Atypical ulcers show atypical clinical features, histology, localization, and resistance to standard therapies. The persistence of a chronic ulcer despite treatment with standard therapies requires a more specific diagnostic investigation. Diagnosis involves obtaining the history and performing clinical examination and additional tests. A skin biopsy is frequently used to confirm unclear diagnosis. In difficult cases, microbiological and immunohistochemical examinations, laboratory blood tests, or instrumental tests should be evaluated. The treatment of atypical wounds is characterized by local systemic therapy and pain control. Our results highlight the need for early diagnosis, and standardized and targeted management by a multidisciplinary wound healing center.

Objective: Contact allergies can occur frequently in patients with chronic leg ulcers (CLUs), even in those with a short duration of ulcerative disease. The wide spectrum of therapeutic products promotes development of the delayed type of hypersensitivity and continuous changes in the allergens pattern, which make the diagnosis and treatment extremely difficult in many cases. A prompt diagnosis and treatment of allergic contact dermatitis (ACD) in patients suffering from CLUs is very important for a best clinical outcome of these two common diseases. Thus, this review aims to highlight a common, challenging and often neglected problem.Method: The search included all studies published between 2000 and September 2015. Keyword used were: ‘allergic contact dermatitis leg ulcer’, ‘contact dermatitis leg ulcers’ ‘contact dermatitis wound care’ ‘contact dermatitis non-healing wounds’ ‘contact sensitisation non-healing wounds’.Results: Contact allergy and polysensitisation are very frequent in patients suffering from CLUs. Although it is believed modern dressings have a lower potential for inducing cutaneous sensitisation, positive patch test reactions to modern dressing are becoming common: hydrogels, followed by hydrocolloid and the ionic silver-containing wound dressing seem to be the principal causes of ACD.Conclusion: This review wanted to highlighted ACD in CLUs as a common and neglected disease whose economic and social burden has not previously been estimated, giving new insights for clinical and therapeutic management.

Background: There is a strong interaction between the immunological and nervous system in the skin. Lesions that are physically disfiguring and chronically relapsing have a high impact on quality of life (QoL) and can result in the emergence of psychiatric disorders. The literature data confirm a higher prevalence of psychiatric disorders in patients with psoriasis, hidradenitis suppurativa (HS) and atopic dermatitis (AD), but such data are compromised by low‐quality evidence due to methodological heterogeneity.Objectives: The primary aim was to analyse the prevalence of psychiatric comorbidities in a group of psoriasis, AD and HS patients compared with a control group. The secondary aims were to evaluate the impact of psychiatric comorbidities on the disease development, severity, flare‐ups and QoL.Methods: A total of 59 cases and 64 controls were included.Results: Generalized anxiety disorder and depressive disorder with anxious distress were found to be risk factors for AD. Age, smoking and substance‐related disorder showed a specific association with HS. Major depressive disorder showed a specific association with dermatology life quality index (DLQI) and all the above disease flare‐ups.Conclusions: Atopic dermatitis, psoriasis and HS are associated with psychiatric disorders. A psychodermatological approach improves outcomes in terms of QoL, disease flare‐ups and long‐term management.

Er Haar et al1 report a new tool, Autoinflammatory Disease Damage Index (ADDI), to measure damage caused by autoinflammatory diseases. Although this preliminary instrument was for patients with familial Mediterranean fever, cryopyrin associated periodic syndrome, tumour necrosis factor receptor-associated periodic fever syndrome and mevalonate kinase deficiency, we found a great utility also in another auto inflammatory disease (AD), namely hidradenitis suppurativa (HS). HS is a chronic–relapsing, debilitating autoinflammatory disease affecting apocrine gland-bearing skin which is estimated to affect 1% of the population.2 It is occasionally inscribed into more complex autoinflammatory syndromes, such as PASH (pyoderma gangrenosum, acne and HS), or concurrent with other dysimmune conditions such as Crohn's disease.3 HS severity is variously assessed by static scores, such as Hurley's or Canoui-Poitrine, or dynamic ones, such as modified Sartorius' score.4 However, no scores are still present to quantify the persisting systemic damage caused by chronic inflammation in HS, thus we preliminarily adopted ADDI for our cohort of 47 cases of severe Hurley III HS. Interestingly, our patients manifested characteristically high scores for musculoskeletal (97.87%), reproductive (46.8%), developmental (38.3%), ocular (23.4%), renal/amyloidosis (25.53%), neurological (17.15%), serosal (6.38%) and ears (2.13%) items (table 1). Cognitive impairment was calculated as positive if IQ<80 as defined by neuropsychological assessment, namely Wechsler Intelligence Scale for Adults IV, or if Mini-Mental State Examination resulted in a score of <23. Despite the limited number of patients assessed, ADDI may be a promising tool to evaluate the long-term systemic outcome in HS also. Prospective validation in longitudinal studies is needed to validate ADDI also for HS in daily practice