This case report describes a Mediterranean HIV-negative man in his 60s with hypertension, osteoporosis, a history of flaccid paralysis after polio syndrome, and a 4-year history of progressive development of purplish, reddish cutaneous plaques and nodules limited to the lower limbs.

The aim of this study was to compare tumour burden in patients who underwent surgery for melanoma and cutaneous squamous cell carcinoma during nationwide lockdown in Spain due to COVID-19 (for the period 14 March to 13 June 2020) and during the same dates in 2019 before the COVID-19 pandemic. In addition, associations between median tumour burden (Breslow thickness for melanoma and maximum clinical diameter for cutaneous squamous cell carcinoma) and demographic, clinical, and medical factors were analysed, building a multivariate linear regression model. During the 3 months of lockdown, there was a significant decrease in skin tumours operated on (41% decrease for melanoma (n = 352 vs n = 207) and 44% decrease for cutaneous squamous cell carcinoma (n = 770 vs n = 429)) compared with the previous year. The proportion of large skin tumours operated on increased. Fear of SARS-CoV-2 infection, with respect to family member/close contact, and detection of the lesion by the patient or doctor, were related to thicker melanomas; and fear of being diagnosed with cancer, and detection of the lesion by the patient or relatives, were related to larger size cutaneous squamous cell carcinoma. In conclusion, lockdown due to COVID-19 has resulted in a reduction in treatment of skin cancer.

Conventional photodynamic therapy (cPDT) using red light is considered one of the most effective therapy option for the treatment of actinic keratosis (AK). The main disadvantage of cPDT is the pain experienced by the patients during illumination. Daylight PDT (dPDT) represents an effective and painless alternative. It can be speculated that a combination of both regimes combines their benefits. To compare the combination of cPDT and dPDT (combPDT) to dPDT alone in terms of effectiveness and safety. The study was developed as a single-centre, intraindividual, retrospective study. Each patient received one dPDT and a combPDT session with BF-200 ALA. Primary effectiveness endpoints included the reduction in the number of basal AK, percentage of patients with complete response (CR) and partial response (PR). Safety parameters evaluated were local skin response (LSR) and visual analogue scale (VAS). A total of 19 patients with 264 AK were evaluated 12 weeks after both PDT modalities. The area treated with combPDT showed a reduction in the number of AK lesions (82.7%) when compared to the dPDT-treated area (56.8%). Higher rates of CR (31.6% vs 15.8) and PR (63.2% vs 26.3%) were achieved in combPDT fields. Areas treated with combPDT showed enhanced local skin reactions (LSR) in comparison with dPDT-treated areas (6.4 vs.4.4, respectively). In combPDT-treated patients a moderate increase of the pain during illumination was observed when compared to dPDT (VAS: 3.4 vs 0.6). This study reports the first data set on the benefit of a direct combination of daylight and subsequent conventional red light illumination (combPDT) with BF-200 ALA. The combination approach achieved a significant increase in clearance rates of AK lesions, while pain was perceived as mild to moderate during red light illumination.

Langerhans cell histiocytosis (LCH) is a rare proliferative disorder, more frequent in children, characterized by an abnormal accumulation of Langerhans cells admixed with eosinophils, lymphocytes, neutrophils, and macrophages. The clinical presentation is variable and depends on whether a single or multiple organs are affected. Skin lesions are common in LCH (40% of cases) and represent a frequent form of presentation (in up to 80% of cases). Cutaneous manifestations of LCH are highly variable, frequently presenting as crusted papules or scaly seborrheic-like lesions localized in the scalp. We report the first case of a localized acral sclerosing LCH, a new form of LCH. This case highlights the broad and surprising form of presentation of LCH which may be overlooked and can significantly delay its diagnosis. The development of systemic disease may occur months to years after the initial skin presentation. Prompt diagnosis and treatment may prevent progression to systemic disease, as documented in some cases.

Introduction: The aim of the study was to evaluate the results on effectiveness and safety of topical treatment for actinic keratosis (AK) with ingenol mebutate gel (IMG) in real-life conditions and to perform an analysis of the factors that may influence the treatment outcomes.Materials and methods: Retrospective study of patients with non-hyperkeratotic AK lesions prescribed with IMG in Spain according to clinical practice. Dermatologists reported the characteristics of patients and AK at baseline, and the findings observed up to 60d after treatment.Results and conclusions: A total of 260 treatments in 246 patients with a mean (SD) age 70.6 (10.4) years were reviewed. The number of clinically visible AK in the treated area decreased from 6.16 (3.02) to 1.22 (2.02) (p<.001) lesions with an average reduction of 84%. Univariate analysis showed higher reduction rates when IMG was applied in the face/scalp (p=.026), in women (p=.041), and in patients under 70years of age (p=.033). According to multivariate analysis, advanced age was associated with worse clearance rates (p=.038). However, besides statistical significance, we can conclude that gender (female) and age (under 70years-old) show a tendency to have better efficacy outcomes but without clinical relevance. Topical IMG was generally well tolerated and had positive cosmetic results after 60d. Age influences on IMG effectiveness for AK and LSRs were correlated with higher effectiveness ratios.

Sezary syndrome is a primary cutaneous T-cell lymphoma characterized by the triad of erythroderma, lymphadenopathy and circulating atypical cells. The emergence of new molecular targets has enabled the development of drugs such as alemtuzumab, an anti-CD52 monoclonal antibody, which has shown promising results in the treatment of this entity. We report the case of a 70-year-old male with refractory Sezary syndrome in whom treatment with alemtuzumab achieved an 80% skin lesion clearance with complete haematologic and radiologic response. The treatment was discontinued after 4 months due to adverse effects, with the patient showing a sustained response without disease progression after 13 months of follow-up.

BackgroundIntralesional methotrexate (MTX-il) has been used as neoadjuvant therapy for keratoacanthoma but has only been utilized in a few isolated cases of cutaneous squamous cell carcinoma as neoadjuvant therapy (cSCC). ObjectivesThe objective of this study was to evaluate the effectiveness in clinical practice of presurgical MTX-il infiltration to reduce the size of the cSCC. Safety and the impact on subsequent reconstructive surgical techniques was also assessment. MethodsSingle, retrospective, observational study of two historical cohorts differentiated in time. Subjects included were diagnosed with infiltrating cSCC. Patients included in group-A received neoadjuvant MTX-il and patients included in group-B underwent scheduled surgery without prior infiltration. Univariate and multivariate analyses were performed. ResultsGroup-A patients (n=43) showed an average reduction in the tumour area of 0.52cm(2), while in group-B (n=43), the area increased by 0.49cm(2). A multivariate linear regression analysis demonstrated that MTX-il was the only independent variable that significantly reduced the tumour size [mean 42.6% (95% CI: 31.17-54.03)]. Tumours 2cm in size required significantly a lower percentage of complex reconstructions (P=0.026). Lower lip tumours showed a higher reduction in group treated with MTX-il (P=0.045). The only complication observed was discomfort during methotrexate infiltration (60.47%). Conclusions...

Background: Phymatous rosacea is characterized by thickened skin and irregular surface contours as the result of variable combinations of fibrosis, sebaceous hyperplasia and lymphoedema. Otic phyma is rarely seen and has been rarely reported in the English literature. Methods: We present another case of this uncommon condition, frequently misdiagnosed, maybe due to its underrecognition. Results: Phymatous rosacea most commonly occurs on the nose, but may also develop on any sebaceous facial region, including the ears. Although it is a benign condition, there are significant morbidities associated with rosacea, and can even result in conductive deafness because of the obstruction of the external auditory canal. Conclusions: The knowledge of this entity may be important for clinicians, especially dermatologists, ENT specialists and plastic surgeons, for an appropriate treatment and follow-up

Facial angiofibromas are hamartomatous growths that are closely associated with tuberous sclerosis complex and, in fact, they constitute one of the main diagnostic criteria for that disease. These lesions composed of blood vessels and fibrous tissue appear on the face at an early age. Since they have important physical and psychological repercussions for patients, several treatment options have been used to remove them or improve their appearance. However, the lack of treatment guidelines prevents us from developing a common protocol for patients with this condition. The present article aims to review the treatments for facial angiofibromas used to date and to propose a new evidence-based treatment protocol.

Background: Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder characterized by the development of multisystem hamartomatous tumours. Topical sirolimus has recently been suggested as a potential treatment for TSC-associated facial angiofibroma (FA). Aim: To validate a reproducible scale created for the assessment of clinical severity and treatment response in these patients. Methods: We developed a new tool, the Facial Angiofibroma Severity Index (FASI) to evaluate the grade of erythema and the size and extent of FAs. In total, 30 different photographs of patients with TSC were shown to 56 dermatologists at each evaluation. Three evaluations using the same photographs but in a different random order were performed 1 week apart. Test and retest reliability and interobserver reproducibility were determined. Results: There was good agreement between the investigators. Inter-rater reliability showed strong correlations (> 0.98; range 0.97-0.99) with inter-rater correlation coefficients (ICCs) for the FASI. The global estimated kappa coefficient for the degree of intra-rater agreement (test-retest) was 0.94 (range 0.91-0.97). Conclusions: The FASI is a valid and reliable tool for measuring the clinical severity of TSC-associated FAs, which can be applied in clinical practice to evaluate the response to treatment in these patients.

Background: Phaeohyphomycosis can be caused by a number of different species, being the most common Alternaria alternata and Alternaria infectoria. The biggest risk factor for the development of the infection is immunosuppression. Aims: We present the case of a 64-year-old male renal transplant patient who came to hospital for presenting a tumour in the Achilles region which had been gradually growing in size. Methods: A skin biopsy was taken for histological study and culture of fungi and mycobacteria. Blood tests and imaging studies were performed. Results: Histopathology study and cultures identified A. infectoria as the causal agent. Imaging studies ruled out internal foci of infection. The lesion was surgically removed with no signs of recurrence after 24 months of follow-up. Conclusions: There are no treatment guidelines at present for cutaneous and subcutaneous Alternaria spp. infections. Various systemic antifungals have been used, either in combination with surgical removal or alone, with varying results. Surgery alone could be useful in the treatment of solitary, localised lesions in transplant patients in whom there are difficulties in controlling immunosuppression.

Background: Tuberous sclerosis complex (TSC) is an autosomal dominant neurocutaneous disorder characterized by the development of multisystem hamartomatous tumours. Facial angiofibroma appears in up to 80% of patients and has a considerable psychological impact. Various invasive procedures have been used, although they show limited effectiveness and potential adverse effects. Objectives: To evaluate the sustained clinical benefits and safety profile of topical sirolimus applied to treat facial angiofibromas. Methods: This study was a non-blinded, uncontrolled case-series comprising 10 patients with TSC-associated facial angiofibroma that was treated with 0.4% sirolimus ointment 3 times a week for 9 months. Patients were clinically evaluated at baseline and at 6, 12, 24 and 36 weeks. Plasma levels of sirolimus were determined. Results: A sustained improvement was observed in erythema and in the size and extension of the lesions as early as the first weeks of treatment. Sirolimus plasma levels remained below detection limits (0.3 ng/mL) in all cases. The formula was well-tolerated with no local or systemic adverse effects. Conclusions: Topical sirolimus seems to be an effective and safe medical alternative to surgery or laser-based treatments in patients with TSC-associated facial angiofibromas.