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Erythema chronicum migrans (ECM) is the pathognomonic sign of the early stage of Lyme disease, a tick-borne illness caused by pathogenic species of Borrelia, a genus of bacteria of the spirochete phylum. Lyme disease has a broad spectrum of clinical manifestations that can vary in severity and imitate other diseases. ECM consists in a slow enlarging erythema with central clearing. Its recognition allows to state the diagnosis and prescribe the correct therapy and blood tests. But beside the classical manifestation of ECM, some other peculiar variants are possible, such as the vesiculobullous, the purpuric-hemorrhagic, the urticarial, the panniculitis-erysipeloid and the necrotic variant. It is important to know these variants in order to recognize Lyme disease in its early stage, and to avoid sequelae that can involve joints, hearts, central and peripheral nervous system. We present our experience with iconographic examples and check the literature about the possible manifestations of ECM.

We describe a rare case where the development of cutaneous lymphoid hyperplasia was correlated with the topic administration of squaric acid dibutyl ester for immunotherapy in alopecia totalis. Because of the way this disease affects self-esteem and social interaction, an increasing number of patients seek medical attention. Hence, it is important to raise awareness regarding the possible side effects of alopecia treatments.

LA BORRELIOSI DI LYME E' UNA ZOONOSI, TRASMESSA DA UNA ZECCA DURA ED è CAUSATA DA UNA SPIROCHETA: BORRELIA BURGDORFERI SENSU LATOLA MANIFESTAZIONE TIPICA E PRECOCE è L'ERITHEMA (CHRONICUM) MIGRANS.IL TRATTAMENTO ANTIBIOTICO SI EFFETTUA CON AMOXICILLINA O DOXICILLINA PER OS NELLA FASE PRECOCE, E CEFRIAXONE O PENICILLINA GI.V. NELLA FASE TARDIVA E NELLE MANIFESTAZIONI NEUROLOGICHE.

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Dermatologists are often faced with the challenge of patients presenting with non specific symptoms such as itching and or erythema. These symptoms may be attributed to a number of diseases, many of which are trivial, and others even life-threatening. In order to establish the correct diagnosis, dermatologists must rely on good diagnostic tools and knowledge. Dermoscopy was introduced mainly for inspection of pigmented lesions, but its use has now also spread to non-melanoma skin cancer, inflammatory diseases, and almost any skin disease. This diagnostic technique also applies to skin infestation today, often offering the opportunity to rapidly identify new hidden features of parasites. This case report describes an unusual but representative case in which entomodermoscopy enabled a rapid diagnosis in a patient with a non specific erythematous patch. Whereas differential diagnosis of such skin manifestations could have been too laborious and misleading, dermoscopy easily allowed us to find a small parasite, later identified as Trombicula autumnalis.

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The basal cell carcinoma (BCC) assessment in dermoscopy is based on the recognition of specific characteristics synthesized and described as classical and non-classical criteria, but which may not necessarily present all at the same time. Consequently, a deep knowledge in detecting the aforementioned dermoscopic criteria is crucial in diagnosis. The aim of the study was to evaluate which criteria are more frequently recognized among a group of low-experienced dermoscopists when confronted with the difficult diagnosis of BCC with a diameter lower than 5 mm. We examined 100 BCC finding that data displays a full agreement only for one classical criterion, the lack of pigmented network (Fleiss' κ = 1), while among other classical criteria only arborizing vessels and ulceration exhibit a good agreement among observers (Fleiss' κ > 0.40). Analyzing non-classical criteria, only blue-whitish veil and blue in-focus dots show a good agreement among low-experience observers (Fleiss' κ > 0.40). It is evident that in small size BCC classic dermoscopic criteria are often substituted by non-classical criteria, which represent the neoplasm's early phase. Thus, it is of importance, especially for low-experience dermoscopists, to analyze even the non-classical criteria in order to obtain a diagnosis of early BCC. © 2016 Japanese Dermatological Association

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.