Resumo em Inglês:

Abstract Pressure injuries remain a significant challenge in healthcare services. They negatively impact these services by increasing workload, financial burden, and direct and indirect costs related to detection, prevention, treatment, and rehabilitation. It is of utmost importance that dermatologists and other healthcare professionals are knowledgeable about these lesions. The first part of this review discusses the history and terminology of pressure injuries, epidemiology in different settings, from adults to pediatric and neonatal patients; etiopathogenesis, demonstrating the current scheme of the vicious cycle of ischemia and tissue death; associated risk factors, both intrinsic and extrinsic; classification of all stages of pressure injuries with clinical images; and the main anatomical areas at risk in each position ‒ lateral, seated, supine, prone, and with medical devices. Differential diagnoses were detailed, including incontinence-associated dermatitis, and the “Kennedy terminal ulcer”, providing support for proper evaluation and guidance on preventive measures and treatment, which will be further detailed in Part II of this review. The primary focus was to provide resources for healthcare professionals to holistically assess, prescribe, and monitor patients at risk for or with pressure injuries.

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Abstract Background The FricTest is used as a valuable tool for diagnosing and conducting threshold testing for Symptomatic Dermographism (SD). Objective In this study, the authors aimed to make a comparison between the Urticaria Activity Score (UAS), Urticaria Control Test (UCT), Visual Analog Scale (VAS), Dermatology Life Quality Index (DLQI), and Chronic Urticaria-Specific Quality of Life (CU-QoL) used to evaluate disease activity and control in the follow-up of urticaria patients and the Fric Test responses used in the diagnosis of dermographism. Methods 71 patients with SD were included in the study. Fric test 4.0 was performed in all patients at baseline and at month 1. The correlations of Fric test scores with UCT, UAS, VAS, DLQI, and CU-QoL at baseline as well as the changes in responses of treatment in the mean scores at month 1 were performed. Results In the correlation analyses, positive correlations were observed between UAS, DLQI, and CU-QoL scores and changes in Fric test 4.5 mm and 4 mm responses from baseline to the first month of treatment (p< 0.05). No significant correlations were found between Fric test 3.5 mm and 3 mm responses and CU-QoL, UAS, DLQI, and VAS scores (p> 0.05). Study limitations This study includes results from a small sample size, and larger-scale clinical trials are needed. Conclusion Changes in the Fric test 4.5 mm and 4 mm responses of treatment were found to be more sensitive in detecting UCT, UAS, CU-QoL, and DLQI changes than the responses of the Fric test 3.5 mm and 3 mm.

Resumo em Inglês:

Abstract Background Rosacea is the most prevalent chronic vascular-inflammatory dermatosis of the face. Its pathogenesis includes genetic and environmental factors, neurovascular alterations, and innate immunity. Many triggering and aggravating factors, as well as systemic comorbidities, have been associated with the disease, but there are few studies on its epidemiology in Brazil. Objectives To describe the profile of patients with rosacea treated at referral centers, as well as to investigate the presence of comorbidities, dietary aspects, worsening factors, and quality of life. Methods Cross-sectional and multicenter Brazilian study. Clinical and demographic data, disease severity, triggering and/or aggravating factors, diet, comorbidities, and impact on quality of life were evaluated. Results 258 patients were included, predominantly women, between 35 and 65 years old and phototypes III, IV and II. The clinical picture ranged from mild to moderate in 89% of cases and quality of life was reasonable to slightly affected in 58% of cases. Aggravating factors for rosacea were reported by 96% of patients, with climate exposure, alcoholic beverages, and emotional changes being the most frequent. Among the foods mentioned as aggravating factors (28%), pepper, other condiments and hot beverages were the most frequently reported. Comorbidities were reported by 89% of the participants, with emphasis on endocrine (48%), psychiatric (35%), cardiovascular (31%) and gastrointestinal (28%) diseases. Study limitations Uncontrolled study, including patients undergoing dermatological treatment. Conclusions This study establishes that the profile of Brazilian patients with rosacea corroborates that described in the literature, with the presence of the disease in higher phototypes being relevant. Pepper and other condiments and hot beverages were important aggravating factors, and the presence of various comorbidities was reported by most of the patients.

Resumo em Inglês:

Abstract Background Arsenic, recognized as a potentially lethal substance and a carcinogen, has been associated with an increased risk of skin cancer; however, the findings have been inconsistent. The aim of this study was to assess the impact of arsenic exposure on skin cancer risk (including melanoma and non-melanoma) through a meta-analysis of the available data. Objectives To assess the risk of skin cancer from arsenic exposure. Methods Searches were performed in databases such as PubMed, Web of Science, Embase, and CNKI (as of June 10, 2024). The pooled odds ratio (OR) and its 95% Confidence Interval (95% CI) were calculated using a random effects model. Subgroup analyses were performed considering sample size, study centers, U.S. regions, arsenic exposure routes, and measurement methods. Results A total of 12 papers were included, comprising 48,003 participants. The findings indicated an association between arsenic exposure and the risk of skin cancer ([OR = 1.51], 95% CI 1.26-1.80). Specifically, the OR was 1.52 (95% CI 1.06-2.17) for melanoma, 1.64 (95% CI 1.16-2.32) for squamous cell carcinoma, and 1.36 (95% CI 1.04-1.77) for basal cell carcinoma. Subgroup analyses also revealed an association between arsenic exposure and skin cancer in the United States (OR = 1.52, 95% CI 1.25-1.87). Both ingestion and inhalation pathways of arsenic exposure showed a trend toward an increased risk of skin cancer. Study limitations An important limitation of this study is a degree of heterogeneity, and another is due to the limited number of research papers available. Conclusion This meta-analysis indicates that arsenic exposure may be associated with an elevated risk of skin cancer. Additional prospective research is necessary to verify the association between arsenic exposure and the incidence of skin cancer, encompassing both cutaneous malignant melanoma and non-melanoma skin cancer.

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Abstract Background Superficial infection in venous ulcers (VU) hinders healing. Objective To evaluate the action of hydrofiber dressing with silver (HAg) compared to collagenase ointment (Col) in VU. Methods Randomized controlled clinical trial in which patients with VU with superficial infection were randomized to the intervention (HAg) or comparison (Col) group. After 30 days (T30), the primary outcomes evaluated were: rate of ulcers without signs of superficial infection, decrease in bacterial load, presence of biofilm-producing bacteria, and bacterial clonality. Results Thirty-four patients (56 ulcers) were included ‒ 18 patients (28 ulcers) in the HAg group and 16 (28 ulcers) in the Col group. There was a reduction in ulcers with superficial infection in both groups over time but with no differences (p = 0.422). There was no decrease in total bacterial load over time (p = 0.054) or between the groups (p = 0.113). There was a reduction in the rate of ulcers with biofilm-forming bacteria over time (p = 0.047) but no differences between groups (p = 0.558). Regarding the clonality of Staphylococcus aureus, 92.8% of ulcers in the HAg group and 85% in the Col group, the clones identified at T0 were the same at T30 (p = 0.553). There was no change in the identity of Pseudomonas aeruginosa in any ulcer in either group. Study limitations Short follow-up time. Conclusion Both interventions improved the clinical and some microbiologic characteristics, but there was no difference between both interventions. In addition, most ulcers showed indistinguishable genetic profiles of S. aureus and P. aeruginosa between T0 and T30, with no difference between the groups.

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Abstract Background Bullous pemphigoid (BP) is the most prevalent autoimmune bullous dermatosis with increasing incidence globally. There is a lack of literature on BP in the multiethnic Brazilian population. Objectives To assess the epidemiological, clinical, and therapeutic characteristics of BP patients in a tertiary center in Brazil. Methods Retrospective longitudinal review of clinical records of 189 BP patients from January 1986 to September 2023. Results BP primarily affected elderly individuals, predominantly females, with an average onset of symptoms at 65.7-years. Non-bullous presentations had a longer time to diagnose compared to the bullous form. Mucosal involvement was observed in 24.9% of patients. Subepidermal blistering was the predominant histopathological feature. Most cases presented fluorescence of IgG and C3 at the basement membrane zone (BMZ) on direct immunofluorescence. Indirect immunofluorescence mainly revealed fluorescence of IgG along the BMZ, and with salt-split skin technique demonstrated predominantly IgG fluorescence on the epidermal side of the cleavage. Eosinophilia, elevated IgE levels, and D-dimer were common. Systemic corticosteroids remained the mainstay of treatment. BP was associated with significant complications, including thromboembolism, hospitalization, and infections, along with numerous comorbidities and a notable percentage (10.6%) of patients using potentially BP-inducing medications. Study limitations The study's limitations include its retrospective design, reliance on potentially incomplete clinical records, and findings of a single tertiary center. Conclusions This study provides crucial insights into the multifaceted nature of BP in the Brazilian population, emphasizing the need for comprehensive management strategies to address its diverse complications and associated conditions.

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Abstract Background RNA sequencing-based studies have identified the transcription processes that contribute to psoriasis development, but the associations of these processes with specific phenotypes need further investigation. Objective The authors aimed to determine the associations of specific Peripheral Blood Mononuclear Cell (PBMC) endotypic profiles with loss of treatment response in psoriasis patients. Methods A Psoriasis Area and Severity Index (PASI) > 10 was the main outcome. The gene expression of Tyrosine Kinase-2 (TYK), Interleukin (IL)-12A, IL-12B, IL-23A, IL-23 Receptor (IL-23R), IL-6, IL-6R,IL-17A and Tumor Necrosis Factor (TNF) in PBMCs was quantified as possible risk factors. Single-Nucleotide Polymorphisms (SNP) were screened using a genotyping technique. Hierarchical clustering of the gene expression results was performed. Results The authors included 178 psoriasis patients. TYK2 was upregulated in the PBMCs of patients with a PASI score > 10, but its distribution was widely variable. A cluster of 19 patients exhibited upregulated expression of most TYK2-dependent mediators and increased PASI (p = 0.021) and Dermatology Life Quality Index (DLQI) scores (p = 0.034). Three patients harbored the TYK2I684S variant. Study limitations The utility of using single markers for psoriasis diagnosis is limited due to the wide variability of results, but the utility of the simultaneous evaluation of a set of markers has promise. Conclusions The present study suggests an association between multiple TYK2 pathway markers and loss of systemic treatment response.

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Abstract Background Accurate diagnoses in dermatology can be challenging for general practitioners. In this context, the support of artificial intelligence tools can be beneficial in the Brazilian primary care setting. Objectives To develop an interpretable machine-learning algorithm capable of assisting in the diagnosis of erythematous-squamous dermatological diseases through clinical data, without histopathological support. Methods The random-forest algorithm was trained with the public Dermatology database of 366 patients diagnosed with: chronic dermatitis, lichen planus, pityriasis rosea, pityriasis rubra pilaris, psoriasis, or seborrheic dermatitis. The model was evaluated by performance metrics and interpretability techniques. Results The model showed good predictive performance, with ROC-AUC ranging from 0.89 to 1.00, and overall accuracy of 0.86. The best results were for the diagnosis of pityriasis rubra pilaris (f1-score: 1.00) and the worst for chronic and seborrheic dermatitis (f1-score: 0.77 and 0.76, respectively). The clinical characteristics that most influenced the model's decision were, in decreasing order: involvement of knees and elbows, involvement of scalp, Koebner phenomenon, polygonal papules, and involvement of oral mucosa. Study limitations The model was not validated with Brazilian data. Conclusion The developed technology obtained good predictive performance and clinical coherence. There is a need for adaptation for implementation, using national data. The results indicate the potential for similar models to be improved and adapted to clinical practice for the benefit of the Unified Heath System.

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Abstract Background Xeroderma pigmentosum (XP) is an autosomal recessive genetic disorder characterized by a defect in the nucleotide excision repair (NER) pathway, responsible for repairing DNA damage induced by ultraviolet rays. The most common symptom in affected patients is an increased photosensitivity associated with early development of cutaneous and internal malignancies. Objective To describe whether the follow-up of xeroderma pigmentosum patients using total body mapping (TBM) with digital dermoscopy (DD) and in vivo reflectance confocal microscopy (RCM) increases early detection of melanoma and reduces unnecessary biopsies of benign melanocytic lesions. Methods Twelve XP patients were followed-up with TBM and DD from February 2008 until March 2020. The number of melanocytic lesions excised (NNE) was counted before and after the surveillance with TBM, DD, and RCM. Results In the 12-year surveillance period, twelve XP patients were followed-up with TBM, DD, and RCM. The proportion of thinner and in situ melanomas diagnosed increased after the implementation of TBM and DD in the follow-up of this group (from 67% to 82%). The association of technologies caused a reduction in the NNE from 4.02 to 2.88 and promoted early detection of melanoma. Study limitations Maintaining regular follow-up with some XP patients can be challenging due to comorbidities and social issues. Although XP is a rare disease, this represents an especially small number of cases. Conclusion XP patients are generally submitted to multiple surgical excisions, with high morbidity. Based on this experience, TBM, DD and RCM have improved the early detection of melanoma and reduced the NNE with a positive impact on health and quality of life.

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Abstract Background Leprosy is a chronic infectious disease marked by complex immune interactions, yet the roles of specific B-lymphocyte subsets in its pathology are poorly understood. Objectives To investigate the presence and distribution of B-cell subsets, including B1 cells, Marginal Zone (MZ) B-cells, Regulatory B-cells (Bregs), and Effector-1 B-cells (Be1), across different clinical forms of leprosy and reactional states. Methods Immunohistochemical and morphometric analyses were performed on skin lesions from patients with various clinical presentations of leprosy. Results CD20+ B-cells were abundant in tuberculoid lesions, whereas MZB-1 expression varied significantly among leprosy subtypes. Type 1 Reaction (T1R) lesions exhibited significantly higher counts of B1 and MZ B-cells compared to Type 2 Reaction (T2R), lepromatous leprosy (LL), and indeterminate leprosy (I). Expression patterns of PAX5/MZB-1 and PAX5/CD5 suggested a dominant presence of these cells in the Th1 pole. Be1 cells, strongly linked to Th1 immune response, were also more abundant in Th1 clinical presentations (tuberculoid and T1R leprosy). Although Bregs were generally scarce, they were most frequently observed in T1R. Study limitations This study was limited by the relatively small number of cases analyzed per clinical subtype and reactional state. Conclusions This is the first study to document the presence and distribution of these specific B-cell subsets in leprosy lesions. The findings suggest distinct roles for B-lymphocyte subtypes, particularly at the tuberculoid pole and during Type 1 reactions.

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Abstract Background The understanding of chronic spontaneous urticaria pathogenesis has been increasing recently. The central role of mast cells is being reinforced, but multiple cells, pathways, and mediators are involved in a complex interrelationship. Modern therapies for its management reflect the need to encompass different mechanisms and promise to alter the course of urticaria and the long journey of those with refractory disease. Continuous updating of these aspects is necessary to optimize patient care. Objectives To review concepts and advances in the pathogenesis of chronic spontaneous urticaria, in addition to contextualizing promising drug options for its management. Method A narrative review was conducted between 1977 and 2024, including relevant articles published in the scientific literature, indexed in the PubMed system. Results A total of 25,732 articles were found. Inclusion criteria were determined by the authors' decision regarding their level of importance for furthering knowledge in the areas of pathogenesis and treatment of chronic spontaneous urticaria, with preference given to meta-analyses, systematic reviews, and randomized trials. Regarding therapeutics, 138 articles from the last 15 years were prioritized, in addition to records on ClinicalTrials.gov, and the drugs could be in the clinical trial phase. Immunobiologicals and small molecules hold promise for future treatment regimens for chronic spontaneous urticaria. Study limitations Narrative reviews do not provide statistical value to the results and outcomes studied. Conclusion A review of the pathogenesis of chronic spontaneous urticaria was conducted, contextualizing these aspects with promising drug options for its treatment, particularly immunobiologicals and small molecules.

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Abstract Phenol, or carbolic acid, is an organic compound with caustic and antiseptic properties widely used in dermatology. Since its introduction as an antiseptic in the 19th century, its use has expanded to various areas of medicine, including the treatment of dermatological conditions such as vitiligo, warts, guttate leukoderma, hidradenitis suppurativa, angiosarcoma, acne scars, alopecia areata, onychocryptosis, and actinic keratoses. In deep peels, phenol stands out for its effectiveness in skin rejuvenation, promoting intense and sustained neocollagenesis, with unparalleled results. Its ability to alter dermal structure makes it an essential therapeutic tool in various dermatological approaches. However, its use requires extreme caution due to its rapid cutaneous absorption and unique toxicokinetic profile. The substance can induce serious complications, such as cardiac arrhythmias, renal failure, neurotoxicity, and multiple organ failure, especially when applied to large areas or with inadequate techniques and formulations. Historical and contemporary studies report cases of fatal poisoning due to cutaneous exposure to phenol, highlighting the need for strict precautions in its use. To minimize these risks, it is essential that procedures be performed by highly trained physicians, with constant monitoring and controlled application, to ensure safety and maximize the therapeutic benefits of this substance, whose efficacy is widely recognized.

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Abstract Background Artificial intelligence (AI) is increasingly gaining ground in dermatology, with studies reporting accuracy equal to or greater than dermatologists for the diagnosis of skin lesions from clinical and dermoscopic images.1 AI has been developed and improved constantly for dermatology, however, the focus has been much more on neoplastic diseases, due to their high prevalence and high morbidity. Objectives Describe the possible applications of AI in inflammatory dermatoses. Methods Articles published between 2013 and 2023 in Medline and Lilacs were retrieved after applying the inclusion and exclusion criteria 19 articles were selected. From each selected article, the necessary information was extracted and with this data, the present review was written. Results The first studies on AI in dermatology focused on the diagnosis of neoplasms, especially melanoma, due to the ease of standardization of images, obtaining accuracy equivalent to that of a dermatologist in clinical and dermoscopic lesions. Actually, there are many studies on artificial intelligence in inflammatory dermatosis, such as psoriasis, helping to calculate the PASI, hidradenitis suppurativa, and atopic dematitis. Study limitations The limitation of the study is that it is a literature review and because it is an innovative topic with a limited number of studies published in the literature. Conclusions Considerable of what is published in the literature is in computer science journals, but it is possible to perceive that there is an important interest in the area and that artificial intelligence will advance to assist dermatologists.