Molluscum contagiosum in pediatric patients: to treat or not to treat? Could a personalized imiquimod regimen be the answer to the dilemma?

BACKGROUND: Although molluscum contagiosum virus (MCV) infection is a common disease widespread among children and young adults, there is no shared opinion on treatment that can be divided into physical, chemical, medical (immunomodulating or anti-viral). According to some authors, MCV is best left to clear by itself. OBJECTIVES: To assess the clearance of MCV lesions in a sample of pediatric patients. It compares outcomes in treated with Imiquimod cream, compared with non-treated patients. METHODS: The sample consits of 48 pediatric patients affected by MVC clinically diagnosed. It was divided into two groups: Group I, treated with Imiquimod 5% cream once/day until the onset of a visible inflammatory reaction. Once the reaction was illicited, application was suspended until the irritation resolved. If the lesion was still present, drug was administered again using the same regimen. The cycle was repeated until complete clinical resolution. Group II, control, comprises non-treated patients. Follow up visits were carried out 12, 16, 20, 48, and 52 weeks from the beginning of treatment. RESULTS: At week 20, all patients except one in the treated group were lesion free. Persistence of MCV lesions was documented in one patient only until week 48. In the control group all patients were still affected by MCV lesions during the follow-up period. Spontaneous clinical resolution of the infection was observed in only 2 patients at week 52. The results of the study show Imiquimod's significant efficacy. CONCLUSIONS: Our study is one of the few case-control studies in pediatric population carried out with such long-term follow-up. Efficacy of this personalized treatment, scarce recurrence, absence of cicatricial sequelae and lack of necessity for deep sedation, in the case of children with disseminated lesions, makes the use of Imiquimod the first line of treatment compared with other destructive treatments or with no-treatment at all.

The association between vitamin D deficiency and the risk of resistant hypertension.

Background: Previous studies have already shown a link between vitamin D deficiency and hypertension. The impact of vitamin D deficiency in resistant hypertension is currently unknown. This study examined whether an association between the two entities exists.Method: We analysed 2953 known hypertensive subjects surveyed by NHANES (National Health and Nutrition Examination Survey) among the United States population between 2003 and 2006. Subjects were categorized as having either resistant hypertension or hypertension based on the number of anti-hypertensives in use and their overall blood pressure control. Subjects were also categorized as vitamin D deficient if they had 25(OH)D (25-hydroxycholecalciferol) levels less than 20ng/ml.Results: Out of the 2953 subjects, 362 (12%) were found to have resistant hypertension and 2591 (88%) had controlled hypertension. The prevalence of vitamin D deficiency in resistant hypertension and controlled hypertension groups was 61% and 46% respectively. Following adjustments for other variables such as age, renal function, obesity and ethnicity, the odds ratio (OR) for concomitant presence of resistant hypertension and vitamin D deficiency was 3.49 (95% confidence interval [CI] 1.69-7.17; P < 0.009). The OR for having resistant hypertension and chronic kidney disease, older age and obesity were 2.5 (95% CI 1.5-4; P < 0.0003), 1.034 (95% CI 1.02-1.07; P < 0.0001) and 1.048 (95% CI 1.02-1.07; P < 0.0001) respectively.Conclusion: This study found a statistically significant association between vitamin D deficiency and resistant hypertension.Abbreviations: US, United States; NHANES, National Health and Nutrition Examination Survey; UVB, ultraviolet B; PTH, parathyroid hormone; IRB, Institutional Review Board; NCHS, National Centers for Health Statistics; BMI, body mass index; BP, blood pressure; ACE, angiotensin-converting-enzyme; RIA, Radio Immuno Assay; SAS, Statistical Analysis System; 25(OH)D or 25OHD3, 25-hydroxycholecalciferol or 25-hydroxyvitamin D3 or calcifediol or calcidiol; Vitamin D3, cholecalciferol; OR, odds ratio; CI, confidence interval.

Malignant Melanoma Treated with Topical Imiquimod: A Bespoke Treatment That Spared the Amputation.

Surgical excision represents the primary treatment for malignant melanoma. On occasion, however, surgery may not be possible, and a different approach is required. Imiquimod is a Toll-like receptor 7 agonist involved in the activation of the innate immune system. We report the case of a 77-year-old female with a large, invasive, malignant melanoma of the malleolar area. Due to the size of the lesion, its location, and the patient's general condition, neither surgery nor radiotherapy were indicated. We offered topical treatment with 5% imiquimod to be applied once/day continuously over a 3-month period, pausing only when intense inflammation on the area of application occurred. Complete clinical and histological resolution of the lesion were observed. This case adds further merit to the growing body of evidence that imiquimod can be used to successfully treat malignant melanoma in cases where no other options are suitable.

Basal cell carcinoma arising from an epidermal cyst: when a cyst is not a cyst.

Malignant degeneration within epidermal cysts is very rare. However, these lesions may not be recognised clinically, and histological examination plays an important role in arriving at a correct diagnosis. Hence, we believe that benign-looking cystic lesions with a history of progressive growth should be surgically excised and submitted for histopathological assessment.

Long-Term Response of Classic Kaposi's Sarcoma to Intralesional Doxorubicin: A Case Report.

Classic Kaposi's sarcoma (KS) is a disease with low mortality but high morbidity. The optimum treatment of KS depends upon several factors, including location of lesions, disease progression, severity of symptoms and patient preference. We report the long-term response to the use of intralesional doxorubicin to successfully treat a large cutaneous lesion of KS on a patient refractory to traditional treatments.

Evaluation of follicular T-helper cells in primary cutaneous CD4+ small/medium pleomorphic T-cell lymphoma and dermatitis.

BACKGROUND: CD4+ small/medium-sized pleomorphic T-cell lymphoma (SMPTCL) is a controversial primary cutaneous lymphoma, in which the candidate neoplastic cells express a follicular T-helper phenotype. We describe 16 cases of SMPTCL and compare expression of PD-1, CXCL-13 and ICOS in these tumors with 40 dermatitis cases. METHODS: Histopathologic examination and immunocytochemistry were performed for 16 tumors and 40 assorted dermatitis cases. RESULTS: All but one patient presented with solitary lesions. Each biopsy revealed a dense nodular non-epitheliotropic infiltrate of atypical T-cells. Neoplastic cells were CD3+/CD4+/CD8(-)/CD30(-). Cutaneous recurrence occurred in one patient over a median follow up of 8 months (range 5-36). All tumors widely expressed PD-1 and ICOS to a lesser extent. CXCL-13 stained much fewer cells. Of the dermatitis cases, PD-1 (most numerous) and ICOS labeled lymphoid cells in all cases, albeit fewer than in the tumors, and CXCL-13 was negative in 32. A rosette pattern of PD-1 expression was identified in all the SMPTCL cases but not in dermatitis. CONCLUSIONS: There remains uncertainty about the appropriate nosological status of SMPTCL, which some authors consider to be a pseudolymphoma. However, this study suggests a significant difference in the prevalence and pattern of follicular T-helper cell markers between this tumor and lymphoid proliferations known to be reactive.

Extragenital lichen sclerosus et atrophicus mimicking cutaneous T-cell lymphoma: report of a case.

Early lesions of lichen sclerosus et atrophicus (LSA) may present as a mild lichenoid tissue reaction, occasionally together with basilar epidermotropism, mimicking early cutaneous T-cell lymphoma, mycosis fungoides (MF) variant. We report a case of extragenital LSA in which both histological patterns were present in the same clinically homogenous and stable lesion. A 27-year-old man presented with a history of white atrophic plaques on the trunk. A biopsy of an abdominal lesion revealed epidermal thinning, a superficial perivascular lymphoid cell infiltrate with focal epidermotropism, mild nuclear atypia and perinuclear halos. Immunophenotyping showed decreased CD5 and CD7, with a slight predominance of CD8-positive T-lymphocytes. All these changes were suggestive of MF. However, a repeat biopsy 3 months later from the same stable plaque revealed features diagnostic of LSA. LSA mimicking early MF histologically has been reported in genital skin. Conversely, MF may clinically and histopathologically resemble LSA. With gene rearrangement studies, clonal proliferation may not be detected in early MF but has been reported to occur in LSA. Awareness of the histopathologic spectrum of LSA within a stable plaque is important to avoid a potential diagnostic pitfall, and should prompt a repeat biopsy.

Histopathologic evidence of the nondermatophytic mould Scopulariopsis brevicaulis masking the presence of dermatophytes in a toenail infection.

Nondermatophytic toenail infection with Scopulariopsis brevicaulis is rare, but may occur often in association with dermatophytes. We report a case of an 84-year-old man who presented with onychomycosis of the big toenail. Histopathologic examination of the avulsed nail showed evidence of S. brevicaulis coinfection with a dermatophyte, despite negative mycology results for the latter. Our case underscores the importance of histopathologic examination of nail specimens as an additional invaluable tool in the diagnosis of onychomycosis, as it may unmask false-negative mycology findings.

Eotaxins and CCR3 receptor in inflammatory and allergic skin diseases: therapeutical implications.

Cell migration is mediated by a group of chemotactic cytokines called chemokines: low molecular weight molecules that have been shown as important leukocyte chemical attractants to sites of inflammation and infection. Eotaxin-1, also called CCL11, was first described in 1994, as a highly specific eosinophils chemokine. Many cell types including lymphocytes, macrophages, bronchial smooth muscle cells, endothelial cells and eosinophils, are able to produce this chemokine, predominantly after cytokine stimulation, however little is known about its expression in human skin in vivo. Eotaxin-1 also regulates the chemiotaxis and, in some conditions, activation of basophils, mast cells and T lymphocytes. Chemokine receptors are named from their ligand families, thus the CC chemokine eotaxin-1 binds to the CCR3 receptor which is expressed on eosinophis, mast cells, Th2 type lymphocytes and even on keratinocytes. It seems that eotaxin-1 is one of the most important cytokines involved in tissue inflammation playing a central role in the pathogenesis of allergic airway diseases (asthma and rhinitis), in inflammatory bowel disease and gastrointestinal allergic hypersensitivity and recently it has been proposed as a therapeutical target for these conditions. Our group has studied the role of eotaxin-1 in the pathogenesis of two skin conditions: dermatitis herpetiformis and AIDS-associated eosinophilic folliculitis, demonstrating that this chemokine, together with Th2 type cytokines (IL-13 and IL-4) is important in cell recruitment, inflammation and tissue damage; moreover eotaxin has proven to paly an important role in other skin conditions such as, bullous pemphigoid, pemphigoid gestationis, atopic dermatitis and allergic drug reactions Recent advances in the understanding of eotaxin-1-mediated mechanisms of chemotaxis in allergic and inflammatory conditions may predict that therapeutic antagonism is achievable. This paper will focus on the role that eotaxin and its receptor play in the pathogenetical mechanism in a number of dermatologic diseases, some of which, like atopic dermatitis, may benefit from the introduction of novel and more selective therapeutic options.

Autoimmune subepidermal bullous skin diseases: the impact of recent findings for the dermatopathologist.

In recent years improved knowledge of the mechanisms of intercellular and cell-matrix adhesion has led to better understanding of the blistering process in many bullous dermatoses. The wide characterisation of adhesion molecules has partially changed some traditional views and invariably has made the routine work of the pathologist more complex. If understanding cell-cell cohesion structures such as desmosomes and adherens junctions is complex enough, the cell-matrix adhesion structures, such as hemidesmosomes and their structural analogues on the basement membrane and superficial dermis, are even more complex. Defects of such structures cause the subepidermal bullous diseases in which there has been most characterisation of the adhesion molecules and has also led to the discovery of new diseases (e.g. p200 pemphigoid). Most of the antigens are also the targets for mutations seen in patients with the inherited type of epidermolysis bullosa, a group of rare blistering genodermatoses. Another important aspect of bullous skin conditions is the more accurate definition of the role of the different inflammatory cells involved in triggering, development and maintenance of these diseases. Recent studies have outlined the important role of T-cell lymphocytes and their cytokines in their pathogenesis. All these studies, based mainly on highly sophisticated ultrastructural and molecular biology techniques, have updated our knowledge of the pathogenesis of blistering diseases. Nevertheless, the diagnostic characterisation of bullous diseases remains sometimes difficult, and some pathological features and mechanisms still represent an enigma. Diseases such as bullous pemphigoid and cicatricial pemphigoid, or anti-laminin cicatricial pemphigoid and acquired bullous epidermolysis share the same molecular target but have very different clinical manifestations. Explaining this phenomenon, probably linked to different expressions of MHC, is one of the challenges for the future.