Scielo RSS <![CDATA[Anais Brasileiros de Dermatologia]]> vol. 90 num. 3 lang. en <![CDATA[SciELO Logo]]> <![CDATA[The case of a boy with nevus of Ota, extensive Mongolian spot, nevus flammeus, nevus anemicus and cutis marmorata telangiectatica congenita: a unique instance of phacomatosis pigmentovascularis]]> Abstract Phacomatosis pigmentovascularis is a rare, congenital condition characterized by a combination of cutaneous melanocytic lesions and vascular malformation. We discuss an entirely unique case of Phacomatosis pigmentovascularis with nevus of Ota, extensive Mongolian spot, nevus flammeus, nevus anemicus and cutis marmorata telangiectatica congenita, which may represent a heretofore undescribed variant of phacomatosis pigmentovascularis. <![CDATA[Dermatoscopic fi ndings as a complementary tool in the differential diagnosis of the etiological agent of tinea capitis]]> Abstract Tinea capitis is a scalp infection caused by fungi. In Brazil, the main causative agents are Microsporum canis and the Trichophyton tonsurans. Etiological diagnosis is based on suggestive clinical findings and confirmation depends on the fungus growth in culture. However, it is not always possible to perform this test due to lack of availability. We reveal the dermoscopic findings that enable distinction between the main causative agents of Tinea capitis, M. canis and T. tonsurans. The association of clinical and dermatoscopic findings in suspected Tinea capitis cases may help with the differential diagnosis of the etiological agent, making feasible the precocious, specific treatment. <![CDATA[A case of acquired tufted angioma in adulthood]]> Abstract Tufted angioma is a rare vascular tumor whose name derives from its histopathological appearance, characterized by tufts of capillaries within the dermis. Its etiology and pathogenesis are uncertain. Tufted angioma typically occurs during infancy or early childhood and displays various clinical patterns. It may present as a subtle stain-like area that later thickens as a large plaque, infi ltrated or dusky blue-purple lesion, or as an exophytic, fi rm, violaceous, cutaneous nodule. Medical treatment is not necessary for tufted angioma, given its benign nature and slow progression. Only clinical follow-up is therefore recommended. <![CDATA[A case of malignant atrophic papulosis with cranial nerve and peripheral nerve impairment]]> Abstract Malignant atrophic papulosisis is a rare, multisystem obliterative vasculopathy of unknown etiology, occasionally involving the cranial nerve. We describe the first case of malignant atrophic papulosisis with cranial nerve and peripheral nerve involvement in China. A 47-year-old woman presented to our hospital with atrophic porcelain white papules over the trunk and extremities, numbness in the right calf, vision decrease and impaired movement of the right eye. She was diagnosed with malignant atrophic papulosisis, based on characteristic symptoms and histopathologic examination. The patient was treated with dipyridamole and aspirin for 9 months, but later died of gastrointestinal hemorrhage. We reviewed currently available case reports on cranial nerve involvement in malignant atrophic papulosisis and emphasized the importance of skin biopsy in diagnosing this disease. <![CDATA[Anaphylaxis caused by stings from the <em>Solenopsis invicta</em>, lava-pés ant or red imported fi re ant]]> Abstract Ants are social insects with species of medical interest, such as the fi re ants (Solenopsis sp.). The sting causes inflammation, vesicles and sterile pustules, which may cause allergic phenomena and even anaphylactic shock. We describe a patient who suffered a large number of stings and an episode of syncope with fall in blood pressure and complete regression of symptoms after resuscitation and medication for anaphylaxis. Considering the clinical manifestations and images of wheals and blisters on the patient’s feet at the time of syncope, this report should serve as a warning for the diagnosis and treatment of this condition and even for counseling and prevention regarding patients exposed to this risk. <![CDATA[Angioma serpiginosum: report of an unusual acral case and review of the literature]]> Abstract We report the case of a 35-year-old woman with deep-red asymptomatic macules on the plantar and dorsal skin of the right great toe. Histopathologic fi ndings were compatible with Angioma serpiginosum. Immunohistochemical stains for estrogens and progesterone receptors were negative. Dermoscopy showed an erythematous parallel ridge pattern with double rows of irregular dots and globules. We report an unusual case of angioma serpiginosum with acral volar skin involvement. The dermoscopic features described may aid in the diagnosis of AS in this specifi c skin area. Acral volar skin involvement must be included in the clinical spectrum of Angioma serpiginosum and in the differential diagnosis of acral vascular lesions. <![CDATA[Clinical presentation of <em>pili torti</em> - Case report]]> Abstract Pili torti also known as ‘twisted hairs’ (Latin: pili=hair; torti=twisted) is a rare, congenital or acquired clinical presentation, in which the hair shaft is flattened at irregular intervals and twisted 180º along its axis. It is clinically characterized by fragile, brittle, coarse and lusterless hairs, due to uneven light reflection on the twisted hair surface. Pili torti may be associated with neurological abnormalities and ectodermal dysplasias. There is no specifi c treatment for this condition, but it may improve spontaneously after puberty. We report a case of pili torti in a child who presented fragile, brittle, diffi cult to comb hair. The patient had no comorbidities. <![CDATA[Atypical presentation of histoplasmosis in an immunocompromised patient]]> Abstract We present a case of disseminated cutaneous histoplasmosis in a male patient, rural worker, HIV positive for 20 years, with a history of irregular use of antiretroviral therapy, T cell counts below 50 cells/mm3 and with good response to treatment with Itraconazole. We highlight importance of skin lesions in clarifying early diagnosis, since this co-infection often leads patients to death. <![CDATA[Microcystic adnexal carcinoma simulating scarring alopecia]]> Abstract The microcystic adnexal carcinoma is a rare, locally aggressive malignant adnexal neoplasm associated with signifi cant morbidity. It is often underdiagnosed due to clinical and histopathological resemblance with other cutaneous neoplasms and / or a combination of lack of familiarity associated with inadequate samples. We report a case with clinical hypothesis of scarring alopecia and histopathological diagnosis of microcystic adnexal carcinoma with favorable outcome in a follow-up of eleven years, after surgical treatment. <![CDATA[Collision of malignant neoplasms of the skin: basosquamous cell carcinoma associated with melanoma]]> Abstract Collision tumors are characterized by the coexistence of two cancers in the same anatomical site and its pathogenesis remains controversial. Although uncommon, the association of basal cell carcinoma and melanocytic nevus is the most common among combinations of skin tumors. Even rarer is the association of two malignant tumors. We report a case of tumor collision representing melanoma and basosquamous cell carcinoma, a combination not previously described in the literature, since there are no reported cases of melanoma with this type of basal cell carcinoma. <![CDATA[Combined acute interstitial pneumonitis and pancytopenia induced by low-dose methotrexate in a hemodialysis patient treated for bullous pemphigoid]]> Abstract Methotrexate has been widely used for many years in the treatment of a variety of diseases. Acute pneumonitis and bone marrow suppression are very serious side effects in methotrexate treatment. A 48-year-old man with end-stage renal disease undergoing chronic hemodialysis developed combined acute pneumonitis and pancytopenia after a cumulative dose of 20 mg methotrexate for bullous pemphigoid. Continuous renal replacement therapy (CRRT) can effi ciently decrease serum methotrexate concentration. A rapid improvement of clinical symptoms and resolution of pulmonary opacifi cation were found after CRRT. Blood cell counts returned to normal after component blood transfusion and cytokine supportive therapy. Patients with impaired renal function are at high risk of methotrexate toxicity, and low-dose methotrexate should be prescribed with great caution. <![CDATA[Cutaneous metastases from gastric adenocarcinoma 15 years after curative gastrectomy]]> Abstract We report the case of a 38-year-old man, who developed cutaneous metastases in the left inguinal groove 15 years after curative gastrectomy for advanced gastric adenocarcinoma. Histopathologic examination revealed poorly differentiated adenocarcinoma cells. They were stained positive for villin, CDX-2, CKpan (AE1/ AE3), CEA, CK8/18, CK19, CK7, EMA, Ki-67 (50%), and negative for S-100, CK20, CD34, GCDFP-15 and TTF-1. The patient underwent local excision, after the presence of other metastases was excluded. Nevertheless, local recurrence developed at the surgical bed one year later and PET/CT revealed metastases to lymph nodes, bone and skin. He died 2 years after the appearance of cutaneous metastases. We have reviewed the literature and described the immunohistochemical characteristics of cutaneous metastases from gastric adenocarcinoma. <![CDATA[Dapsone in the treatment of pemphigus vulgaris: adverse effects and its importance as a corticosteroid sparing agent]]> Abstract Pemphigus vulgaris is an autoimmune disease characterized by suprabasal blisters with acantholysis, which has a fatal course in a large number of untreated patients. Systemic corticosteroid therapy is considered first-line therapy. Adjuvant treatment with the goal of sparing corticosteroids include, among others, dapsone. This drug is not without side effects and its use requires clinical and laboratory control. We present a patient with PV initially managed with suboptimal dose of prednisone, evolving into drug-induced hepatitis after introduction of dapsone. <![CDATA[HTLV-1-associated infective dermatitis and probable HTLV-1- associated myelopathy in an adolescent female]]> Abstract Human T cell lymphotropic virus type 1 (HTLV-1)-associated infective dermatitis (ID) is a chronic, severe and recurrent eczema occurring during childhood in patients vertically infected with HTLV-1. HTLV-1-associated myelopathy/tropical spastic paraparesia (HAM/ TSP) is slow and progressive. We report the case of an adolescent female from a non-endemic area for HTLV-1 who presents ID and, most likely, associated HAM/TSP. <![CDATA[Dermatosis neglecta]]> Abstract Dermatosis neglecta is the name of a skin condition characterized by papules and polygonal plaques, which are sometimes warty, brownish and hyperpigmented, adherent and symmetric, though removable with ethyl or isopropyl alcohol. It occurs due to inadequate skin cleansing causing accumulation of sebum, sweat, keratin and impurities. Its occurrence, though little reported, is frequent. The main differential diagnosis is the Terra fi rma-forme dermatosis. The treatment is simple, with exfoliation, moisturizing and even rubbing of alcohol. Causes of negligence on the patient’s side, which can range from hygiene carelessness to psychiatric disorders, local hypersensitivity, limbs negligence or motor paralysis, should be investigated. We illustrate the case of dermatosis neglecta in a 45-years old patient admitted with pulmonary sepsis. <![CDATA[Segmental Darier's disease: a presentation of difficult diagnosis]]> Abstract Darier's disease is a rare autosomal dominant genodermatosis. It has an estimated prevalence of 1 in 55,000 to 100,000 individuals, regardless of gender. It is characterized by multiple keratotic papules on the seborrheic areas of the trunk, scalp, forehead and flexures, and the clinical picture is worsened by heat, sun exposure, perspiration and mechanical trauma. Histopathology observed loss of epithelial adhesion and abnormal keratinization. About 10% of cases present in the localized form of the disease. We report a case of segmental Darier's Disease Type I and discuss the main characteristics of this condition. <![CDATA[Severe Darier's disease in a psychiatric patient]]> Abstract Darier’s disease is characterized by dense keratotic lesions in the seborrheic areas of the body such as scalp, forehead, nasolabial folds, trunk and inguinal region. It is a rare genodermatosis, an autosomal dominant inherited disease that may be associated with neuropsichiatric disorders. It is caused by ATPA2 gene mutation, presenting cutaneous and dermatologic expressions. Psychiatric symptoms are depression, suicidal attempts, and bipolar affective disorder. We report a case of Darier’s disease in a 48-year-old female patient presenting severe cutaneous and psychiatric manifestations. <![CDATA[Eccrine poroma and porocarcinoma on the same unusual location: report on two cases]]> Abstract Eccrine poroma is a benign adnexal tumour of the uppermost portion of the intraepidermal eccrine sweat gland duct and acrosyringium. Eccrine porocarcinoma is the malignant phenotype arising from the intraepidermal portion of the eccrine sweat gland duct epithelium or from pre-existing eccrine poroma. Both commonly occur in the palms or sides of the feet; these areas have a high concentration of eccrine sweat glands. We describe two respective cases of benign and malignant eccrine poroma on the scrotum, which entailed good excisional results. <![CDATA[Leprosy type-I reaction episode mimicking facial cellulitis-the importance of early diagnosis]]> Abstract Leprosy is aneasily recognizable disease due to its dermato-neurological manifestations. It must be present in the physician’s diagnostic repertoire, especially for those working in endemic areas. However, leprosy reaction is not always easily recognized by non-dermatologists, becoming one of the major problems in the management of patients with leprosy, as it presents clinical complications characterized by inflammatory process, accompanied by pain, malaise and sometimes the establishment or worsening of the patient’s disabilities. We report the case of a patient with type-1 periorbital reaction admitted to the hospital, diagnosed and treated as facial cellulitis, whose late diagnosis may have contributed to the appearance or worsening of facial neuritis. <![CDATA[Possibly drug-induced palpable migratory arciform erythema]]> Abstract Palpable migratory arciform erythema is an entity of unknown etiology, with few published cases in the literature. The clinical and histopathological features of this disease are difficult to be distinguished from those of Jessner’s lymphocytic infiltration of the skin, lupus erythematous tumidus and the deep erythema annulare centrifugum. We describe here the first two Brazilian cases of palpable migratory arciform erythema. The patients presented with infiltrated annular plaques and erythematous arcs without scales. These showed centrifugal growth before disappearing without scarring or residual lesions after a few days. They had a chronic course with repeated episodes for years. In addition, these cases provide evidence of a drug-induced etiology. <![CDATA[Scleredema associated with Sjögren’s syndrome]]> Abstract Scleredema adultorum of Buschke is a rare disorder characterized by diffuse swelling and non-pitting induration of the skin usually involving the face, neck, arms and upper trunk. It has been associated with previous infectious diseases, diabetes, paraproteinemia and, more rarely, malignant neoplasms or autoimmune disorders. We report the case of a 30-year-old man who presented with a 2-year history of scleredema. Further investigation led to the diagnosis of primary Sjögren’s syndrome. The association between scleredema and autoimmune disorders has been rarely seen. To our knowledge, there are no other reports describing the association between primary Sjögren’s syndrome and scleredema adultorum of Buschke. <![CDATA[Sporotrichosis in an unusual location - Case report]]> Abstract Sporotrichosis is the most common subcutaneous mycosis. It is caused by the dimorphic fungus Sporothrix schenckii, and the infection is usually acquired by traumatic inoculation. We describe a case of sporotrichosis in an uncommon location with an unusual mode of transmission. A 49-year-old female patient who lived in an urban area of Rio de Janeiro presented with involvement of the left ear. No history of contact with soil, plants or animals was elicited. The suspected source of infection was a pair of handmade wooden earrings. The delay in the diagnosis and treatment resulted in higher morbidity, unsightly scarring and loss of ear lobe. <![CDATA[Eosinophilic ulcer of the tongue - Case report]]> Abstract Eosinophilic ulcer of the oral mucosa is a rare, self-limiting, chronic and benign lesion of unknown pathogenesis that affects the oral mucosa. We present the case of a 65 year-old Caucasian female with a fivemonth history of a painful ulcer on the lateral side of her tongue. The ulcer was not adhered to the underlying structures and there was no evidence of regional lymph node involvement. Laboratory examinations and X-rays revealed no abnormalities. Topical treatments had been performed without any improvement. Histopathological examination showed an ulcerated surface and mixed inflammatory infiltrate with several eosinophils extending into the mucosa and submucosa. No cellular atypia was observed. Based on the patient-s history and mucosal biopsy, a final diagnosis of eosinophilic ulcer of the oral mucosa was made. <![CDATA[Wolf's isotopic response, presenting as lichen planus]]> Abstract The term "Wolf's isotopic response" describes the occurrence of a new skin disorder at the site of another unrelated and already healed skin disease. In most cases, herpes zoster is the inicial disease. Different disorders may develop on the same site, most commonly granulomatous and lichenoid reactions, infiltration of hematologic diseases, skin tumors and infections. There are few related cases of lichen planus presenting as isotopic response. We report a case of a 74 year-old woman, with multiple itchy, rose-colored and shiny papules that developed at site of previously healed herpes zoster, on the right arm and shoulder. The pathogenesis of this phenomenon is still unknown and further studies are needed. <![CDATA[Proliferating pilomatricoma - Case report]]> Abstract Proliferating pilomatricoma is proliferative, rare tumor variant of pilomatricoma. It is a benign neoplasm of hair matrix that can have potentially involve local recurrence. We report the case of a 60-year-old man who presented an asymptomatic nodule on the scalp. Histological exam demonstrated a basaloid epithelium at the periphery, filled with eosinophilic cornified material containing shadow cells. The tumor was excised and there was no evidence of recurrence one year later. <![CDATA[Type 2 segmental glomangioma - Case report]]> Abstract Glomus tumors originate from modified perivascular muscle cells. The most common form is the solitary one. The multiple form may be associated with dominant genetic inheritance. We report a case of a patient with hemangiomatous lesions on the calcaneus and wrist since birth. In 6 years, there was progression of lesions throughout the body. Multiple glomangiomas are asymptomatic and more common in childhood. They can be confused with other vascular malformations. Histopathological diagnosis is essential. The case shows a type 2 segmental manifestation that can be explained by genetic mutation leading to the loss of heterozygosity. As the child grows, the lesions may disseminate due to mutation in distant parts of the skin. Literature shows few reports. The treatment is conservative. <![CDATA[Granulomatosis with polyangiitis, a new nomenclature for Wegener's Granulomatosis - Case report]]> Abstract The granulomatosis with polyangiitis, initially known as Wegener's granulomatosis, is a small and medium vessels vasculitis. It's classic form presents a triad: necrotizing granuloma of respiratory tract, necrotizing cutaneous vasculitis and glomerulonephritis. This vasculitis has cytoplasmic antineutrophil antibodies as signal. This work illustrates a case, of multisystemic rare disease, in which the segment and treatment were considered satisfactory for symptoms remission. <![CDATA[Cutaneous histoplasmosis as a complication after anti-TNF use - Case report]]> Abstract Anti-TNF agents are effective in the treatment of psoriasis. However, they render individuals more susceptible to infections. We report an atypical case of histoplasmosis in an immunosuppressed patient due to anti- TNF therapy. A patient who used anti-TNF for the treatment of psoriasis had had a lesion on the right eyebrow since discontinuation of the medication. The diagnostic hypothesis was basal cell carcinoma, but the histopathological examination was compatible with histoplasmosis. <![CDATA[Post-kala-azar dermal Leishmaniasis in two different clinical contexts]]> Abstract In Brazil, visceral Leishmaniasis is caused by Leishmania chagasi. The development of cutaneous lesions in visceral leishmaniasis patients has been described in two different clinical contexts. Patients with compromised immunity can develop skin lesions as a direct consequence of a current visceral disease. Equally, patients with a history of kala-azar and progressive, immune improvement occasionally develop skin lesions as a consequence of immune reconstitution infl ammatory syndrome. These cases manifest in similar fashion to the classic form of post-kala-azar dermal Leishmaniasis. We describe different cases that exemplify these two clinical presentations. <![CDATA[Primary cutaneous follicle center lymphoma simulating basal-cell carcinoma on the nasal ala]]> Abstract Primary cutaneous B-cell lymphomas (PCBCLs) constitute 25% of all primary cutaneous lymphomas. They present in the skin with no evidence of systemic or extracutaneous disease at the time of diagnosis, after adequate staging. Primary cutaneous B-cell lymphomas differ significantly from their nodal counterparts in relation to both clinical behavior and prognosis. The distinction between primary and secondary B-cell lymphomas is essential for defining prognosis/course of action. Such distinction is also very difficult to make, since primary and secondary B-cell lymphomas are clinically and histologically indistinguishable. We report the case of a patient with primary cutaneous follicle center lymphoma who underwent surgical excision. <![CDATA[Membranous lipodystrophy: case report and review of the literature]]> Abstract Membranous lipodystrophy is a distinct type of membranocystic fat necrosis. It is associated with many local and systemic diseases, including vascular disorders. The histopathological changes which characterize this phenomenon are variably sized cysts in the fat lobules of the subcutaneous tissue, which are surrounded by eosinophilic membranes projecting into the cystic space. We report a case of secondary membranous lipodystrophy associated with both hypertension and venous insufficiency. <![CDATA[Bullous and hemorrhagic lichen sclerosus - Case report]]> Abstract Lichen sclerosus is a chronic inflammatory disease, usually located in the genital area. The etiology of lichen sclerosus is multifactorial, with participation of genetic, autoimmune, infectious and hormonal factors. Bullous clinical form stems from hydropic degeneration of the basal membrane, constituting a less frequent variant of the disease. In this work, we report the case of a female patient, 55 years old, who in the last three years presented whitish plaques, with horny spikes, located on back and arms. Some of these lesions evolved with hemorrhagic blisters, which after histopathological examination confirmed the diagnosis of bullous and hemorrhagic lichen sclerosus. The patient was treated with high-potency topical corticosteroid for two months, resulting in remission of bullous and hemorrhagic lesions. <![CDATA[Drug-induced lupus with leukocytoclastic vasculitis: a rare expression associated with adalimumab]]> Abstract TNF alpha antagonist-induced lupus-like syndrome is a rare condition which predominantly affects women (4:1). The average age of onset is 46-51 years. It occurs after exposure to TNF alpha antagonist and disappears after discontinuation of such agents. The pathogenic mechanism for development of the TNF alpha antagonist-induced lupus-like syndrome is not fully defined. It is believed that the medication induces apoptosis, leading to an accumulation of nucleosomal antigens of apoptotic cells. This would cause autoantibodies to be produced by susceptible individuals. The most common cutaneous manifestations include maculopapular exanthem, malar rash, alopecia, photosensitivity and, more rarely, vasculitis. Extracutaneous manifestations include: fever, weight loss, arthritis or arthralgia, myositis and hematological abnormalities. Antinuclear antibody may be positive in 80% of cases and anti-histone antibody is considered a disease marker for TNF alpha antagonist-induced lupus-like syndrome. Treatment corresponds to drug discontinuation. We report a rare case of sub-acute cutaneous lupus erythematosus with leukocytoclastic vasculitis induced by adalimumab in a 42-year-old patient. <![CDATA[Anti-TNF-α and hydralazine drug-induced lupus]]> Abstract Drug-induced lupus is a rare drug reaction featuring the same symptoms as idiopathic lupus erythematosus. Recently, with the introduction of new medicines in clinical practice, an increase in the number of illness-triggering implicated drugs has been reported, with special emphasis on anti-TNF-α drugs. In the up-to-date list, almost one hundred medications have been associated with the occurrence of drug-induced lupus. The authors present two case reports of the illness induced respectively by hydralazine and infliximab, addressing the clinical and laboratorial characteristics, diagnosis, and treatment. <![CDATA[Frontal cutaneous meningioma - Case report]]> Abstract Cutaneous meningiomas are rare tumors most commonly located on the scalp. We report the case of a 55-year-old male who presented with a 2x3 cm tumoral lesion on the forehead. The lesion was hard, adherent and covered by normal skin. Incisional biopsy revelead a proliferation of monomorphic round cells, organized in nests and focally forming pseudovascular spaces. Immunohistochemical study revealed positivity for epithelial antigen membrane and vimentin. Vascular markers, cytokeratins and S100 protein were negative. A brain CT scan did not show any evidence of intracranial meningioma. The authors describe the case of a cutaneous frontal meningioma in probable relation with previous cranioencephalic trauma. <![CDATA[Cutaneous metastasis of a breast cancer diagnosed 13 years before]]> Abstract Metastasis is defined as a neoplastic lesion originating from another primary tumor, with which it is no longer in contact. Cutaneous metastases result from lymphatic embolization, hematogenous or contiguous dissemination or also direct implantation during surgical procedures. In women, the tumor most likely to metastasize to skin is breast cancer, which may manifest as papulonodular neoplastic lesions. We report the case of a 66 years old female patient, presenting papulonodular lesions13 years after the initial treatment with surgery and chemotherapy for a cancer of the left breast. <![CDATA[Disseminated cutaneous atypical mycobacteriosis by <em>M. chelonae</em> after sclerotherapy of varicose veins in a immunocompetent patient: a case report]]> Abstract Atypical mycobacteria are saprophytic organisms not transmitted from person to person, which affect mainly immunosuppressed but also immunocompetent individuals. We present a case of atypical mycobacteriosis after a vascular procedure, with widespread cutaneous lesions associated with polyarthralgia. Mycobacterium chelonae was identified by the polymerase chain reaction (PCR) method. The patient showed improvement after treatment with three antibiotics. Mycobacterium chelonae causes skin lesions after invasive procedures. The clinical form depends on the immune state of the host and on the entry points. The diagnosis is based essentially on culture and the mycobacteria is identified by PCR. We highlight the importance of investigating atypical mycobacteriosis when faced with granulomatous lesions associated with a history of invasive procedures. <![CDATA[Pre-tibial myxedema: treatment with intralesional corticosteroid]]> Abstract The pretibial myxedema is a manifestation of Graves' disease characterized by accumulation of glycosaminoglycans in the reticular dermis. The dermopathy is self-limiting but in some cases may cause cosmetic and functional damage. Conventional treatment is use of topical steroids under occlusive dressing, however the intralesional application has shown good results. We present a case of pretibial myxedema treated with single injection of intralesional corticosteroid. <![CDATA[Follicular mucinosis: an important differential diagnosis of leprosy in an endemic area]]> Abstract Primary follicular mucinosis is a rare dermatosis characterized by the accumulation of mucin in the follicular epithelium and sebaceous glands. Clinically, it is characterized by the presence of papules or well-circumscribed and infiltrated plaques. In this paper, we report the case of a female patient, seven years old, evolving for three months with an asymptomatic, erythematous and infiltrated plaque located in the chin region. The research of thermal, pain and tactile sensitivity was inconclusive. Histological findings confirmed the diagnosis of follicular mucinosis. There was regression of the lesion with the use of medium potency topical corticosteroids for 20 days. The pathogenesis of follicular mucinosis remains unknown, being in some cases associated with lymphoproliferative disorders. In endemic areas of leprosy, isolated and infiltrated follicular mucinosis lesions should be further differentiated from leprosy. <![CDATA[Multiple giant angiokeratoma of Fordyce on the shaft of the penis masquerading as keratoacanthoma]]> Abstract The term 'angiokeratoma' includes a wide range of dermatological conditions of hyperkeratotic vascular disorders with a similar histologic combination of hyperkeratosis and superficial dermal vascular ectasia. Angiokeratomas can be classified into localized and systemic forms. Angiokeratoma of Fordyce (AKF) is a localized form of angiokeratoma, clinically characterized by 1- to 6-mm, black, blue, or dark red, dome-shaped papules located on the scrotum, shaft of penis, labia majora, clitoris, inner thigh, and lower abdomen. We describe herein a case of giant angiokeratoma of Fordyce on shaft of the penis in an elderly man, clinically masquerading as keratoacanthoma. <![CDATA[Multiple minute digitate hyperkeratosis - a peculiar entity]]> Abstract Multiple minute digitate hyperkeratosis is a rare, non-follicular dermatosis, with fewer than 30 cases described worldwide. It can be either acquired or inherited in an autosomal dominant pattern. We describe the case of an 83-year old patient with life-long, multiple, digitate, milimetric lesions, and a positive family history for the same dermatosis. <![CDATA[Cellular neurothekeoma: case report and its (un) relation with nerve sheath myxoma]]> Abstract Neurothekeoma is an uncommon, benign neoplasm presenting in young adults, primarily on the head and neck. It was initially related to nerve sheath myxoma but with the advent of immunohistochemistry, new insights into its cellular differentiation and origin have emerged, unlinking Neurothekeoma and nerve sheath myxoma. Herein we describe a 19-year-old male who had had a frontal, fl esh-colored, asymptomatic papule for 2 years. Histology showed a dermal fusocellular-spindle cell tumor, including an eosinophilic cytoplasm with mild cellular pleomorphism and moderately dense fi brous stroma. IHQ was positive for CD10 and negative for S100 and Claudin-1. These fi ndings were compatible with cellular Neurothekeoma. The lesion was completely extirpated and at the 6-month follow-up, the patient was asymptomatic and had experienced no recurrences. <![CDATA[Cerebriform sebaceous nevus: a rare presentation]]> Abstract A 13-year-old boy presented congenital, raised, yellowish colored plaques with fibroelastic consistency, which were velvety in appearance, alopecic, with clearly defined limits and sulci or well-marked meandering invaginations, a cerebriform appearance on the upper part of the right ear, accompanied by alopecia in the temporomandibular region-parietal. The lesion was asymptomatic. Histopathologic examination revealed acanthosis, hyperkeratosis, papillomatosis and follicular plugging in the epidermis. The upper dermis showed underdeveloped hair follicles with sebaceous glands, consistent with sebaceous nevus. There were no skeletal, cardiological, ophthalmological or neuropsychomotor changes; nor were there any records of relevant pathologies in the family history. The patient complained of his appearance, experiencing aesthetic and social issues. Following a diagnosis of cerebriform nevus sebaceous, complete excision was performed with excellent aesthetic results. <![CDATA[Azathioprine-induced accelerated cutaneous and pulmonary nodulosis in a patient with rheumatoid arthritis]]> Abstract We report the case of a 42-year-old female with a 5-year history of rheumatoid arthritis treated with Rituximab and Azathioprine. Three months after the initiation of Azathioprine, the patient started with dry cough and noted the rapid development of multiple subcutaneous nodules on her right leg. CT scan of the chest demonstrates pulmonary nodulosis. Skin biopsy was compatible with rheumatoid nodule. A diagnosis of "accelerated cutaneous and pulmonary nodulosis" was considered. Azathioprine was discontinued and Rituximab was restarted. Two months later, most of the subcutaneous nodules had disappeared. This is the second case report of accelerated rheumatoid nodulosis in association with Azathioprine treatment. <![CDATA[New drugs, new challenges for dermatologists: mucocutaneous ulcers secondary to everolimus]]> Abstract Everolimus, a mammalian target of rapamycin inhibitor, is an emerging drug, which is being increasingly applied in oncology and solid organ transplantation. Oral ulcers are a frequent side effect associated with this immunosupressor. We report the case of a renal transplant recipient who developed disfiguring oral and perianal ulcers secondary to everolimus's toxicity. This is probably the first report of perianal involvement. Dermatologists need to be aware of the potential mucocutaneous adverse effects related to these new drugs that are becoming evermore common in our clinical practice. <![CDATA[The role of immunohistochemistry in the Muir-Torre Syndrome]]> Abstract Muir-Torre Syndrome is defined by the coexistence of sebaceous skin tumors and internal malignancies. Mutations in the DNA mismatch repair genes are found in the inherited form of the disease, resulting in the absence of crucial enzymes involved with DNA replication process. This case describes a patient with sebaceous adenoma and colorectal carcinoma, meeting the criteria for Muir-Torre Syndrome. The immunohistochemical analysis of the skin lesion was an important tool to confirm the diagnosis, as it revealed nuclear negativity for MSH2 and MSH6. <![CDATA[Use of tumor necrosis factor alpha (TNF α) antagonists in a patient with psoriasis and Chagas disease]]> Abstract There are several studies on the benefits of using TNFα antagonists in the treatment of psoriasis, but few studies addressing the interaction of these drugs with chronic infections. We report the case of a 52-year-old patient diagnosed with psoriasis refractory to traditional systemic agents, who was treated with biologic therapies. After one year of treatment with biologic agents, the patient was diagnosed with Chagas Disease. <![CDATA[Palmar and plantar lichen planus: a case report and review of the literature]]> Abstract Palmoplantar lichen planus is an uncommon dermatosis. We present a case of 38-year-old Caucasian male with a history of pruritic, scaly lesions on the right plantar foot. Physical examination revealed whitish plaques and numerous spiny hyperkeratotic papules and focal scaling. A biopsy demonstrated orthohyperkeratosis and acanthosis of the epidermis. Immunohistochemical staining revealed positivity within the epidermis and/or lichenoid infiltrate with CD3, CD8, CD45, CD68, myeloid histiod antigen, BCL2, p27, p53, HLA-DPDQDR, metallothionein and tissue inhibitor of metalloproteinases 1. The diagnosis of PPLP was thus confirmed; this case illustrates that PPLP should be considered in the differential diagnosis of uncommon foot dermatoses with a significant junctional inflammatory component. <![CDATA[Piloleiomyoma with segmental distribution - Case report]]> Abstract Piloleiomyoma is an uncommon benign neoplasm arising from the erector pilorum muscle. It presents as reddish-brown papules or nodules, in general located on the limbs or trunk, often painful. The present paper describes a case of piloleiomyoma with segmental distribution on left trunk, with an important expression of pain. <![CDATA[Pityriasis lichenoides et varioliformis acuta after influenza vaccine]]> Abstract The etiology of pityriasis lichenoides is unknown. One of the accepted theories admits that PL is an inflammatory response to extrinsic antigens such as infectious agents, drugs and vaccines. In recent medical literature, only the MMR vaccine (Measles, Mumps and Rubella) was associated with the occurrence of this disease. We present a case of a male, 12 year old healthy patient who, five days after Infl uenza vaccination, developed erythematous papules on the trunk, abdomen and limbs, some with adherent crusts and associated systemic symptoms. This case report is notable for describing the first case of pityriasis lichenoides et varioliformis acuta associated with the vaccine against Influenza. <![CDATA[Actinic comedonal plaque-variant of Favre-Racouchot syndrome: report of two cases]]> Abstract The actinic comedonal plaque is characterized by papules, cysts and comedones forming a yellowish plaque in areas of chronic sun exposure skin. There are few reports in literature about this entity, considered a rare and ectopic form of Favré-Racouchot Syndrome. We report two cases of lesions located on forearms and thorax. Favré-Racouchot Syndrome is a condition usually restricted to the periorbital area; however, there are reports of similar findings in atypical locations, such as forearms and chest, which are known as actinic comedonal plaque. Ultraviolet radiation exposure is the main factor involved in its pathogenesis. The objective of this study was to provide accurate knowledge of this dermatosis and stimulate dermatologists to provide a correct diagnosis of the condition. <![CDATA[Cutaneous polyarteritis nodosa]]> Abstract Polyarteritis nodosa is a rare vasculitis in children characterized by necrotizing inflammation in small and medium size arteries. It is classified into systemic and cutaneous PAN according to the presence of systemic symptoms or visceral involvement. We describe the case of a 14-year-old girl with cutaneous Polyarteritis nodosa with an atypical clinical presentation. <![CDATA[Porokeratosis ptychotropica of the scrotum: dermoscopic evaluation of an atypical presentation]]> Abstract Porokeratosis ptychotropica is a rare variant of porokeratosis that is classically located on the gluteal and perianal regions, seldom extending to the genitalia. The authors report an atypical presentation of porokeratosis ptychotropica and discuss the use of dermoscopy in evaluating this dermatosis. Dermoscopic findings, although not specific to this variant of porokeratosis, are helpful in the differential diagnosis of other genital disorders. Histopathology, through the visualization of multiple cornoid lamellae, prevails as the gold standard for the definite diagnosis of porokeratosis ptychotropica. <![CDATA[Linear psoriasis: case report on three year old child]]> Abstract Atypical and unusual locations of psoriasis are very frequent. However, localized linear psoriasis is rare, with few cases described in the literature. It is characterized by a linear distribution of psoriasis lesions along Blaschko lines. We report the case of a three years old child, who presented unilateral erythematous scaly plaques arranged along Blaschko lines in the left hemithorax, with no associated symptoms and no lesions in other parts of the body. The differentiation of linear psoriasis from other linear dermatoses is not easy. The combination of a thorough history, a careful examination of the skin and histopathology are essential to ensure the correct diagnosis and appropriate treatment. <![CDATA[A case of generalized ostraceous psoriasis mimicking dermatitis neglecta]]> Abstract Lithium has been implicated in the exacerbation of pre-existing psoriasis, in the induction of psoriasis on previously uninvolved skin of psoriasis patients, and in the triggering of psoriasis for the first time in patients without a personal or family history. Lithium-induced psoriasis (and its resistance to treatment) is one of the major reasons for noncompliance in patients treated with lithium. We describe a male patient who developed generalized ostraceous psoriasis whose clinical appearance mimicked dermatitis neglecta, 10 months after starting therapy with lithium. <![CDATA[Cheilitis granulomatosa associated with lupus erythematosus discoid and treated with methotrexate: report of a case]]> Abstract We present the rare case of a 47-year-old patient, suffering from cheilitis granulomatosa and lupus erythematosus discoid: this association is really exceptional because only once reported in English literature. In addition, the treatment of cheilitis granulomatosa is a challenge for the dermatologist: the gold standard, represented by steroids, is in fact designed as a short-time option. Our report confi rms the good efficacy of methotrexate as a steroid-sparing agent. <![CDATA[Complex nasal reconstruction after paracoccidioidomycosis infection - Case report]]> Abstract Paracoccidioidomycosis is an infectious disease whose etiological agent belongs to the Paracoccidioides genus. Although it affects primarily the lungs, it can spread to other tissues, including the skin and mucous membranes. Despite the clinical treatment for this disease, scarring can produce sequelae, manifesting as anatomical and functional deformities of the face. We present a case of extensive, nasal unaesthetic and functional sequelae resulting from paracoccidioidomycosis, reconstructed using the paramedian forehead flap in three stages, through the regional unit principles. <![CDATA[Lower lip reconstruction with nasolabial flap - going back to basics]]> Abstract Squamous cell carcinoma of the lower lip is frequent, and radical excision sometimes leads to complex defects. Many lip repair techniques are aggressive requiring general anesthesia and a prolonged post-operative period. The nasolabial flap, while a common flap for the repair of other facial defects, is an under-recognized option for the reconstruction of the lower lip. We describe the use of nasolabial flap for the repair of a large defect of the lower lip in a ninety year-old male, with good functional results and acceptable cosmetic outcome. We believe the nasolabial flap is a good alternative for intermediate-to-large lower lip defects in patients with impaired general condition. <![CDATA[Serious stomatitis and esophagitis: a peculiar mucous reaction induced by pegylated liposomal doxorubicin]]> Abstract Pegylated liposomal doxorubicin is an important antineoplastic agent with activity in a variety of solid tumors. It has a totally different profile of pharmacokinetics and toxicity compared with doxorubicin. It rarely causes side-effects like cardiotoxicity or hair loss, but frequently results in many kinds of mucocutaneous reactions, including palmar-plantar erythrodysesthesia, diffuse follicular rash, intertrigo-like eruption, new formation of melanotic macules, stomatitis and radiation recall dermatitis. We present a rare case of multiple myeloma who immediately developed serious stomatitis and esophatitis associated with minor palmar-plantar erythrodysesthesia after a single course of pegylated liposomal doxorubicin. <![CDATA[Syphilis associated with paretic neurosyphilis mimicking Reiter’s syndrome in HIV-infected patients]]> Abstract HIV/syphilis co-infection is common because both conditions affect similar risk groups. HIV interferes with the natural history of syphilis, which often has atypical clinical features and nervous system involvement in the early stage of disease. We report the case of an HIV-positive patient with secondary syphilis, scaling palmoplantar keratoderma, scrotal eczema, balanitis and urethritis mimicking Reiter’s syndrome. Immunohistochemistry using polyclonal antibodies against Treponema pallidum revealed the presence of spirochetes, associated with the paretic form of parenchymal neurosyphilis. The patient was given crystalline penicillin, with complete resolution of dermatological and neurological symptoms, and no sequelae. <![CDATA[A case of secondary syphilis mimicking palmoplantar psoriasis in HIV infected patient]]> Abstract Due to diverse clinical and histopathological presentations, diagnosis of secondary syphilis can occasionally prove challenging. Variable clinical presentations of secondary syphilis in HIV disease may result in an incorrect diagnosis and an inappropriate treatment regimen. Similarly, the histology of secondary syphilitic lesions may show considerable variation, depending on the clinical morphology of the eruption. We report a case of secondary syphilis in an HIV infected patient with cutaneous palmoplantar lesions simulating palmoplantar psoriasis. <![CDATA[Ehlers-Danlos Syndrome associated with cardiomyopathy hypertrophic obstructive]]> Abstract Ehlers-Danlos syndrome is a rare clinical condition caused by a genetic change that results in the formation of structurally or functionally altered collagen. The clinical manifestations are varied, being the most obvious skin hypermotility and increased joint flexibility, although other systems - such as cardiovascular, respiratory and neurological - may also be affected. This paper presents the report of a patient who sought medical attention with complaints of atypical chest pain. Clinical evaluation enabled hypothetical diagnosis of hypertrophic obstructive cardiomyopathy and Ehlers-Danlos syndrome. Initial electrocardiogram, echocardiogram and 24 hours holter allowed the confirmation of the first hypothesis. A skin biopsy performed later associated clinical data and confirmed the second hypothesis. <![CDATA[Laugier-Hunziker syndrome - Case report]]> Abstract Laugier-Hunziker syndrome is a rare, acquired disorder characterized by lenticular hyperpigmentation of the oral mucosa and longitudinal melanonychia. We present the case of a 63-year-old female with progressive, asymptomatic hyperpigmentation of buccal mucosa and a 7-year history of hyperpigmentation in several fingernails. Laugier-Hunziker syndrome was diagnosed based on the clinical features presented, dermoscopic findings and exclusion of underlying systemic diseases. Laugier-Hunziker syndrome is regarded as a diagnosis of exclusion. By identifying Laugier-Hunziker syndrome, other, more severe syndromes associated with hyperpigmentations can be excluded, namely Addison’s disease and Peutz-Jeghers syndrome. <![CDATA[Rendu-Osler-Weber syndrome: dermatological approach]]> Abstract The Rendu-Osler-Weber syndrome is a rare systemic fibrovascular dysplasia, recognized by mucocutaneous telangiectasias, arteriovenous malformations, epistaxis and family history. Recurrent bleeding, hypoxemia, congestive heart failure, portosystemic encephalopathy, and symptoms related to angiodysplasia of the central nervous system may occur. Since the treatment is based on supportive measures, early recognition is of utmost importance. This article reports the case of a 53-year-old male patient who presented telangiectasias on fingers, oral cavity and nasal mucosa for 10 years, with a history of recurrent epistaxis of varying severity since childhood. Mother, sister and daughter have similar lesions. <![CDATA[Stewart Treves Syndrome]]> Abstract Stewart-Treves Syndrome is characterized by the presence of lymphangiosarcoma on limb extremities. Rare, it occurs in 0.5% of patients who have undergone radical mastectomy with axillary node dissection. The main cause is chronic lymphedema with endothelial and lymphatic differentiation, with no direct relationship to breast cancer. Seven years after a radical right-side mastectomy with lymph node dissection and adjuvant therapy, the patient developed a lesion on her right arm. The dermatological examination revealed an erythematous nodule with bleeding surface on chronic right forearm lymphedema. After the biopsy, a lymphangiosarcoma on chronic lymphedema was diagnosed. Infrequent, this syndrome is relevant because of its associated mortality. Early diagnosis is important to improve survival and reduce complications. <![CDATA[Stewart-Treves Syndrome of the Lower Extremity]]> Abstract Stewart-Treves syndrome is a rare cutaneous angiosarcoma that develops in long-standing chronic lymphedema. Though most commonly this angiosarcoma is a result of post mastectomy lymphoedema, it also develops in Milroy disease, idiopathic, congenital, traumatic and filarial lymphoedema. Despite the rarity of this syndrome and its poor prognosis, early diagnosis associated with radical surgery can provide improved survival. We report a case of angiosarcoma in the lower limb in a patient with chronic lymphedema associated with history of repeated erysipela episodes. <![CDATA[Solitary eccrine syringofibroadenoma - Case Report]]> Abstract Eccrine syringofibroadenoma is a rare benign adnexal neoplasm derived from cells of the acrosyringium of eccrine sweat glands. ESFA usually manifests as a solitary nodule on the extremities of elderly patients, but it may also present as papules, nodules or plaques. Its clinical appearance is nonspecific and malignant neoplasms should beconsidered in the differential diagnosis. However, histopathological findings are typical. The main treatment is surgical excision. In order to illustrate a typical presentation of the tumor, we report a case of solitary eccrine syringofibroadenoma, including the surgical treatment used and its result. <![CDATA[Late-onset of eruptive syringomas: a diagnostic challenge]]> Abstract Syringoma is a benign, adnexal tumor of the eccrine sweat gland ducts. Eruptive syringomas are a rare variant, occurring before or during puberty in most cases. A 57-year-old man was observed in our department, with a 10-year history of multiple brownish papules (1-4mm in diameter), localized on the neck, shoulders, trunk and axillae. The clinical diagnosis was cutaneous mastocytosis. Histopathological examination from a papule in the trunk was compatible with the diagnosis of syringoma. The patient was treated with isotretinoin, without any improvement. The clinical diagnosis of eruptive syringoma is diffi cult and histological examination is crucial for its diagnosis. Long-term morbidity is not associated with syringomas; they are treated for cosmetic reasons with unsatisfactory results. <![CDATA[Vemurafenib and cutaneous adverse events - report of five cases]]> Abstract Vemurafenib is a selective inhibitor of V600E-mutant BRAF protein used to treat metastatic and unresectable melanoma. Clinical trials have shown increased overall survival and progression-free survival in patients treated with Vemurafenib. However, cutaneous adverse events are common during treatment. We report fi ve cases of metastatic melanoma with BRAF V600E positivity, treated with Vemurafenib and its cutaneous adverse events. Dermatologists and oncologists need to be aware of possible skin changes caused by this medication, which is increasingly employed in melanoma treatment. Monitoring of patients during therapy is important for early treatment of adverse cutaneous cutaneous adverse events, improvement in quality of life and adherence to treatment.