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Background: Dermoscopy, a non-invasive diagnostic technique, is being increasingly used to evaluate cutaneous T-cell lymphomas such as mycosis fungoides (MF) and Sézary syndrome (SS). However, its diagnostic accuracy and role in staging remain underexplored. Objective: This study aimed to assess the dermoscopic patterns in MF and SS, correlating the findings with the disease stage and lesion type to evaluate dermoscopy’s diagnostic utility. Methods: A retrospective, monocentric analysis was conducted on patients with histologically confirmed MF or SS. Dermoscopic images were evaluated for vascular patterns, pigmentation, scaling, and keratin plugs. The statistical analysis assessed the correlations between these dermoscopic features and the TNMB staging and lesion type. A literature review was also performed to contextualize the findings, focusing on studies describing dermoscopic features in MF based on retrospective, prospective, and cross-sectional data. Results: The study included 30 patients with histologically confirmed MF or SS (19 males and 11 females; mean age: 64.5 years). The dermoscopic evaluation revealed that all the lesions were pigment-free, with vascular structures as the predominant feature. Linear vessels (40%) and serpentine vessels (13.3%) were the most frequently observed, along with dotted vessels (36.7%) and clods (10%). The vessel distribution was diffuse (40%) or perifollicular (36.7%), with a predominant red (56.7%) or orange (40%) background. Scaling was present in 76.7% of cases, either diffuse (40%) or perifollicular (36.7%), and keratin plugs were detected in 40% of the lesions. No statistically significant correlations were found between dermoscopic features and the TNMB stage or lesion type (p > 0.05). A cluster analysis identified two patient groups with differing vascular and scaling features but no clear association with disease stage. The literature review identified studies that commonly reported features in MF dermoscopy, including fine, short linear vessels and an orange-yellow background, particularly in early-stage MF. Spermatozoa-like structures have been marked as highly specific for diagnosing MF. Some studies also suggested a transition in vascular morphology from linear vessels in early disease to branched vessels and ulceration in advanced stages. Conclusions: Our results showed some vascular patterns have some potential but lack sensitivity for staging MF and SS. The terminology used and the reproducibility of our results compared to those reported in the literature showed little consistency, with none of our cases showing spermatozoa-like structures. Moreover, the same issues with the use of non-reproducible terminology were noted across the studies because it is not standardized and due to different incongruent dermoscopic patterns. More significant prospective studies with standardized descriptors and larger groups are needed to refine its diagnostic and staging utility.

Bullous pemphigoid (BP) is an autoimmune bullous disease caused by circulating autoantibodies toward the hemidesmosomal antigens BP180 and BP230. Cases of BP have been described following vaccinations against tetanus, poliomyelitis, diphtheria, influenza, pneumococcus, meningococcus, hepatitis B and rabies. The putative mechanism by which COVID-19-vaccines may induce BP has not been clarified. An Italian multicentre study was conducted to collect clinical, histopathological and immunopathological data of patients with BP associated with COVID-19-vaccines. Twenty-one cases were collected, including 9 females and 12 males (M/F = 1.3) with a median age at diagnosis of 82 years. Seventeen patients received the COMIRNATY Pfizer-BioNTech vaccine, two the Moderna mRNA-1273 vaccine, one the ChAdOx1/nCoV-19-AstraZeneca/ Vaxzevria vaccine and one received the first dose with the ChAdOx1/nCoV-19-AstraZeneca/Vaxzevria vaccine and the second dose with the COMIRNATY Pfizer-BioNTech vaccine. Median latency time between the first dose of anti-SARS-CoV-2 vaccine and the onset of cutaneous manifestations was 27 days. Median BPDAI at onset was 42. Eleven out of seventeen patients (65%) had positive titres for anti-BP180 antibodies with a median value of 106.3 U/mL on ELISA; in contrast, only five out of seventeen (29%) were positive for anti-BP230 antibodies, with a median of 35.3 U/mL. In conclusion, in terms of mean age, disease severity at diagnosis and clinical phenotype vaccine-associated BP patients seem to be similar to idiopathic BP with an overall benign course with appropriate treatment. On the other hand, the slight male predominance and the reduced humoral response to BP230 represent peculiar features of this subset of patients.

It is well known that viral infections play a relevant role in inducing or protecting from autoimmune diseases, thus representing a major environmental factor in the disruption of the immune system in genetically susceptible individuals. Since the beginning of the Covid-19 pandemic a great number of clinical and epidemiological studies have demonstrated that SARS-CoV-2 infection is no exception to the rule by interfering on many different levels in the normal functioning of our immune system. Even though a growing number of case series and case reports has been cited in the literature linking the infection to the new onset of autoimmune diseases, to date very little has been reported concerning a possible correlation between the virus and the clinical resolution of any kind of autoimmune pathology. Here we describe an interesting case of abrupt and unexpected resolution of Lichen planus pemphigoides mucocutaneous lesions in a fully vaccinated patient after a mildly symptomatic SARS-CoV-2 respiratory infection and we speculate on the possible underlying mechanisms correlating the two events.

Pemphigus encompasses a group of muco-cutaneous autoimmune bullous diseases characterized by the loss of adhesion between keratinocytes. The disease is associated with increased morbidity and mortality. We characterized clinical patterns, survival, comorbidities, and drug prescriptions in patients with pemphigus referred to the Section of Dermatology of the University of Florence from January 2010 to December 2021. A total of 149 patients were identified (female/male sex ratio = 2.0). Median age at diagnosis was 57.7 ± 17.2 years; 108 patients were diagnosed with pemphigus vulgaris (PV) (72.5%) and 35 (23.5%) with pemphigus foliaceus (PF). Paraneoplastic pemphigus (PNP) and IgA-pemphigus accounted for three patients each. The overall survival rate was 86.9%. Accordingly, 14 (9%) patients died during the study period. The average age at death was 77.8 ± 9.3. Age at diagnosis was a risk factor for death in patients with pemphigus. Average concentration of Dsg3-IgG and Dsg1-IgG was 85.6 ± 68.8 and 75.9 ± 68.4, respectively. The most serious comorbid diseases included cerebro- and cardiovascular accidents and malignancies. Regarding the treatment regimen, we found a substantially stable use of systemic steroids in the 2010-2018 period; the prevalence of use of mycophenolic acid increased, whereas that of azathioprine decreased. The use of rituximab showed the highest increase in the 2013-2018 period. Proton-pump inhibitors and antibiotics were the most frequently prescribed non-immunomodulating drugs. In this large series of the patients, patients with pemphigus showed a high incidence of serious comorbid diseases, highlighting the importance of a multidisciplinary approach for a proper management of the patients. Rituximab was the immunomodulating drug showing the highest increase in use over time, reflecting the growing evidence of its efficacy as a first-line treatment in pemphigus.

Management of cutaneous lupus erythematosus (CLE) involves a combination of preventive measures, topical and systemic drugs, fairly similar for the different subtypes. Although guidelines exist, to date, no specific drugs have been specifically licensed for CLE. Antimalarials remain the first-line systemic treatment, but many patients do not respond, making refractory lupus a challenge for clinicians. The choice of alternative medication should be based on effectiveness, safety and cost. Most of the available drugs for CLE have been adapted from systemic lupus erythematosus (SLE) treatment but the existing literature is limited to small studies and evidence often lacks. As knowledge of pathogenesis of both CLE and SLE is improving, promising new therapies are emerging. In this review, we discuss the available medications, focusing on the novelties under development for CLE.

Bullous Pemphigoid (BP) is a common autoimmune blistering disorder with unknown aetiology. During the last decades, its association with various common comorbidities, including cardiovascular, metabolic, neuropsychiatric, and neoplastic disorders, has been established. However, in recent years an increasing number of BP cases have also been reported in association with rarer diseases, including Acquired Reactive Perforating Collagenosis (ARPC). Patients with coexisting BP and ARPC have been reported to share common clinical features including metabolic comorbidities e.g., Diabetes Mellitus (DM). As the evolution from ARPC cutaneous involvement to classic BP lesions has been more frequently described, it has been suggested that it may represent a new clinical variant of BP with a specific pathogenetic background. Here is reported a challenging case in which a typical onset of BP was later followed by the eruption of atypical ARPC lesions in a patient with multiple non-compensated metabolic and cardiovascular comorbidities.

Cutaneous vasculitis (CV) is an inflammatory skin-limited vascular disease affecting the dermal and/or hypodermal vessel wall. From the pathogenetic point of view, idiopathic forms are described as well as the induction from various triggers, such as drugs, infections, and vaccines. Following SARS-CoV-2 pandemic outbreak, cases of CV induced by both COVID-19 and COVID-19 vaccinations have been reported in literature. The aim of our work was to collect multiple cases available in the literature and analyze the frequency of the different forms of induced vasculitis, as well as their histological and immunopathological features. Although rare, CV induced by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and vaccines may provide interesting insights into the pathogenesis of these inflammatory processes that may in the future be useful to understand the mechanisms underlying cutaneous and systemic vasculitis.

The term gluten-related disorders (GRD) refer to a spectrum of different clinical manifestations triggered by the ingestion of gluten in genetically susceptible individuals, including coeliac disease (CD), wheat allergy and non-celiac gluten sensitivity (NCGS). GRD are characterized by a large variety of clinical presentations with both intestinal and extra-intestinal manifestations. The latter may affect almost every organ of the body, including the skin. Besides the well-known association between CD and dermatitis herpetiformis, considered as the cutaneous specific manifestation of CD, many other muco-cutaneous disorders have been associated to GRD. In this review, we analyzed the main features of dermatological diseases with a proven association with GRD and those that improve after a gluten-free diet, focusing on the newly described cutaneous manifestations associated with NCGS. Our main hypothesis is that a “cutaneous-gluten sensitivity,” as specific cutaneous manifestation of NCGS, may exist and could represent a diagnostic marker of NCGS.

[...]the authors found no difference in risk of BP onset among two large cohorts of COVID-19 vaccinated individuals and unvaccinated matched ones, suggesting that the previously observed associations may be a random coincidence. [...]of this rare event, we think that the incidence rate estimation is not the ideal approach to assess the possible association between AIBD occurrence and COVID-19 vaccine. [...]to reach a statistically significant result (with α = 0.05 and β = 0.20), a sample size of over 2 billion individuals in each exposure group would be needed (20). [...]the data from Birabaharan et al., that reported a not significant difference of BP onset between vaccinated and unvaccinated individuals, may suggest a random association with COVID-19 vaccination but cannot exclude that such association does exist.

Lupus erythematosus tumidus (LET) is a subset of cutaneous lupus erythematosus that generally presents with urticaria-like papules and plaques located on sun-exposed areas. Systemic treatment with antimalarials, especially hydroxychloroquine (HCQ), is the first-line systemic therapy for LET. Even if these drugs have a safe profile, side effects such as retinal toxicity, maculopapular rash, gastrointestinal upset, hemolytic anemia and blue-gray discoloration of the skin or the mucous membranes, have been rarely reported in the literature. Herein, we describe a rare case of a 46-year-old smoking woman with LET who developed a generalized myopathy after HCQ treatment.