more usually skin-coloured, and these lesions included 7 neoplasms located in the armpits and 18 on the head and neck. The correct preoperative diagnosis was made in 12 cases of 33 detected poromas (36%), all of which were localized to the palmoplantar surfaces. CONCLUSIONS: Based on our experience, we consider that there are no 'unusual' sites for poromas, and palmoplantar poromas were in fact in the minority. Furthermore, some localizations suggest derivation of these palmoplantar poromas from the folliculosebaceous apocrine unit.

Tinea capitis in the paediatric population in Milan, Italy: the emergence of Trichophyton violaceum.

Tinea capitis (TC) is the most common type of dermatophytosis in children. The epidemiology of TC depends on the geographical areas, and it changes over time. The aim of the study is to determine the incidence of TC and to identify the causative species in children observed at Dermatology Outpatient Department of the University of Milan, Italy, between January 2004 and December 2011. Four hundred and eighty-six children with suspected dermatomycosis were observed; TC was the most prevalent dermatomycoses with 86 cases. The most common isolated dermatophyte in scalp lesions was Trichophyton violaceum with 33 cases. The most recent epidemiological Italian studies still show zoophilic fungi as primary cause of TC. We are the first medical team in Italy to demonstrate a dominance of anthropophilic fungi, in particular T. violaceum.

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.

Tinea corporis due to Trichophyton rubrum in a woman and Tinea capitis in her 15-day-old baby: molecular evidence of vertical transmission.

We report a case of a 40-year-old Caucasian woman who came under our observation with a 7-year history of a chronic erythematous scaly dermatitis, diagnosed as psoriasis, involving gluteal area and thighs, and treated with topical steroids without benefit. During pregnancy, a progressive worsening of her condition and an extension of cutaneous lesions were observed. Her newborn, a 15-day-old girl, presented a similar scaly and squamous lesion on her scalp. Mycological examination was positive for Trichophyton rubrum in both cases, and random amplified polymorphic DNA analysis confirmed the isogenicity of the two isolates. We performed a diagnosis of T. rubrum tinea corporis and tinea capitis. The case we describe illustrates an unusual clinical presentation of tinea corporis with remarkable extension of cutaneous lesions due to the diagnostic delay and the continuous use of local steroids, together with a rare tinea capitis in the newborn. Our experience highlights the possibility of mother-child transmission and the importance of an early diagnosis.

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.

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.

An unusual bilateral areolar dermatitis.

This article describes an uncommon clinical manifestation of contact dermatitis due to dyed tissues, showing bilateral plaque lesions on the mammary areolas. The clinical history, histological and patch testing examinations confirmed the diagnosis. The possible triggering factors related with this kind of contact dermatitis and possible differential diagnosis are briefly discussed.

Keratinocytic epidermal nevus with oral involvement and cleft palate.

Epidermal nevus syndromes are a heterogeneous group of genetic disorders characterized by the presence of an epidermal nevus with visceral involvement. Keratinocytic epidermal nevus syndromes are not a clear entity, but all the reported cases showed the presence of a keratinocytic epidermal nevus associated with different systemic lesions. In our report the keratinocytic epidermal nevus syndrome is defined by the presence of the nevus on the face, intraoral lesions and cleft palate in a 1-year-old girl.