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Abstract The guidelines project of the Brazilian Society of Pathology aims to disseminate recommendations for pathologists, surgeons, and clinicians, based on solid data from the literature and through adaptations of international guidelines to the reality of Brazilian physicians. This article is the result of the efforts of a group of pathologists, members of the Dermatopathology Committee of the Brazilian Society of Pathology, focused on melanocytic diseases, who, through topics, established pertinent recommendations for clinicians and surgeons for the accurate diagnosis of melanocytic lesions suspected of melanoma. This article aims to clarify the best way to perform excision in cases of suspected melanocytic lesions, as well as the pre-analytical care related to the material, how to interpret the anatomopathological report, and the situations in which immunohistochemical and molecular studies can be auxiliary tools for diagnosis and/or therapy.

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Abstract Background: Cutaneous squamous cell carcinoma (cSCC) includes in situ cSCC (Bowen’s disease [BD]) and invasive cSCC. By contrast, keratoacanthoma (KA) is a well-differentiated cSCC with self-resolving tendencies. Dermoscopy aids in monitoring vascular and keratin pattern changes to diagnose and track cSCC invasion. Objectives: To examine dermoscopic findings of cSCC according to histopathological differentiation and clinical morphological characteristics. Methods: Clinical and dermoscopic images of 118 cSCCs were retrospectively examined. Results: Compared to other cSCC subtypes, BD more frequently presented with pigmentation (p = 0.028) and a clustered (p = 0.042) or serpiginous (p = 0.006) vascular arrangement. Central keratin plugs were more common in well-differentiated invasive cSCCs (p = 0.021), while white circles surrounding follicles (p < 0.001), ulceration/bleeding (p = 0.001), and red background (p = 0.004) were observed more in poorly differentiated invasive cSCCs. Central keratin plugs (87.5%) and branched vascular arrangements (75%) were observed in patients with nodular KA, with both statistically more frequent than in invasive cSCC (p < 0.001, p = 0.040, respectively). White halos surrounding vessels (p = 0.004) and a clustered vessel arrangement (p = 0.037) were more common in nodular invasive cSCC compared to nodular KA. Study limitations: The number of examined lesions in the subgroups was relatively small. Conclusions: Dermoscopy aids in distinguishing well-differentiated invasive cSCC from poorly differentiated invasive cSCC, distinguishing nodular KA from nodular invasive cSCC, and diagnosing BD. Further studies are needed to identify dermoscopic findings that can distinguish moderately differentiated invasive cSCC from other invasive cSCCs.

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Abstract Background: Chronic pruritus is the defining symptom of atopic dermatitis (AD). Although AD is common in Latin America, there is little data regarding pruritus intensity, characteristics, and effects on quality of life in this population. Objective: This cross-sectional study aimed to evaluate pruritus in 91 patients with AD at a tertiary university hospital in São Paulo, Brazil. Patients aged 14 65-years old were included in this study. Methods: Patients completed the Itch Questionnaire, the ItchyQoL, and the POEM questionnaires and were asked to rate their itch severity using a 10-point peak pruritus Numerical Rating Scale (NRS). AD severity was assessed via the EASI and the vIGA-AD. Results: The mean age was 29.68 ± 12.87years, and 56.0% of patients were White. 97.8% of patients were currently experiencing pruritus with an average NRS of 7.32 ± 2.22. Patients had associated bleeding (71.4%), heat sensation (63.7%), and pain (54.9%). Worsening factors included stress (93.4%), dry skin (91.2%), and sweat (75.8%). The mean total ItchyQoL score was 78.93 ± 17.20. Female gender was significantly associated with a higher total ItchyQoL score (p = 0.009). Pruritus on the neck, foot, and whole body was associated with higher total ItchyQoL scores in adjusted models (p < 0.05). The EASI, vIGA-AD, and POEM were moderately correlated with itch intensity (r = 0.434, 0.406, and 0.610) and total ItchyQoL score (r = 0.425, 0.436, and 0.631). Study limitations: The predominantly White population cohort may not be representative of the diverse AD phenotypes in the Brazilian patient population. Children under the age of 14 and adults over the age of 65 were excluded from the population cohort. Furthermore, patients included in the study may suffer from other non-dermatological diseases that cause itch, which may influence the outcomes oberserved. Conclusions: Patients with AD in Brazil experience significant pruritus that impacts their quality of life. Gender, body location of itch, associated pain, and stress should all be taken into consideration when evaluating AD patients with pruritus.

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Abstract Background: Contact dermatitis is a common dermatosis in dermatology. The patch test is the gold standard for diagnosis, using a panel of common allergens and irritants. In Brazil, a standardized battery of 30 substances is used. However, comprehensive epidemiological data on contact dermatitis are limited, and no studies have compiled and compared nationwide results. Objectives: This study aimed to assess the positivity rate of patch tests using the Brazilian Standard Battery in suspected contact dermatitis cases from 2000 to 2022. We also evaluated associations between reactive substances and clinical and demographic variables and examined the variation in reactivity frequency to allergenic substances over the study period. Methods: A systematic literature review was conducted using PubMed, Scielo, and LILACS. We evaluated the prevalence of positive tests for each substance, examined associations between variables such as gender, region, and age, and assessed variations in patch test positivity over time. Results: Initially, 55 articles were identified, and 10 were included in the review. Nickel sulfate was the most frequently positive allergen, while triclosan, P-tertiary buthyphenol, and anthraquinone were the least prevalent. Test positivity increased every 5-years for kathon CG, neomycin, and nickel sulfate, while it decreased for quaternion 15 and thimerosal. Study limitations: The results were limited by the small number of articles included in the review. Conclusions: This pioneering study in Brazil provides valuable insights for dermatological allergy practitioners into the prevalence of patch test positivity for each substance in the Brazilian Standard Battery, aiding in informed decision-making and patient management.

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Abstract Background: Leprosy is an infectious disease, endemic to Brazil, associated with poor living conditions. Although curable, it is a neglected disease, posing a serious public health problem. The literature lacks comprehensive and recent analyses of the pathology. Objectives: The study aims to describe and analyze the clinical-epidemiological profile of leprosy patients in large Brazilian regions and compare it with regional sociodemographic indicators. Methods: This is an ecological, descriptive, and analytical observational study, carried out through the collection of secondary data from the Disease Notification Information System from 2014 to 2019, the 2010 census, and population estimates from the Brazilian Institute of Geography and Statistics. Results: A total of 215,155 new cases were reported and the annual detection rate was maintained in four Brazilian regions, with only the South showing a significant decrease. The highest rate was observed in the Midwest and the lowest in the South. The predominant profile was male, age range between 60 and 79 years old, literate, and black and brown ethnicity. There was a predominance of the borderline cases, multibacillary form, more than five skin lesions, and zero grade of disability at diagnosis. Bacilloscopy was not performed in 42.8% of the cases and cure was the outcome in 77%. Study limitations: The use of secondary data and the time interval analyzed are restricted by the data source platform and the COVID-19 pandemic. Conclusions: This shows a perpetuated public health problem, mainly in the North, Northeast, and Midwest regions, associated with socioeconomic indicators and has a clinicalepidemiological profile that favors the bacillus transmission.

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Abstract Background: The increasing prevalence of gastrointestinal (GI) malignancies highlights the critical need for a better understanding of associated dermatological manifestations to improve early diagnosis and patient management. Objectives: This study aims to catalog the dermatological findings in patients with GI malignancies, emphasizing the implications for early diagnosis, and management. Methods: The authors conducted a comprehensive whole-body dermatologic examination on 150 patients diagnosed with GI malignancies. Data on sociodemographic factors, lifestyle habits, comorbid conditions, and malignancy characteristics were meticulously collected. Results: The cohort comprised 96 males (64%) and 54 females (36%), with a mean age of 62.47 (SD ± 10.7) years. The most prevalent primary malignancy was colonic (32.7%), with a mean disease duration of 12.72 (SD ± 20.5) months. Xerosis (dry skin) was the most frequent dermatological condition, affecting 92% of patients. The itching was reported by 31.3% of patients. Eruptive seborrheic keratosis (20.7%) and acanthosis nigricans (10.7%) were the most common paraneoplastic dermatoses observed. Both conditions were more common in patients with BMIs above 28.5, and seborrheic keratosis was seen more often in men. Dry skin, itching, paraneoplastic dermatoses, and skin infections were significantly more prevalent in patients older than the mean age of 62 years. Study limitations: The cross-sectional design of the present study limits causal inference. Longitudinal studies are needed to explore the temporal dynamics between dermatological manifestations and GI malignancy progression. Conclusions: Dermatologic symptoms including pruritus, xerosis, seborrheic keratosis, and acanthosis nigricans should be considered potential indicators of underlying malignancy. Routine dermatological screening is essential for comprehensive patient care.

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Abstract Background: Sentinel lymph node (SLN) biopsy in melanoma patients has an important role in staging, prognosis assessment, and treatment definition. Few studies have evaluated its role in the Acral Melanoma (AM) subtype. Objective: To evaluate the results of SLN biopsy in 79 patients with acral melanoma treated at a single oncological center and compare them with the data described in the literature. Methods: Between January 2016 and December 2022, the authors analyzed all patients with AM who underwent SLN biopsy in a single institute. The authors analyzed the epidemiological, clinical and histopathological data. Overall Survival (OS) and Disease-Free Survival (DFS) curves were estimated using the Kaplan-Meier method. Multivariate analyses were conducted using the Cox regression model. Results: During the period, the authors analyzed 79 cases. The mean age was 60 years and median thickness was 4.5 mm and 67.1% had ulceration. SLN was positive in 27 patients (34.2%). The estimated OS and DFS were 67.7% and 45.2%. OS was better in the negative SLN group compared to the positive SLN group (70.9% vs. 53.2%), but without statistical significance (p = 0.08). Estimated DFS for positive SLN was associated with a significantly worse prognosis (33.8 × 46.7%, p = 0.001). Study limitations: The retrospective nature of the study and the limited number of patients. Conclusions: The present study has significant implications for determining prognosis. Patients with AM and positive SLN had a worst prognosis compared to those with negative SLN.

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Abstract Background: Juvenile Dermatomyositis (JDM) is a rare myopathy. Lipodystrophy is an underreported chronic JDM complication. Objective: Assess the long-term outcome of JDM associated with lipodystrophy. Methods: Retrospective study of JDM patients who developed lipodystrophy, diagnosed and treated between 1st January 1990 and 31st December 2023, in a University Clinic of Dermatology. The mean follow-up was 150.8-months (range 29-291). Results: Lipodystrophy was diagnosed in 5 children (4 girls and one boy, aged 3-14 years) of 22 JDM patients (17 girls and 5 boys). Four patients had partial, and one had focal lipodystrophy that occurred 34.2-months (mean period) after the initial JDM symptoms. All five children had antinuclear antibodies, but none had dermatomyositis-specific/associated antibodies. No malignancies or visceral involvement were found. At JDM presentation, all 5 patients had low serum vitamin D, body mass index (BMI) ranged from 14.3 to 20.7. Triglycerides and fasting glucose levels were normal in all patients, while cholesterol was elevated in one patient. Despite Standard Immunosuppressive Therapy (IST), 2/4 of patients with initially partial lipodystrophy progressed to generalized lipodystrophy and 4/5 patients developed calcinosis 46 months (mean period) after JDM diagnosis. At the last check-up, 3/5 patients had chronic JDM course, requiring IST, while 2/5 patients were in remission, without IST, with only residual lipodystrophy. Study limitations: Retrospective study. Conclusions: During the 34-year period, 5/22 (23%) JDM patients developed lipodystrophy. Metabolic complications were not found. All patients had significant delays in JDM diagnosis. Early diagnosis and IST are necessary to reduce the risk of lipodystrophy, as a severe, chronic JDM complication.

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Abstract Background: Psoriasis is a chronic multisystem disorder, and the inhibition of different cytokine pathways has been associated with different treatment responses. Objective: To demonstrate independent predictors of PASI90 response in patients with psoriasis under biologic therapy and compare the effectiveness of different biologic classes Methods: This cross-sectional study was conducted in a single tertiary center between January 2023 and May 2024 and included 623 patients (M/F: 320/303). PASI90 response was the primary end-point of the study, and PASI100 was the secondary end-point. Univariate and multivariate cox-regression analyses were used to identify predictors of PASI90. The efficacy of different biologic classes for achieving PASI90 and PASI100 responses was assessed using the Kaplan-Meier method. Results: The age of disease onset (HR = 1.037, 95% CI [1.029-1.044], p < 0.001) and being biologic-naïve (HR = 1.261, 95% CI [1.046-1.521], p = 0.015) were identified as significant predictors of PASI90 response. IL23 inhibitors showed considerably superior efficacy in achieving PASI90 response than both TNF inhibitors (p = 0.042) and ustekinumab (p = 0.027). Also, IL17 inhibitors exhibited near-significantly higher effectiveness than TNF inhibitors (p = 0.090) and ustekinumab (p = 0.050). The performance of biologic classes was not substantially different in reaching PASI100 overall. Study limitations: The most important limitation of this study is the retrospective data collection. Conclusion: Age of disease onset and being biologically naïve were positively associated with achieving PASI90 response, whereas ustekinumab use was negatively associated. Age of disease onset was the strongest predictor of PASI90. Also, IL23 and IL17 inhibition, especially IL23, appeared to provide a better therapeutic response.

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Abstract Background: White piedra is a disease caused by some species of the genus Trichosporon. A case of white piedra was investigated, whose molecular examination identified Cutaneotrichosporon (Trichosporon) debeurmannianum as the causative agent. Methods: Scanning electron microscopy (SEM) was used to examine the affected hairs, as well as the fungal colony of C. debeurmannianum obtained from the hairs. For comparative purposes, a colony of Trichosporon mucoides obtained from a mycotheque was also examined. Results: Examination of the affected hairs using SEM easily demonstrates nodules on the hair shaft with a predominance of rounded yeast-like structures, adhered to each other by a cementing substance. Examination of the C. debeurmannianum colony demonstrates significant adhesion between the fungal cells by a reticular extracellular matrix. Examination of the T. mucoides colony obtained from a mycotheque demonstrates a small production of fibrillar substance between the blastoconidia. Discussion: Examination of the colony obtained from the piedra showed significant formation of extracellular matrix, adhering to and covering the fungal structures, forming a biofilm. This matrix must correspond to the cementing substance described in the condition. Conclusion: The synthesis of the extracellular matrix must be crucial in the formation of white piedra nodules.

Resumo em Inglês:

Abstract Background: Atopic dermatitis (AD) is a chronic inflammatory skin disease affecting a significant portion of the global population. While conventional treatments effectively control and manage symptoms, there is a growing need for more personalized and precise approaches for patients. Precision medicine has emerged as a promising therapeutic strategy that tailors treatment to the individual characteristics of each patient. Complementing this, the Treat-to-Target (T2T) strategy sets specific clinical goals and involves continuous monitoring and treatment adjustments based on real-time patient responses and biomarker data. Objectives: This review aims to explore the latest advancements in precision medicine and the T2T strategy for AD. Methods: A comprehensive literature review was conducted to identify the most recent studies and advancements in precision medicine and the T2T strategy for AD. Results: Recent studies highlight the effectiveness of precision medicine in achieving sustained remission and improving the quality of life for patients. The T2T strategy was shown to be effective in preventing exacerbations and adapting treatments based on real-time patient responses and biomarker data. Study limitations: The lack of a consensus on the clinical implementation of precision medicine and T2T, limited longitudinal studies validating long-term outcomes, challenges in stratifying patients due to biomarker heterogeneity, and barriers to integrating emerging diagnostic technologies into routine practice. Conclusions: Precision medicine and the T2T strategy represent significant advancements in the management of AD. These approaches offer the potential for more personalized, effective, and adaptive treatment protocols, leading to improved patient outcomes. Continuous research and development in these areas are essential to fully realize their potential and integrate them into routine clinical practice.

Resumo em Inglês:

Abstract Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by a complex interaction between genetic, immunological, and environmental factors. The combination of immune dysregulation and skin barrier dysfunction plays a crucial role in the pathogenesis of the disease. The inflammasome, an important intracellular complex of pattern recognition receptors (PRRs), plays a crucial role in the cutaneous inflammatory response, activating caspase-1 and promoting the release of pro-inflammatory cytokines such as interleukin (IL)-1β and IL-18. The role of inflammasome components in regulating the inflammatory response in AD highlights how the activation of these complexes exacerbates inflammation and contributes to the worsening of the disease and tissue damage. The review included observational and experimental studies investigating inflammasome activation in AD and other inflammatory skin diseases. The main mechanisms of inflammasome activation and their impact on the inflammatory environment and skin barrier integrity were discussed. Understanding the role of the inflammasome in AD is essential for the development of new therapeutic approaches aimed at both modulating the immune response and restoring the skin barrier, improving more effective clinical management and patients’ quality of life.

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Abstract Background: Biologic therapy is an effective psoriasis treatment. However, its long-term use carries the risk of serious adverse effects and high costs for the healthcare system, which is particularly relevant in resource-limited Latin American countries. Therefore, there is scientific interest in exploring the feasibility of tapering therapy in low disease activity or clinical remission. Objective: To provide expert consensus-based recommendations to guide personalized and efficient tapering of biologic agents in adult patients with cutaneous psoriasis. Methods: Following an exhaustive systematic literature review, a consensus was developed using a modified Delphi methodology by a group of Latin American clinical dermatologists and an independent methodological team. The topics covered include treatment goals, tapering objectives and strategies, regimens, monitoring and tapering failure, and implementation considerations in patients with psoriasis treated with biological agents. Results: The expert panel reached a consensus on five general principles and 13 recommendations for tapering biological therapy for psoriasis. These recommendations provide scientific support for dermatologists and healthcare providers regarding criteria for tapering, strategies and regimens, monitoring, failure management, and considerations for implementation. Conclusion: Tapering of biologics appears to be effective and safe in psoriasis patients with low stable activity or clinical remission. This Latin American consensus was developed in recognition of the need for rational and optimal use of biologics, while individualizing cases to apply best clinical practices.