Topical treatment of eczematous external otitis involving the ear canal: long-term results of a trial comparing pimecrolimus 1 per cent versus clobetasone butyrate 0.05 per cent.

BACKGROUND: Eczematous external otitis is a common chronic condition that can have a significant impact on the life of sufferers, causing constant discomfort and pruritus, and leading to sleep deprivation. Treatment is based on the use of topical steroids, moisturisers and occasionally antibiotics. Results, however, can be disappointing, especially over the long term. METHODS: This study compared the long-term response to pimecrolimus, administered to a group of 11 patients, against clobetasone butyrate, administered to an equivalent number of patients. Response to the treatment was assessed and statistically analysed at 3 and 12 months. CONCLUSION: Whereas the degree of improvement following the use of pimecrolimus and clobetasone butyrate was similar for the two groups at month 3, a highly statistically significant difference was documented at month 12, with a much greater and sustained improvement in the pimecrolimus group.

Symmetric bilateral transposition flap: a very versatile option in facial dermatological surgery.

AIM: Repair following excision of large tumours of the face can be problematic; primary closure may not be achievable and grafting or secondary intention healing carry the risk of necrosis and lengthy healing times. Flaps are usually associated with earlier healing and better cosmetic results, as the skin used for closure is similar to the tissue requiring repair. However, large wound sizes and difficulty in finding a suitable donor area means flaps can be complicated to perform. The aim of this paper was to identify a comparatively quick and simple alternative to standard repair techniques for the closure of large wound defects in critical anatomical areas, when the only realistic alternative would be grafting, offering both good cosmetic results and minimal risk of complications. RESULTS: We have developed a flap, modified from the classic, single lobe transposition flap. Two similar lobes placed symmetrically and perpendicularly to two opposite sides of the surgical wound are incised with fulcra centred on two opposite corners. The flaps are then rotated by approximately 80-90º into position side by side, sutured to the borders of the surgical wound and finally together with a longitudinal suture. The principle behind this flap is the split of the covering surface into 2 small units, rather than using a large single lobe, which, for large wounds, would make closure of the single donor area by first intention impossible. The split of the donor area in 2 smaller subunits makes it easier to close the two donor areas and allows a larger amount of tissue to be harvested. CONCLUSION: We have developed a twinned symmetric transposition flap to close large wounds on the face when the only realistic alternative would have been the use of grafting. It offers minimal distortion, and is both quick and simple to perform. The use of tissue similar to the original defect ensures good cosmetic results. Healing times were usually very rapid and complications limited to a very few cases of end flap necrosis. This technique is not applicable where donor areas fall in anatomic spots where harvesting of the lobes is impossible, e.g. when the wound is too close to the hair line and transposition of the lobes would cause the transfer of hairy skin to an area where the presence of hair is not desirable.

Alitretinoin: a useful agent in the treatment of hidradenitis suppurativa, especially in women of child-bearing age.

AIM: Despite a better insight into its pathogenesis, hidradenitis suppurativa (HS) remains very frustrating to treat. Acitretin has been described as one of the agents with the highest effective profile. Acitretin however, due to its teratogenicity and prolonged half-life (up to three years) is not an option in young women of fertile age who, unfortunately, are the target of this disease. Alitretinoin has a similar pharmacology action to acitretin, but much shorter half-life (only four weeks), making it a far much more attractive option compared to acitretin for women of child-bearing age. The aim of this paper was to evaluate the use of alitretinoin in treating recalcitrant cases of HS, which have not been responsive to standard treatments. METHODS: Fourteen patients (all female, of child-bearing age), who persistently failed traditional treatments, were treated with alitretinoin 10 mg/day for 24 weeks. The disease trend was evaluated by using both Sartorius and Dermatology Life Quality Index scores at time 0, at week 12 and at week 24. RESULTS: A significant improvement was recorded in 78.5% of the cases. CONCLUSION: Although more studies are necessary, this preliminary study shows that alitretinoin may have a role in the treatment of HS specifically in women of fertile age.

Catamenial dermatoses: has anyone ever considered prostaglandins?

Catamenial dermatoses are unusual, cyclic, perimenstrual reactions to hormones produced during the menstrual cycle. They occur in a variety of clinical presentations, including urticaria, eczema, fixed drug eruptions, erythema multiforme and anaphylaxis. Autoimmune progesterone dermatitis is the most common, and is caused by an autoimmune response to endogenous progesterone in women of reproductive age. We report a case of catamenial dermatosis in a 42-year-old Jamaican woman with a 10-year history of cyclic blistering and ulcerative eruptions of her mouth and limbs. Her symptoms were fully in keeping with a Stevens-Johnson-type reaction, and were associated with production of prostaglandins occurring during her menstrual cycle.

Metformin for the treatment of hidradenitis suppurativa: a little help along the way.

BACKGROUND: Despite recent insights into its aetiology, hidradenitis suppurativa (HS) remains an intractable and debilitating condition for its sufferers, affecting an estimated 2% of the population. It is characterized by chronic, relapsing abscesses, with accompanying fistula formation within the apocrine glandbearing skin, such as the axillae, ano-genital areas and breasts. Standard treatments remain ineffectual and the disease often runs a chronic relapsing course associated with significant psychosocial trauma for its sufferers. OBJECTIVE: To evaluate the clinical efficacy of Metformin in treating cases of HS which have not responded to standard therapies. METHODS: Twenty-five patients were treated with Metformin over a period of 24 weeks. Clinical severity of the disease was assessed at time 0, then after 12 weeks and finally after 24 weeks. Results were evaluated using Sartorius and DLQI scores. RESULTS: Eighteen patients clinically improved with a significant average reduction in their Sartorius score of 12.7 and number of monthly work days lost reduced from 1.5 to 0.4. Dermatology life quality index (DLQI) also showed a significant improvement in 16 cases, with a drop in DLQI score of 7.6. CONCLUSION: Metformin helps control HS with minimal side effects and good patient compliance and can represent a further agent in the spectrum of treatments available in the treatment of this disease.

Multiple widespread blue nodules: a clinicopathological case.

Glomangiomas are a variant of benign glomus tumours; glomus tumours are benign neoplastic proliferations of the glomus body, which is made up of perivascular smooth muscle cells. This forms arteriovenous anastomoses which play an important role in vascular regulation of skin temperature. The aim of this article is to describe 2 cases of hereditary glomangiomas.

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.

Recurrent epithelioid angiosarcoma of the scalp simulating melanoma. A 10-year follow-up.

We present a case of an intriguing mesenchymal neoplasm of the scalp that recurred several times over 10 years before a final diagnosis was possible. The case was sent for expert opinions to various international dermatopathological authorities and was, for a long time, unanimously interpreted as malignant melanoma. This diagnosis was supported by immunohistochemical examinations demonstrating S-100 positivity. Nevertheless, the clinical behaviour, as well as some histopathological features raised doubt regarding the diagnosis. Only after the last recurrence, followed by a repeat extensive immunohistochemical study, the diagnosis of epithelioid angiosarcoma was made. Histologically malignant melanoma can be highly misleading and in literature, reports of misinterpreted cases of melanoma are published. In contrast, tumours that can simulate melanoma are also not infrequent and it is essential to perform immunohistochemistry to confirm diagnosis and exclude a melanocytic lesion.

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.

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.

Role of Th2 cytokines, RANTES and eotaxin in AIDS-associated eosinophilic folliculitis.

The pathogenesis of AIDS-associated eosinophilic folliculitis is still unknown. The expression of chemokines and Th2-type cytokines is increased in other conditions associated with tissue eosinophilia and in allergic reactions. We evaluated the mRNA expression by reverse transcriptase polymerase chain reaction of two Th2 cytokines (interleukin-4 and interleukin-5) and of two chemokines (RANTES and eotaxin) in the skin of 6 patients with AIDS-associated eosinophilic folliculitis; the tissue localization of eotaxin was shown by immunohistochemistry. We demonstrated the increased expression of interleukin-4, interleukin-5, RANTES and eotaxin in lesional skin of the patients compared to normal skin of HIV+ individuals. We concluded that a Th2 pattern is present in AIDS-associated eosinophilic folliculitis. The cytokine milieu in this disease may favour a Th2 immune response to an unknown antigen, whereby RANTES and eotaxin act in synergy with interleukin-4 and interleukin-5 to mediate tissue inflammation.

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.

Calciphylaxis in two patients with end-stage renal disease.

Fatal calciphylaxis (CPX) occurred in two 71-year-old females both requiring haemodialysis for end-stage renal disease. Case 2 also had an associated follicular lymphoplasmocytoid lymphoma. Although laboratory tests disclosed normal coagulation parameters, this woman had a striking cutaneous histological picture of vessel thrombosis and finally died of disseminated intravascular coagulation. CPX is a rare but potentially life-threatening complication of renal failure. The clinical picture is primarily characterized by livedoid purpura with subsequent cutaneous ischaemia and painful ulcerations. Cutaneous ischaemic phenomena are sustained by a progressive process of vascular calcification and thrombosis involving small to medium size arteries of the dermis and subcutis. Although not yet clearly explained, the pathogenetic role of a predisposing hypercoagulability state is currently the most frequently considered hypothesis.

Madura's foot: report of a case caused by Madurella mycetomatis.

We present a case of mycetoma by Madurella mycetomatis on the foot of a Chinese young man, living in Italy for more than ten years. Clinically the lesion closely resembled and was initially misinterpreted as a vascular neoformation. We analyze the histological and morphological features of the Madurella mycetomatis infection through which we managed to type the etiological agent. Our case is worth reporting because of the rarity of this disease in Europe and the unusual clinical presentation. It also offers the opportunity to stress the need for the clinical suspicion of this dermatosis, considering the increase of immigration towards our regions.

Expression of eotaxin, interleukin 13 and tumour necrosis factor-alpha in dermatitis herpetiformis.

BACKGROUND: The dermal and perivascular infiltrate in dermatitis herpetiformis (DH), which is mainly composed of CD4+ lymphocytes, neutrophils and eosinophils, is believed to play an important part in the pathogenesis of the disease. Previous studies suggest that cytokines such as interleukin (IL) -8, granulocyte-macrophage colony-stimulating factor, IL-4 and IL-5 could be involved in the pathogenesis of DH. These cytokines appear to drive tissue infiltration and maturation of eosinophils. Part of the effect of T-helper (Th) 2-type cytokines (IL-4, IL-5) on eosinophils could be mediated by eotaxin, which is a highly specific chemotactic protein induced by various cytokines [IL-4, IL-13, tumour necrosis factor (TNF) -alpha and interferon-gamma]. OBJECTIVES: To evaluate the expression of eotaxin and its inducers, IL-13 and TNF-alpha, in DH. METHODS We examined lesions collected from 10 DH patients with active disease. Sections from each specimen were incubated with anti-IL-13, anti-TNF-alpha and anti-eotaxin antibodies. Chloroacetyl esterase reaction was performed to show mast cell infiltration. RESULTS: Eotaxin was mainly expressed at the tips of the dermal papillae, within the microabscesses. Positivity was also found in the lymphomonocytic infiltrate in the dermis. IL-13 was expressed in the dermal infiltrate and TNF-alpha was found in the inflammatory infiltrate and in dermal vascular cells. CONCLUSIONS: These findings confirm the importance of the lymphomonocytic infiltrate and of Th2 cytokines in the pathogenesis of this disease, suggesting that tissue infiltration in DH is mediated by cell-specific chemokines such as eotaxin and not only by non-specific chemokines such as IL-8.