SARS-CoV-2 Infection-A Trigger Factor for Telogen Effluvium: Review of the Literature with a Case-Based Guidance for Clinical Evaluation.

Telogen effluvium post-COVID-19 is a condition characterized by the diffuse and reversible loss of scalp hair in the period following infection with SARS-CoV-2, and it is currently the second cause of alopecia in women. In the context of the COVID-19 infection, intense psychological stress contributes to alopecia appearance, along with systemic inflammation, autoimmune reactions, oxidative stress, and virally induced hypoxia. Cytokines with proinflammatory action and vasoactive substances negatively modulate the metabolism of some molecules, such as proteoglycans, involved in the hair follicle's growth cycle. Studies show that a large percentage of hairs will suddenly enter the catagen phase during a moderate to severe COVID-19 infection. In the present paper, we update the data from the literature with a clinical example. Our case highlighted that the telogen effluvium after infections with SARS-CoV-2 is reversible with appropriate dermatological treatment. For therapeutic success, informing the patient about this pathology's self-limited and reversible character is essential to reduce the emotional stress that may aggravate the disease.

The Many Roles of Dermoscopy in Melanoma Detection.

Dermoscopy is a non-invasive method of examination that aids the clinician in many ways, especially in early skin cancer detection. Melanoma is one of the most aggressive forms of skin cancer that can affect individuals of any age, having an increasing incidence worldwide. The gold standard for melanoma diagnosis is histopathological examination, but dermoscopy is also very important for its detection. To highlight the many roles of dermoscopy, we analyzed 200 melanocytic lesions. The main objective of this study was to detect through dermoscopy hints of melanomagenesis in the studied lot. The most suspicious were 10 lesions which proved to be melanomas confirmed through histopathology. The second objective of this study was to establish if dermoscopy can aid in estimating the Breslow index (tumoral thickness) of the melanomas and to compare the results to the histopathological examination. We found that the tumoral thickness may be estimated through dermoscopy, but the histopathological examination is superior. To conclude, the aim of this study was to showcase the versatility and many roles of dermoscopy, besides being one of the most important tools for early melanoma diagnosis.

Review: The Key Factors to Melanomagenesis.

Melanoma is the most dangerous form of skin cancer that develops from the malignant transformation of the melanocytes located in the basal layer of the epidermis (cutaneous melanoma). Melanocytes may also be found in the meninges, eyes, ears, gastrointestinal tract, genito-urinary system, or other mucosal surfaces (mucosal melanoma). Melanoma is caused by an uncontrolled proliferation of melanocytes, that at first may form a benign lesion (nevogenesis), but in time, it may transition to melanoma, determining what it is named, melanomagenesis. Some tumors may appear spontaneously (de novo melanoma) or on preexisting lesions (nevus-associated melanoma). The exact cause of melanoma may not be fully understood yet, but there are some factors that initiate and promote this malignant process. This study aims to provide a summary of the latest articles regarding the key factors that may lead to melanomagenesis. The secondary objectives are to reveal the relationship between nevi and melanoma, to understand the cause of "de novo" and "nevus-associated melanoma" and highlight the differences between these subtypes.

A prospective study on hyperhomocysteinemia as an aggravating factor in chronic venous insufficiency.

The role of hyperhomocysteinemia (HH) in the etiopathogenetics of systemic thrombotic events has been confirmed by numerous studies. However, it has been insufficiently studied as an etiopathogenic factor in chronic venous insufficiency (CVI). The present prospective study included 166 patients with CVI at stages C3-C6. Homocysteine levels and the inflammatory, metabolic and procoagulant profiles of the patients were determined. High-performance liquid chromatography was used to determine the homocysteine level. Within the patients with HH, the thromboembolic risk was analyzed. Smoking was determined to represent the most common procoagulant factor (21.67%), whereas in the subgroup of women, abortions represented a procoagulant factor for 31.93%. The metabolic profile was altered in approximately half of all cases (42.77%), whereas proinflammatory status was a contributing factor in 23.50% of the cases. HH was present in 54.22% of the CVI patients, mainly in the moderate HH category (53.01%), mostly linked to venous ulcers, thrombophlebitis and pulmonary thromboembolisms. The highest average values of homocysteine were recorded in patients >75 years old and when the venous disease age was >20 years (15.03 µmol/l). In summary, in the present study, HH was a contributing factor of CVI alongside the chronic inflammation that is well known in CVI, which increased thrombogenic risk, especially in elderly patients with an advanced age of venous disease.

Ophthalmic herpes zoster with severe complications in an immunocompromised patient: A case report and review of the literature.

The increasing incidence for herpes zoster, including its ophthalmic form, is based on physiological (senescence) and acquired immunosuppression, particularly under oncologic treatment. The immunocompromised status of the patient favors the appearance of severe complications. The patient, aged 54, with chronic lymphocytic leukemia, presented 1 week from the onset with an erythematous, vesicular-bullous rash on the right trigeminal nerve's ophthalmic dermatome, marked edema, intense pain and large submandibular ganglion masses. There were cutaneous (necrotic ulcerations superinfected with methicillin-resistant Staphylococcus aureus), ocular (keratoconjunctivitis, total ophthalmoplegia, lagophthalmia, anterior hemorrhagic uveitis with hyphema and right eye blindness) and neurological (postherpetic neuralgia) complications. Systemic therapy was performed with acyclovir, antibiotics, supportive, rebalancing and symptomatics. With regards to treatment for skin ulcers, disinfection and necrectomy were performed, and epithelialization agents were subsequently administrated. At the ocular level, the ophthalmologist carefully monitored the patient and administered antivirals, antibiotics, epithelialization agents and autologous serum. The evolution of the case recorded severe, disabling complications, with extensive eyelid necrosis and definitive blindness. In this case, the severity of the ophthalmic herpes zoster (OHZ) was favored by the synergistic action of four factors: Acquired immunosuppression (chronic lymphocytic leukemia), delayed consultation, superinfectious lesions and patient non-compliance regarding the chronic lymphocytic leukemia treatment.

Clinical-dermoscopic similarities between atypical nevi and early stage melanoma.

Atypical (Clark) nevi are benign tumors that may be considered precursors of melanoma. Many studies acknowledge a linear progression from typical to atypical nevi that eventually transform into melanoma. It is often challenging to differentiate a Clark nevus from melanoma, especially in its early stages, due to their clinical, dermoscopic, and histological resemblance. Dermoscopy is a powerful tool in early melanoma diagnosis, but it is a subjective method of examination. Therefore, the use of dermoscopic algorithms and checklists can overcome this issue. In the case of a difficult diagnosis, since both dermoscopy and histopathological exam are subjective methods of examination, modern molecular biology techniques can be used to distinguish between benign and malignant tumors. This study aimed to test the accuracy of specific clinical and dermoscopic criteria in order to distinguish between benign and malignant tumors, with a secondary objective to provide an overview of the clinical and dermoscopic features of atypical nevi and melanoma. In the present study, dermoscopic algorithms did not necessarily help distinguish benign and malignant tumors but demonstrated that nevi and melanoma have similar characteristics.

Evolution of syphilis incidence in Sibiu county (Romania) over a period of 10 years (2009-2018).

Syphilis is the most common sexually transmitted disease that mainly affects socially active people, with a fluctuating worldwide incidence over the years. A retrospective study was conducted over a period of 10 years (2009-2018) that included 396 patients with syphilis diagnosed and monitored by Sibiu County Emergency Clinical Hospital, Romania. During this period (2009-2018), we observed a decrease in the new cases of syphilis by 35.90%, and the average syphilis incidence was 9.90 new cases per 100,000 inhabitants. Syphilis was diagnosed more frequently in men with an average age of 35.39 years, from urban areas, with and educational level of grades 9-12, unmarried, workers, or without occupation. Out of the 396 patients with syphilis, about 6% were HIV coinfected. Over half of the HIV coinfected cases were declared MSM (men who have sex with men), and 40% of these cases were registered in 2018. The most common clinical stage of syphilis was the latent form (67.93%). Regarding the syphilis treatment regimen, we noted the transition from the classic regimen with benzathine-penicillin G (100% in 2009) to alternative therapies (mainly with cephalosporins) in 2018 (56.86%). Our findings showed that in the last 10 years in our county, the incidence of syphilis had a downward trend, but with an increase in syphilis-HIV co-infection and neurosyphilis cases.

Cutaneous manifestations associated with anosmia, ageusia and enteritis in SARS-CoV-2 infection - A possible pattern? Observational study and review of the literature.

BACKGROUND: The cutaneous manifestations of coronavirus disease 2019 (COVID-19) have been covered insufficiently in the literature. METHODS: Thirty-nine patients admitted to the study hospital with confirmed COVID-19 who experienced various skin manifestations during hospitalization or in the convalescence period, were analysed retrospectively. RESULTS: Thirty-nine patients with COVID-19, admitted to the study hospital between 23 March and 12 September 2020, had intra-infectious rash or lesions of cutaneous vasculitis during convalescence. The most common cutaneous manifestations of COVID-19 were erythematous and erythematous papular rash. Twenty-seven of the 39 patients had anosmia (69.2%), 26 patients had ageusia (66.7%), 34 patients had pneumonia (87.2%) and 24 patients had intra-infectious enterocolitis (61.5%). Skin biopsies were rarely performed in these patients. This article reports the results of biopsies performed in two patients, showing histopathological and immunohistochemical changes in erythematous rash and erythema multiforme-like lesions. Both skin biopsies revealed early fibrous remodelling of the dermis, suggesting similarity with changes that occur in the lungs and other tissues in patients with COVID-19. CONCLUSIONS: Correlations between skin lesions and anosmia, ageusia and enteritis in patients with COVID-19 do not seem to be accidental, but are associated with a similar response to ACE2 receptor expression in these tissues.

Importance of food in the control of inflammation in atopic dermatitis.

Patients that suffer from inflammatory diseases need to pay special attention to nutrition. For this reason, it is very important to change the approach of both health professionals and food industry specialists. There must be a close collaboration, starting from research, the development phase of foods for special nutrition states. Our primary objective was to identify foods or potential dietary ingredients, which efficacy in the treatment of atopic dermatitis had been scientifically demonstrated in vitro, in vivo and clinically. Furthemore, our perspective is presented regarding the research and development of foods for special nutritional states in atopic dermatitis. The PubMed database was analyzed for the period 2018-2020, as well as the European Legislation regarding the appropriate requirements for the composition and knowledge applicable to foods destined for use in special medical purposes. The search criteria were 'chronic dermatitis', 'atopic dermatitis', 'psoriasis', 'alternative treatments', 'natural treatments', 'complementary treatments', 'treatments for chronic dermatitis'. We also looked for undesirable effects or side effects of the foods included in the research in order to treat atopic dermatitis. The results showed that prebiotics, probiotics and certain plant extracts had a high efficacy in controlling inflammation in atopic dermatitis. The food development research for special nutrition states (atopic dermatitis) involves a multidisciplinary team. We started with the establishment of the general objective and continued with the consultation of the PubMed, EMBASE and other databases, and with the in vitro, preclinical and/or clinical determination of the efficacy of new developed foods, that must be protected with patents. The development of foods for special nutrition states represents a solution for improving the quality of life of atopic dermatitis patients.

Hydroxyurea-induced superinfected ulcerations: Two case reports and review of the literature.

The chronic use of hydroxyurea (HU) in some oncologic and non-oncologic diseases (psoriasis, sickle cell anemia) can be accompanied by side effects, both systemic and mucocutaneous. The most severe adverse events known in HU therapy are leg ulcers and cutaneous carcinomas. At skin level may also appear: xerosis, persistent pruritus, skin color changes (erythema, hyperpigmentation), cutaneous atrophy. Likewise, oral ulcerations and stomatitis may occur at mucosal level. Hair damage can be expressed through alopecia and nail damage through melanonychia and oncycholysis. First case, a 63-year-old woman with severe psoriasis vulgaris and chronic granulocytic leukemia, with 5 years of HU therapy, was admitted to hospital for submammary and palmoplantar ulcers, superinfected with methicillin-resistant Staphylococcus aureus and Proteus mirabilis. Clinical exam showed that the patient had also cutaneous atrophy, marked palmoplantar xerosis and melanonychia. The second case, a 72-year-old woman with primary thrombocytemia, treated with HU for 3 years, presented with necrotic leg ulcers that were superinfected with Pseudomonas aeruginosa, Enterobacter and E. Coli. The patient associates cellulitis, microbial eczema and xeroderma. In both cases, after HU discontinuation, systemic antibiotics, topical epithelizing agents and emollients, the ulcers had a slow favorable evolution. In our cases, the ulcers appeared after 5, respectively 3 years of HU therapy. It is stressed that in the first case, which had associated psoriasis, after 1 year of 1 g of HU/day, the psoriatic lesions completely disappeared. The severe progression of the ulcers was also favored by the superinfection of the ulcers with 2, respectively, 3 identified germs for which appropriate systemic antibiotics was required.

A 10-year retrospective study of melanoma stage at diagnosis in the academic emergency hospital of Sibiu county.

Melanoma is considered to be the most aggressive skin cancer, with an increasing incidence worldwide. An accurate staging of melanoma is crucial in describing the cancer status, estimating prognosis and deciding the optimal treatment solution. In the present study, melanoma staging highlights the importance of early detection, most of the patients having been diagnosed with advanced stages of this skin cancer. A retrospective study was conducted among 117 patients of the Academic Emergency County Hospital of Sibiu, diagnosed with melanoma between 2007 and 2016. The staging of the patients with melanoma was made using the American Joint Committee on Cancer (AJCC) 7th edition, and reconsidered in the light of the AJCC 8th edition. The results showed that the majority of the cases had distant metastases, 40.17% were diagnosed with stage IV melanoma. 25.65% of the patients were diagnosed with stage III melanoma, having a regional disease. The rest of the cases had localized melanoma (stages I and II, 30.76%), while only 3.42% of them were diagnosed with melanoma in situ, the melanoma type with the greatest chances of survival. Analyzing the Breslow index, it was observed that the most common tumor thickness was 2.1 to 4 mm (34.19%). In conclusion, as the incidence of melanoma increases in Romania, further efforts are needed to improve the early detection of melanoma. There are hopes that with the correct and early diagnosis of melanoma, the mortality rate of this neoplasm will decrease in the future.

A Case of Generalized, Superinfected Dermatitis and Inguinal Mycobacterium Lymphadenitis - TB or not TB?

Dear Editor, Eczema is an inflammatory dermatitis mediated by cellular immunity, with an etiology in which environmental, immunological, and genetic factors are involved. Skin inflammation through proinflammatory cytokines creates a favorable environment for microbial antigens and optimal conditions for infection (1). In case of underlying immunosuppression, inflammatory features of dermatitis and superimposed infections are more severe. The presence of minor trauma of the skin in the form of fissures can favor both easier inoculation of some bacterial germs, leading to a dermatitis superinfection, and/or the transcutaneous inoculation of atypical mycobacteria, with a possibility of developing localized types of tuberculous lymphadenitis (TLA). TLA, the localized type of systemic tuberculosis (TB) infection, is the most common form of extra-pulmonary TB in developing countries (2), while lymphadenitis due to atypical mycobacteria is a localized disease, more frequently seen in developed countries (3,4). In tuberculosis, the transmission of Mycobacterium tuberculosis is airborne, while in atypical mycobacterium lymphadenitis transmission can be both airborne or by ingestion or inoculation (5). In both forms of TB, lymphadenopathy evolves towards abscess and presents fibrotic scars or calcifications upon healing (6). A positive diagnosis involves a clinical and epidemiological investigation, a purified protein derivative (PPD) skin test, ultrasound, and CT / MRI of lymph node masses. A lymph node biopsy is used to confirm the diagnosis of TB and PCR, while positive culture confirms the etiology of TB lymphadenitis. The differential diagnosis of TLA is difficult: neoplastic, bacterial, or viral and fungal infections, sarcoidosis, Castleman's disease, drug reactions, etc. (5). TB-induced immunosuppression may favor the development of fungal and bacterial infections, sometimes severe and poorly responsive to treatment. On the other hand, immunosuppressive conditions increase the risk of extra-pulmonary TB (2). A 40-year old woman who had experienced recurrent episodes of dermatitis over the previous 7 years was hospitalized with fever, malaise, and a disseminated erythematous and crusted, exudative, and flexural itching rash (Figure 1). There were fetid, purulent secretions at the conjunctival, auricular, genital, and umbilical areas. The clinical exam also revealed lymphadenopathy syndrome (large, painful submandibular, cervical, and axillar bilateral lymph nodes; an indurated, painful, and adherent left inguinal lymph node of 5-6 cm). Microbial cultures isolated multiple multi-drug-resistant bacteria (SAH-MRSA, Acinetobacter baumannii, Enterococcus faecalis, E. coli, Enterobacter) and Candida albicans in the oral cavity and conjunctival, auricular, nasal, umbilical, and genital areas. The skin biopsy confirmed the diagnosis of dermatitis. PPD skin test was 21 mm. Other tests (HIV and syphilis serology, blood culture, chest X-ray) were negative. Systemic treatment with vancomycin, metronidazole, fluconazole, local antiseptic compresses, and topical corticosteroid ointments was initiated. 2 days after starting the treatment with vancomycin, Redman syndrome occurred (headache, dyspnea, colicky pains, myalgia, rush, fever (39 °C), hypotension (80/40 mmHg), and tachycardia (100 bpm)). This syndrome resolved upon discontinuation of Vancomycin. Further treatment with imipenem/cilastatinand linezolid for 14 days lead to a favorable response with amelioration of the symptoms. Biopsy of the submandibular lymph node raised the suspicion of Castleman's disease; however, due to the overall incomplete clinical picture (no night sweats, no weight reduction, lack of hepatosplenomegaly and peripheral neuropathy), we decided to perform a biopsy of an inguinal lymph node. The histopathological aspect suggested TLA (lymphoid hyperplasia predominantly diffuse, reactive, presenting tuberculous follicles with central caseous necrosis) (Figure 2). A combination of specific antituberculous drugs (isoniazid, rifampicin, pyrazinamide, and ethambutol) for 6 months resolved the lymphadenopathy syndrome with no further recurrence of eczema and skin infections. Certain delayed hypersensitivity mechanisms are involved both in dermatitis and in TB. CD4 lymphocytes are the primary mediators of anti-TB immunity, while proinflammatory cytokines mediate the activation of macrophages involved in controlling bacillary growth (1). In cases of superinfected dermatitis, microbial exotoxins penetrate the skin barrier more easily due to inflammation. Released cytokines (IL-1, TNF, and IL12) favor the expression of E-selectin on endothelial vascular growth factor and on skin lymphocyte antigen expression, with amplification of initial skin inflammation and creating favorable conditions for microbial colonization and infection (7). The common denominator in dermatitis and TB are the circulating immune complexes (up to 56% of TB cases), which are formed by the interaction between an antibody and bacterial antigen (8), which was in this case evidenced by increased levels of IgA and IgG. In our case, the frequent recurrences of infected dermatitis with multiple multi-drug-resistant germs that were poorly responsive to treatment and displayed a severe evolution towards generalization as well as the lymphadenopathy and the persistence of a biological inflammatory syndrome indicated that another immunosuppressive cause could be involved. Isolated bacterial and fungal germs changed the immune status of the patient. The risk of mycobacterium infection was increased by the environment they created and the patient's underlying skin inflammation. The diagnosis of TB lymphadenitis was established by the histopathologist, but in the absence of PCR we could not determine whether the TB infection was caused by Mycobacterium tuberculosis or by atypical mycobacteria. Given that there was no evidence of other sites of TB infection, we conjectured that inoculation of mycobacterium took place at the skin lesion and that an atypical mycobacterium might have contributed to the etiology of the TLA. In our case, the anti-tuberculous drugs and skin infection treatment with follow-up of the side-effects led to complete remission of mycobacterium lymphadenitis, dermatitis, and infectious processes, without relapses. In conclusion, in the present case chronic dermatitis alongside infection with multi-drug-resistant germs led to an immunosuppressive status which, when associated with the presence of multiple skin ports of entry, allowed a mycobacterial infection at the inguinal lymph node level. Inguinal TLA induced severe dermatitis and difficulties in diagnosis and treatment.

Sinecatechins and imiquimod as proactive sequential therapy of external genital and perianal warts in adults.

This review about the proactive sequential therapy (PST) of external genital and perianal warts (EGW) is based on the most current available clinical literature and on the broad clinical experience of a group of international experts, physicians who are well versed in the treatment of human papillomavirus-associated diseases. It provides a practical guide for the treatment of EGW, including epidemiology, etiology, clinical appearance, and diagnostic procedures for these viral infections. Furthermore, the treatment goals and current treatment options, elucidating provider- and patient-applied therapies, and the parameters driving treatment decisions are summarized. Specifically, the mode of action of the topical treatments sinecatechins and imiquimod, as well as the PST for EGW to achieve rapid and sustained clearance is discussed. The group of experts has developed a treatment algorithm giving healthcare providers a practical tool for the treatment of EGW which is very valuable in the presence of many different treatment options.

Histopathological aspects in autoimmune cutaneous manifestations associated with hepatitis C virus infection.

Autoimmunity is characterized by activation of the immune system that attacks and destroys wrongly, the body's own structures. All body tissues can be affected (erythrocytes, leukocytes, platelets, blood vessels, muscle tissue, endocrine system, and other), including the skin. Autoimmune diseases have an increased frequency in women, especially in adulthood, and they are associated with hereditary factors. Although the etiology of autoimmune diseases is incompletely elucidated, there is an association between chronic infection with hepatitis C and autoimmunity, association highlighted and well documented in clinical studies. Other viral infections do not have the same connotation in the context of autoimmunity, but it is recognized that they are an important triggering factor in the pathophysiological mechanism. The cases associating chronic hepatitis C treated with interferon and ribavirin, with multiple autoimmune diseases substrate, raising the discussion of a possible pathophysiological correlation between them.

Treatment of Plaque-Type Psoriasis With Oral CF101: Data from a Phase II/III Multicenter, Randomized, Controlled Trial.

BACKGROUND: CF101, an adenosine A3 receptor agonist, is an orally bioavailable small molecule drug presenting an anti-psoriatic effect demonstrated in a Phase 2 clinical trial in psoriasis patients.
OBJECTIVE: To evaluate the safety and efficacy of CF101 treatment in a Phase 2/3 study in patients with moderate to severe plaque-type psoriasis.
METHODS: This multicenter, double-blind, 2-segment, placebo-controlled study randomized subjects with moderate to severe plaque psoriasis to CF101 1 or 2 mg, or placebo twice daily. At either week 12 (Segment 1) or 16 (Segment 2), the placebo group crossed over to CF101 BID through week 32 in an open-label fashion. At week 12, following an interim analysis, the CF101 1mg group was discontinued due to futility. The primary endpoint was proportion of patients achieving ≥75% improvement in Psoriasis Area Severity Index (PASI 75). Efficacy testing was performed using the Cochran-Mantel Haenszel test, the primary analysis of PASI 75 was performed at the 0.035 significance level.
RESULTS: CF101 had an excellent safety profile at all tested dosages with a profile similar to the placebo group. The most common adverse events were infections and gastrointestinal events, and there was no cumulative intolerance over the 32-week dosing period. The study did not meet the primary endpoint of PASI 75 at week 12 (2 mg: 8.5% vs. placebo: 6.9%, P=0.621). However, at week 32, PASI mean percent improvement with CF101 2 mg was 57% (P<0.001) compared to baseline, with linear improvement in PASI 50 (63.5%), 75 (35.5%), 90 (24.7%), and 100 (10.6%).
CONCLUSIONS: Oral CF101 was found to be safe and very well tolerated, demonstrating evidence of efficacy in patients with moderate to severe plaque psoriasis through 32 weeks of treatment.

J Drugs Dermatol. 2016;15(8):931-938.

An immunocompetent young patient with tuberculosis of the penis: a challenging case.

Tuberculous chancre is an extremely rare form of cutaneous tuberculosis. The genital area is a possible site of presentation. We present a case of a young male with a persistent balanopreputial ulceration resembling a luetic chancre with negative serology for syphilis. The diagnosis was based on the specific pathologic features and the positive intradermal reaction to tuberculin. A successful treatment was achieved by combining antituberculosis treatment and surgical approach with circumcision. After six months of antituberculosis treatment, the patient developed paradoxical inguinal lymph node enlargement, which, after surgical excision and biopsy, was not followed by a relapse of the disease and needed no further therapy. Tuberculosis should be considered a potential diagnosis in the case of a persistent genital ulcer.

Study regarding the microscopic aspects of pilo-sebaceous units after antiandrogen treatment in hirsute women.

AIM: To analyze the morphological data of pilo-sebaceous units in hirsute women before and 12 months after the antiandrogen treatment with Cyproterone acetate (CPA) 100 mg÷day. MATERIALS AND METHODS: Fourteen female patients with idiopathic hirsutism that followed an antiandrogen treatment with CPA were biopsied from the androgen-dependent area of the chin before and 12 months after the treatment. Routine sections were stained with Hematoxylin-Eosin, Masson, Van Gieson, Sirius red and picric-indigocarmine, while additional sections were immunostained for S100 protein and vimentin. Electron microscopy was performed in two cases with Langerhans cell hyperplasia. RESULTS: On biopsies-stained sections, an increased number of hair follicles, the deeper part of the epithelial sheath of the hair follicle with epithelial buds, hyperplasia of sebaceous glands, and no inflammatory infiltrate were noticed. Langerhans cells identified with S100 protein and vimentin were normal in terms of numbers and distribution. After the administration of the treatment, atrophy of the pilo-sebaceous units was visible in nine (64.2%) cases, while inflammatory infiltrate and cells included in the vacuoles of the basal layer of the epidermis became apparent. In six of the cases treated with antiandrogens, a marked hyperplasia of Langerhans cells was noticed. In conclusion, the benefit of antiandrogen treatments is supported by atrophy of the hair follicle and the sebaceous glands. The activation of Langerhans cells associated with inflammatory infiltrate in the dermis and hair follicles could be considered as a local consequence of the involution process of hair follicles after the administration of the treatment.

Squamous cell carcinoma developed on chronic venous leg ulcer.

Chronic venous leg ulcers (VLU), especially long-lasting non-healing ulcers, are among the risk factors for squamous cell carcinoma (SCC). Malignant transformation of a VLU is a rare finding and the relative risk of carcinomatous transformation is quite low (about 5.8). SCC arising in the context of a VLU has a particularly aggressive behavior. A 76-year-old male patient with no relevant medical familial history, with chronic venous insufficiency CEAP C6 for 10 years [recurrent leg ulcers with favorable outcome (healing) after specific local and systemic treatment], showing for about three years one ulcerated lesion located on the anterior upper third of the right calf non-responsive to specific treatment, which subsequently increased their size and merged. Biopsy sample was taken. Histopathology showed epidermal acanthosis, papillomatosis, intense parakeratosis, pseudoepitheliomatous hyperplasia, dysplasia and moderately differentiated squamous cell carcinoma with areas of acantholysis. Immunohistochemistry (Ki67, EMA, cytokeratin 34ßE12 and p63) was performed and all types of immunostaining were moderately to intense positive. Above-knee leg amputation and specific oncologic treatment were proposed as possible curative solutions but the patient refused. Ten months after diagnosis and discharge form the Department of Dermatology, the patient died. Patients with chronic venous leg ulcers and clinically suspicious lesions should be evaluated for malignant transformation of the venous lesion. When diagnosed, malignancy complicating a chronic venous leg ulcer requires a resolute treatment as it may be fatal.