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Differentiation between psoriatic arthritis (PsA) sine psoriasis and rheumatoid arthritis (RA) may be a challenge, especially in the early stages, hence the need for new instrumental markers to assist their diagnosis. In this study, we investigated possible dermoscopic differences in vascular appearance of nail fold and elbow (a classic site of repeated trauma) in these two conditions. Fifteen patients with PsA sine psoriasis, 12 patients with RA and 12 controls were included in the study. Regarding the nail fold vascular appearance in PsA sine psoriasis and RA cohorts, the presence of diffuse reddish background with or without sparse dotted vessels was significant in the former, whereas the evidence of parallel dotted/short linear vessels ("fish school-like" pattern) or irregular/ramified, blurry, purple vessels were significant in the latter; none of these patterns were detected in the control group. Regarding the elbow, the pattern significantly associated with PsA sine psoriasis consisted of diffusely distributed, red, dotted vessels. On the other hand, RA patients and controls displayed similar dermoscopic findings, with three possible vascular patterns being observed: (i) irregular, blurry, purple vessels; (ii) avascular appearance; and (iii) sparse, dotted, purple vessels. In conclusion, dermoscopy may be a useful supportive tool for differentiating early PsA sine psoriasis from RA., (© 2016 Japanese Dermatological Association.)

Distinguishing Grover's disease from other papular dermatoses is often a troublesome task. According to two relatively recent case reports, dermoscopy may be useful in assisting the diagnosis of such a disorder by showing a peculiar pattern. The aim of this study was to evaluate the dermoscopic features of Grover's disease in a larger series of patients and correlate dermoscopy with histopathological findings. Seven patients with histopathologically confirmed Grover's disease were included in the study, with three of them displaying a Darier-like histology and the remaining four cases having a spongiotic histological pattern. The results of our study suggest that Grover's disease may display different features according to the histological subtype, with a central star-shaped/branched polygonal/roundish-oval brownish area surrounded by a whitish halo being characteristic of the Darier-like histological subtype and whitish scales over a reddish-yellowish background being characteristic of the spongiotic histological subtype., (© 2016 Japanese Dermatological Association.)

Clinical distinction between pityriasis amiantacea-like tinea capitis and pityriasis amiantacea due to noninfectious inflammatory diseases is a troublesome task, with a significant likelihood of diagnostic errors/delays and prescription of inappropriate therapies. We report a case of pityriasis amiantacea-like tinea capitis with its dermoscopic findings in order to highlight the usefulness of dermoscopy in improving the recognition of such a condition.

Dear Editor, Apocrine hidradenoma is a rare benign adnexal tumor related to the more common poroma, as they both originate from sweat glands. Hidradenoma usually has an eccrine differentiation, but an apocrine differentiation is possible. Due to its rarity and non-specific clinical appearance it is difficult to differentiate it from other malignant cutaneous lesions. In this challenging task, dermatoscopy could be particularly helpful to better describe, recognize, and differentiate these lesions. Unfortunately, the literature offers only few dermatoscopic descriptions of this rare cutaneous neoplasm. A 70-year-old woman in fair general condition was referred to our Department for an asymptomatic 10×8 mm single nodule on her left scapula. This nodule was red, dome shaped, well circumscribed, firm, and mildly tender (Figure 1). The patient reported that it had been present since approximately 7 months. The lesion was neither painful nor itchy and there was no bleeding. A skin examination did not show any other lesions with the same features or other suspicious lesions. Dermatoscopy revealed milky-pinkish areas with dotted vessels, linear-irregular vessels, and hairpin vessels: some of these aspects can also be found in amelanotic melanoma (1). There were also homogeneous blue areas similar to lacunae, characteristic but not exclusive to vascular or sarcomatous neoplasms and basal cell carcinoma (1,2). Furthermore, small ulcerations covered by an amber crust were identified, which can usually be found in basal cell carcinoma. Regarding the background of the lesion, we noticed peculiar, translucent, pinkish, soft, large lobular areas (Figure 2). On the basis of this analysis, we suspected an atypical presentation of a basal cell carcinoma, an amelanotic melanoma, or a sarcomatous skin neoplasm. A metastasis of an unknown solid tumor was also taken into consideration. The histological examination revealed an adnexal neoplasm and specifically an apocrine hidradenoma. The neoplasm had variably sized nests and nodules of neoplastic epithelial cells, with a small ductular lumens confined within the upper dermis. The lesion was composed mainly of two cell types: polygonal and smaller, elongated, and darker cells. The cuboidal/polygonal cells were seen lining the duct-like spaces and slots and resembled those of poroma (Figure 3). The adnexal skin tumors group includes a complex variety of uncommon tumors that can be distinguished only histologically, and most of them are benign (3). Searching the literature for "hidradenoma dermoscopy" and "adnexal dermoscopy" yields multiple descriptions of poromas but few dermatoscopic descriptions of hidradenoma (4). There was only one report of the presence of "arborizing vessels"(5), and another described "reddish purple areas and some linear or hairpin-like vessels on the surface of the tumor" (6). In another paper we found: "irregular scar like whitish areas and a polymorphous vascular pattern including irregular reddish-purple areas mimicking lacunar appearance of hemangiomas with thick hairpin vessels at the periphery" (7). It is very difficult make use of such scant data especially in order to detect a leading pattern for a specific diagnosis. Moreover, the described structures lack in specificity, being also present in many other lesions. Analyzing our dermatoscopic image and comparing it to the other ones available in the literature, we identified a peculiar background. It consisted in the presence of multilobular translucent and pinkish soft areas, which fit the previously described dermatoscopic criteria. We hypothesize there is a correlation between this feature and the histopathological presentation with variably sized nests and nodules. Of course, further case reports of hidradenoma are needed to identify the soft lobular background as a distinctive dermatoscopic feature. Due to the lack of specific features both clinically than dermatoscopically, histopathological analysis remains the only gold standard for diagnosis of these benign mimicking lesions.

Background: Acne is treated according to the clinical observations and pathophysiologically relevant mechanisms, such as hyper-keratinization, seborrhea and bacterial proliferation. In mild and moderate forms of inflammatory acne, topical antimicrobials are recommended as a monotherapy or in combination with topical retinoids. The aim of this study was to compare the clinical effectiveness, tolerability, impact on quality of life and effect on sebum excretion of three antimicrobial preparations: clindamycin phosphate, benzoyl peroxide and a combination of clindamycin phosphate plus benzoyl peroxide., Methods: In total, 240 patients were randomized into treatment groups for an 8-week study. Every two weeks the patients were evaluated using the following methods: photography, the Global Acne Grading System, sebumetric evaluation, and the Acne-Specific Quality of Life questionnaire. In addition, 80 healthy controls were enrolled for the sebumetric evaluation., Results: A significant improvement in acne and the quality of life was observed for all three therapies at the end of the study. The sebum excretion results for the three treatment groups displayed significant and unpredictable variation, whereas the controls groups exhibited no significant variation. The three treatments were well tolerated., Conclusions: The efficacy of the three antimicrobial preparations likely results from their anti-inflammatory and bacteriostatic activities. In contrast, seborrhoea seems to be minimally impacted.

Dermoscopy, in expert hands, increases accuracy, sensitivity and specificity in diagnosis of pigmented skin lesions of a single operator, compared with clinical examination. Simplified algorithmic methods have been developed to help less expert dermoscopists in diagnosis of melanocytic lesions. This study included 125 melanocytic skin lesions divided into melanocytic nevi, dysplastic nevi and thin melanomas (<1 mm). We compared the 3-point checklist and CASH algorithm to analyze different pigmented skin lesions. Based on preliminary results, we proposed a new modified algorithm, called the 4-point checklist, whose accuracy is similar to the CASH algorithm and whose simplicity is similar to the 3-point checklist., (© 2015 Japanese Dermatological Association.)

Type 1 segmental Darier's disease is a blaschkolinear variant of Darier's disease resulting from a postzygotic mosaicism. Since it usually lacks diagnostic clues typical of the generalized form, including positive family history of the disease, nail and mucosal abnormalities, and/or acral involvement, its distinction from other acquired inflammatory blaschkolinear dermatoses may often be quite challenging, thus requiring histopathological examination to reach a definitive diagnosis. We report a case of type 1 segmental Darier's disease with its dermoscopic findings in order to show the usefulness of dermoscopy in assisting the noninvasive identification of this condition.

Clinical differentiation between palmar psoriasis and chronic hand eczema may sometimes be a diagnostic challenge; in such cases histopathological analysis helps to differentiate the two conditions. In the present study, palmar psoriasis and chronic hand eczema were investigated using dermoscopy and the significance of specific dermoscopic features was assessed in order to improve their non-invasive differentiation. Ten patients with biopsy-proven palmar psoriasis and 11 patients with biopsy-proven chronic hand eczema were included in the study. We found that the presence of diffuse white scales was significant in palmar psoriasis whereas the presence of yellowish scales, brownish-orange dots/globules and yellowish-orange crusts was significant in chronic hand eczema., (© 2015 Japanese Dermatological Association.)

Pruritic folliculitis of pregnancy is a noninfective dermatosis of the gestation period characterized by multiple pruritic follicular papules and/or pustules which is not uncommonly mistaken for other similar skin disorders that may occur during pregnancy. In the present article we describe the usefulness of dermoscopy as a supportive diagnostic tool in a case of pruritic folliculitis of pregnancy. The main (always present) dermoscopic clue consisted of a vellus hair in the centre of each papule/pustule. Moreover, most papules showed a central yellowish-orange hue with some dotted vessels and irregular haemorrhagic spots. The detection of the aforementioned dermoscopic features might help distinguish pruritic folliculitis of pregnancy from its main differential diagnoses, mainly including microbial folliculitis, prurigo lesions, and the papular stage of pruritic urticarial papules and plaques of pregnancy, as they typically show different dermoscopic patterns.

Background: Cutaneous melanoma is an aggressive form of skin cancer. It has become an increasingly common neoplasm in the most developed countries, especially among individuals of European origin., Patients and Methods: Anonymous data of patients with cutaneous melanoma were collected from the diagnostic database of the University Hospital of Trieste from 1 January 1990 to 10 December 2013. Our study is based on a population which was constant over the period of observation; it was also well-defined and characterised by unrestrained sun exposure., Results: The number of cutaneous melanomas increased during the period of observation with a seasonality trend and gender related differences both for anatomical sites distribution and stage of the disease. Moreover, 6% of our cohort developed multiple melanomas., Conclusions: In a well-defined population devoted to excessive sun exposure the frequencies of skin melanomas roughly doubled from 1990 to 2013 following a seasonal trend. In that population, prevention efforts according to gender specific risk behaviour, as well as follow-up programmes both for evaluation of metastatic spreading and for early diagnosis of additional skin melanomas, are crucial due to gender specific differences and to the occurrence of multiple melanomas.

Clinical differentiation between pityriasis lichenoides chronica (PLC) and guttate psoriasis (GP) may sometimes be a difficult task, which often requires histological analysis to reach a definitive diagnosis. In this study, PLC and GP lesions were examined using dermoscopy, and the significance of specific dermoscopic findings was investigated in order to facilitate their differentiation and decrease the number of cases requiring biopsy. We found that the incidence of orange-yellowish structureless areas, focal dotted vessels and nondotted vessels was statistically significant in PLC, while the incidence of diffuse dotted vessels was statistically significant in GP., (© 2015 British Association of Dermatologists.)

Beside to traditional use, dermoscopy is more and more used in the assessment of other "general" dermatologic conditions, namely scalp and hair disorders (trichoscopy), nails abnormalities (onychoscopy), skin infections and infestations (entomodermoscopy), and cutaneous inflammatory diseases (inflammoscopy). Among the list of new applications of dermoscopy, the study of inflammatory dermatoses is probably the most promising topic in terms of development and usefulness, considering the large number of such disorders and the frequent problems in their differential diagnosis which the dermatologist encounters in own daily clinical practice. In this paper, we report selected relatively common clinical differential diagnosis issues concerning inflammatory dermatoses (and some clinically related noninflammatory conditions), analysing them by a dermoscopic point of view in order to assist their noninvasive resolution according to the available literature data and our personal experience, including papulosquamous dermatoses (guttate psoriasis, pityriasis lichenoides chronica, pityriasis rosea, lichen planus, lymphomatoid papulosis, classic pityriasis rubra pilaris, papulosquamous sarcoidosis, disseminated forms of porokeratosis and papulosquamous chronic GVHD), dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides, subacute cutaneous lupus erythematosus), palmar psoriasis vs. chronic hand eczema, scalp psoriasis vs. seborrheic dermatitis, erythematous-desquamative disorders typically involving the elbows (psoriasis vulgaris, circumscribed juvenile pityriasis rubra pilaris, dermatomyositis/Gottron's sign), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), common facial inflammatory skin diseases (rosacea, seborrheic dermatitis and demodicidosis), lichen sclerosus vs. morphea, urticaria vs. urticarial vasculitis and common inflammatory cicatricial alopecia (discoid lupus erythematosus, lichen planopilaris and folliculitis decalvans).

Bier spots are asymptomatic, small, irregular, hypopigmented macules characterized by a normal histological appearance, which are usually found on the arms and legs of young adults. We describe the simultaneous presence of Bier spots in two siblings. This finding is unusual since, to the best of our knowledge, concurrent familial cases have never been reported in the literature.

The diagnosis of prurigo nodularis is mainly clinical, based on its distinctive features. However, in some cases it may be difficult to differentiate it from other nodular dermatoses only on the clinical basis, thus requiring histopathological examination to reach a definitive diagnosis. The aim of this study was to describe for the first time the dermoscopic features of prurigo nodularis and the useful contribution of dermoscopy in the differential diagnosis of such dermatoses. Fourteen patients with histopathologically proven prurigo nodularis were included in the study. The results of our study suggest that the detection of a "white starburst pattern" surrounding brown-reddish/brown-yellowish crust(s), erosion(s) and/or hyperkeratosis/scales is a useful clue to support the clinical diagnosis of prurigo nodularis, distinguishing it from the other main differential diagnoses., (© 2015 Japanese Dermatological Association.)

We describe the case of an elderly woman who acquired a Mycobacterium marinum infection following skin exposure to the bacteria through a small wound on her right ring finger, obtained while preparing fish. The resultant sporotrichoid nodules of the right hand and the distal forearm, refractory to the initial therapy with doxycycline and rifampicin, were successfully treated with oral regimen of clarithromycin.

Erythrodermic psoriasis (EP) is a severe form of psoriasis that may be associated with serious and sometimes fatal complications. The treatment of EP is often a challenge, since several factors, including treatment failure or possible complications, may limit favorable outcomes with traditional drugs. Recent evidence suggests that biological drugs, including both anti-tumor necrosis factor alpha agents and ustekinumab, may be useful in improving the management of EP. Unfortunately, since subjects with EP are usually excluded from pivotal trials involving biological agents, this evidence is currently dispersed in small case series and single case reports. In this paper, we briefly analyze conventional therapies for EP, before going on to critically evaluate the existing clinical evidence for the role of current biological drugs, namely infliximab, etanercept, adalimumab, and ustekinumab. Finally, we discuss the potential benefits that newer/developmental biological agents could bring to the management of EP.

Unlabelled: Pressure ulcers (PrUs) remain a concern for clinicians, patients, caregivers, and researchers. Although data on prevalence and incidence are available, as well as evidence-based prevention and management intervention, PrU healing time is underreported., Objective: The objective of this study was to evaluate the healing time of Stage II PrUs., Methods: Secondary analysis of data collected from a multicenter randomized clinical trial was undertaken. Patients (a) with a Stage II PrU, (b) older than 18 years, and (c) who had given informed consent were included. The endpoints of the study were complete re-epithelialization of the PrU measured with the Pressure Ulcer Scale for Healing Tool 3.0 and the healing time. A network of 46 healthcare centers located in northern Italy participated in the study., Results: Two hundred seventy patients with an average age of 83.9 years (95% confidence interval [CI], 82.71-85.10) were recruited. Among 270 Stage II PrUs included, 153 lesions healed (56.7%), whereas 74 (27.4%) were still present after 10 weeks of follow-up. For 43 lesions (15.9%), the follow-up evaluation was interrupted because of patient death or transfer to units not included in the study. The PrUs healed on an average of 22.9 days (95% CI, 20.47-25.37 days), with a median of 18 days. The average healing time for PrUs of less than 3.1 cm was significantly shorter (19.2 days; 95% CI, 16.6-21.8) compared with those 3.1 cm or greater (31.0 days; 95% CI, 26.4-35.6 days) (P = .000)., Conclusions: To achieve complete re-epithelialization in Stage II PrUs, it takes approximately 23 days. This is quite a long time if we consider that pressures of only 60 to 70 mm Hg for between 30 and 240 minutes are needed to cause tissue damage. On average, a small ulcer heals 12 days faster compared with those with a surface of 3.1 cm or greater.

Parry-Romberg syndrome is an acquired slowly progressive disease characterized by an atrophy mostly involving half of the face. The pathogenesis of this disfiguring condition is still controversial. The relationship between Parry-Romberg syndrome and Lyme disease needs to be considered in depth. A 16-year-old woman from Albania presented with linear depressions of the right side of the face, clinically compatible with Parry-Romberg syndrome. She had a positive history of Lyme disease. Borrelia infection was confirmed by the positivity of PCR and the presence of IgM antibodies. The patient received intravenous penicillin and metronidazole for 14 days. After treatment and during a 2-year follow-up, the clinical disease progression was halted and the serological and microbiological tests for Borrelia burgdorferi sensu lato were negative. We cannot exclude a coincidence, however, of the bacteriological and serological evidence. Moreover, the interruption of the disease progression after the antibiotic therapy is difficult to ignore without claiming that this association is at least suggestive.

Background: Malignant change in the scars of discoid lupus erythematosus (DLE) is a well-known event. In most cases, tumors are of epithelial origin, particularly squamous cell carcinomas and, less frequently, basal cell carcinomas and keratoacanthomas. The onset of soft tissue sarcomas in a DLE scar is a very rare event, however, because only one case of malignant fibrous histiocytoma has been described in the literature., Objective: We describe the first documented report of atypical fibroxanthoma (AFX) arising in an old scar of DLE., Results: Although we cannot exclude an accidental association between AFX and DLE, our case emphasizes that patients with DLE may develop AFX in the context of an old scar., Conclusion: Our finding further underlines the importance of strict and long-term surveillance of people with DLE to identify and remove eventual tumors at an early stage.

Malignant melanoma presenting as a giant cutaneous mass is rarely observed in clinical practice. A few patients with giant melanoma have been reported, Herein, we document our experience with a patient with giant cutaneous melanoma of the abdomen and review the features of previously reported individuals.

In the present study, we describe the use of electrochemotherapy as alternative therapy for primary cutaneous marginal zone B-cell lymphomas in patients unsuitable for surgery or radiotherapy. Our experience refers to three patients with primary cutaneous marginal zone B-cell lymphomas related to Borrelia burgdorferi infection, treated with specific antimicrobial therapy and electrochemotherapy., (© 2014 Wiley Periodicals, Inc.)

Aim: Accuracy in melanoma detection is important to recognize early curable melanomas and to minimize the unnecessary excision of benign lesions. The aim of this paper was to evaluate melanoma screening accuracy of Italian pigmented lesion clinics in terms of number needed to excise (NNE), melanoma thickness, and number of melanomas diagnosed during patient follow-up., Methods: Information on all skin tumors excised in 2011 were extracted from the databases of the participating centers. Information whether the lesion was excised at the baseline examination or during patient follow-up was recorded, as well as the overall number of patients examined in each center in 2011., Results: After e-mail solicitation, 22 of 40 centers agreed to participate. A total of 8229 excised lesions were collected. The overall number of examined patients was 86.564, thus 9.5% of screened patients had a lesion removed. Of the excised lesions, 866 were diagnosed as melanoma (1% of examined patients) and 5311 (88.9%) were melanocytic nevi. Three NNE were calculated giving values of 7.9 excised lesions to find 1 melanoma, 7.1 melanocytic lesions to find 1 melanoma, and 3.7 lesions to find 1 skin malignancy. The median melanoma thickness was 0.6 mm, with only 15.1% of melanomas ≥ 1 mm of thickness. Melanomas detected over time were 96 (11.1%; mean thickness, 0.3 mm), with 15.6% of lesions excised after short-term follow-up and 84.4% after long-term follow-up., Conclusion: The NNE values comparable to those achieved in specialized clinical settings and the high number of early melanomas diagnosed at the baseline examination or during patient follow-up indicate a high level of accuracy in melanoma screening achieved by Italian pigmented lesion clinics.