Scielo RSS <![CDATA[Anais Brasileiros de Dermatologia]]> http://www.scielo.br/rss.php?pid=0365-059620180002&lang=es vol. 93 num. 2 lang. es <![CDATA[SciELO Logo]]> http://www.scielo.br/img/en/fbpelogp.gif http://www.scielo.br <![CDATA[Gnathostomiasis: an emerging infectious disease relevant to all dermatologists]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200172&lng=es&nrm=iso&tlng=es Abstract: Gnathostomiasis is a parasitic infection caused by the third larval stage of nematodes of the genus Gnathostoma. The disease is endemic in some countries around the world. In the American continent, the majority of cases is concentrated in Mexico, Ecuador, and Peru. However, due to increasing traveling either at the intercontinental or intracontinental level, the disease is seen each time more frequently in tourists. Furthermore, countries, such as Brazil, that have never been considered endemic are reporting autochthonous cases. The disease usually presents as a deep-seated or slightly superficial migratory nodule in patients with history of eating raw fish, in the form of ceviche, sushi, or sashimi. Along with the clinical presentation, diagnostic criteria include either blood or tissue eosinophilia. In most instances, these criteria are enough for the attending physician to institute therapy. Chances of finding the parasite are low, unless the biopsy is taken from a very specific area that develops after antiparasitic treatment is started. The potential of other organ involvement with more serious consequences should always be kept in mind. <![CDATA[Effectiveness of the retreatment of patients with multibacillary leprosy and episodes of erythema nodosum leprosum and/or persistent neuritis: a single-center experience]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200181&lng=es&nrm=iso&tlng=es Abstract: Background: Erythema nodosum leprosum may appear before, during or after treatment of leprosy and is one of the main factors for nerve damage in patients. When it occurs or continues to occur after treatment, it may indicate disease recurrence and a new treatment may be instituted again. Objective: To evaluate the retreatment of patients with multibacillary leprosy who underwent standard treatment with multidrug therapy, but developed or continued to present reactions of erythema nodosum leprosum and/or neuritis 3-5 years after its end. Method: For this objective, a new treatment was performed in 29 patients with multibacillary leprosy who maintained episodes of erythema nodosum and/or neuritis 3-5 years after conventional treatment. Results: In general, we observed that 27 (93.10%) had no more new episodes after a follow up period of eight months to five years. In five of these patients the reason for the retreatment was the occurrence of difficult-to-control neuritis, and that has ceased to occur in all of them. Study limitations: Small number of patients.. Conclusion: In the cases observed, retreatment was an effective measure to prevent the occurrence of erythema nodosum leprosum and/or persistent neuritis. <![CDATA[The tendency towards the development of psychosexual disorders in androgenetic alopecia according to the different stages of hair loss: a cross-sectional study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200185&lng=es&nrm=iso&tlng=es Abstract: Background: Androgenetic alopecia is a common dermatological condition affecting both genders. Objective: To evaluate the tendency towards development of psychosexual disorders according to the clinical stages of androgenetic alopecia. Methods: A cross-sectional study was conducted including 353 patients of both sexes on different clinical stages of hair loss, and the patients were enquired about self-perception, self-esteem, sexual experiences, anxiety and depression states. Hair loss was classified by standardized hair loss scales, and psychological effects were assessed with questionnaires. Results were compared to p&lt;0.05. Results: Negative effects on each psychological parameter of androgenetic alopecia in females were higher than in males. While overall comparisons according to hair loss stages for each parameter were significant in males, only sexual experiences, anxiety and depression values were significant in females. Sexual experiences and depression values were higher in Ludwig 3 than in 1&amp;2, while anxiety was higher in Ludwig 3 than 1. Self-perception values in Norwood 2&amp;2A were higher than 3A, 3V, 4 and 4A, while self-esteem values in 2A were higher than 3&amp;4. Sexual experiences values in 2&amp;2A were lower than 3, 3A, 3V, 4 and 4A, while 3&amp;3A were lower than 4&amp;4A. Depression was lower in 2A than 3, 3A, and 3V, and lower in 2A than 4A. Anxiety was lower in 2A than in 4&amp;4A. Study limitations: Relatively small number of patients, who were from a single center. Conclusions: In the management of androgenetic alopecia, it should be considered that patients may need psychological support according to the clinical stages, because of increased tendency to develop psychosexual disorders. <![CDATA[Macrophage migration inhibitory factor as an incriminating agent in vitiligo]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200191&lng=es&nrm=iso&tlng=es Abstract: Background: Vitiligo is an autoimmune skin disorder in which the loss of melanocytes is mainly attributed to defective autoimmune mechanisms and, lately, there has been more emphasis on autoinflammatory mediators. Among these is the macrophage migration inhibitory factor, which is involved in many autoimmune skin diseases. However, little is known about the contribution of this factor to vitiligo vulgaris. Objective: To determine the hypothesized role of migration inhibitory factor in vitiligo via estimation of serum migration inhibitory factor levels and migration inhibitory factor mRNA concentrations in patients with vitiligo compared with healthy controls. We also aimed to assess whether there is a relationship between the values of serum migration inhibitory factor and/or migration inhibitory factor mRNA with disease duration, clinical type and severity in vitiligo patients. Methods: Evaluation of migration inhibitory factor serum level and migration inhibitory factor mRNA expression by ELISA and real-time PCR, respectively, were performed for 50 patients with different degrees of vitiligo severity and compared to 15 age- and gender-matched healthy volunteers as controls. Results: There was a highly significant increase in serum migration inhibitory factor and migration inhibitory factor mRNA levels in vitiligo cases when compared to controls (p&lt;0.001). There was a significant positive correlation between both serum migration inhibitory factor and migration inhibitory factor mRNA concentrations in vitiligo patients, and each of them with duration and severity of vitiligo. In addition, patients with generalized vitiligo have significantly elevated serum migration inhibitory factor and mRNA levels than control subjects. Study limitations: Small number of investigated subjects. Conclusions: Migration inhibitory factor may have an active role in the development of vitiligo, and it may also be a useful index of disease severity. Consequently, migration inhibitory factor may be a new treatment target for vitiligo patients. <![CDATA[The association between psoriasis and health-related quality of life, work productivity, and healthcare resource use in Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200197&lng=es&nrm=iso&tlng=es Abstract: Background: Psoriasis is a chronic, immune mediated inflammatory condition that affects a significant amount of the global population. Yet geographic variability in the consequences of psoriasis warrants region-level analyses. Objective: The current study contributes to the psoriasis outcomes literature by offering a comprehensive assessment of the humanistic and economic burden in Brazil. Methods: The 2012 Brazil National Health and Wellness Survey (N=12,000) was used to assess health-related quality of life (Short Form-12, version 2), work productivity, and healthcare resource use associated with experiencing psoriasis vs. no psoriasis, along with varying levels of psoriasis severity. Results: A total of 210 respondents reported diagnosis of psoriasis (N=157, 42, and 11 reporting mild, moderate, and severe psoriasis, respectively). Compared with controls, respondents with psoriasis reported diminished mental component summary scores and health utilities, as well as increased presenteeism, activity impairment, and physician visits over the past six months, adjusting for covariates. Among those with psoriasis, physical health decreased as psoriasis severity increased. Although work productivity and healthcare resource utilization did not differ with psoriasis severity, the high rates of productivity loss (e.g. 45.5% presenteeism in the severe psoriasis group) suggest an economic burden. Study limitations: Cost analyses were not performed, and cross-sectional patient-reported data limit causal conclusions and may reflect reporting biases. Conclusions: Nevertheless, these results suggest a significant burden to patients with psoriasis across both humanistic and economic outcomes. The association between psoriasis and mental health aspects and health utilities were particularly strong and exceeded what would be considered clinically meaningful. <![CDATA[Prevalence of smoking, alcohol consumption and metabolic syndrome in patients with psoriasis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200205&lng=es&nrm=iso&tlng=es Abstract: Background: Coexistence of obesity, hypertension, insulin resistance and dyslipidemia is defined as metabolic syndrome (MBS), which is among the important risk indicators for cardiovascular diseases, diabetes and stroke. Smoking and alcohol consumption are the other factors which lead to an increase in the risk of cardiovascular disease. Objective: To investigate the prevalence of metabolic syndrome, smoking and alcohol consumption in psoriasis patients and the relationship between disease severity and these factors. Methods: This cross-sectional study enrolled 563 patients with chronic plaque-type psoriasis, all of which completed a questionnaire and underwent a complete physical examination. Data about MBS components, psoriasis severity/duration, smoking and alcohol consumption, and cardiovascular diseases were recorded. Results: A total of 563 patients with ages ranging from 18 to 78 years were evaluated. Metabolic syndrome was found in 12.6% of the patients [central obesity (38.7%), hypertension (14.3%), dyslipidemia (18.6%), diabetes (9.2%)], while 50.3% had smoking, and 3.3% had alcohol consumption. Patients with metabolic syndrome were older and more likely to have a longer disease duration than those without metabolic syndrome (p&lt;0.05 for each). The prevalence of metabolic syndrome was higher in women than in men. Psoriasis was more severe in patients with central obesity, diabetes and smoking than in those without (p&lt;0.05 for each). Study Limitations: Retrospective design. Conclusions: Our results indicate that MBS is a risk factor for psoriasis patients with advanced age. The relationship between disease severity and obesity, diabetes, and smoking in psoriasis patients indicates that the patients should be informed about the potential metabolic risks and receive therapies for behavioral changes besides anti-psoriatic treatment in order to minimize these risks. <![CDATA[Oxidative stress in patients with endemic pemphigus foliaceus and healthy subjects with anti-desmoglein 1 antibodies]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200212&lng=es&nrm=iso&tlng=es Abstract: Background: Previous studies have shown oxidative stress in pemphigus vulgaris and pemphigus foliaceus, nevertheless, it remains unknown whether a similar response is characteristic of endemic pemphigus foliaceus in Peru. Objectives: To determine the oxidative stress response in endemic pemphigus foliaceus patients and subjects with positive for anti-desmoglein1 antibodies (anti-dsg1) from endemic areas of Peru. Subjects and Methods: This is a cross-sectional study. The study population included 21 patients with Endemic Pemphigus foliaceus and 12 healthy subjects with anti-dsg1 antibodies from the Peruvian Amazon (Ucayali), as well as 30 healthy control subjects. Malondialdehyde, an indicator of lipid peroxidation by free radicals, was measured in serum. Results: We collected 21 cases of endemic pemphigus foliaceus, 15 of them with active chronic disease and 6 in clinical remission. Serum malondialdehyde values in patients with chronic active evolution and healthy subjects with anti-dsg1 antibodies were statistically higher than those of healthy controls (p&lt;0.001). There was no significant difference between serum values of localized and generalized clinical forms. Study limitations: The main limitation of this present study is the small number of patients with endemic pemphigus and healthy subjects positive for desmoglein 1 antibodies. Conclusions: The increased serum levels of malondialdehyde in patients with chronic active endemic pemphigus foliaceus and healthy subjects from endemic areas with anti-dsg1 antibodies may suggest a contribution of systemic lipid peroxidation in the pathogenesis of endemic pemphigus foliaceus. <![CDATA[Clinical and pathological features of myeloid leukemia cutis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200216&lng=es&nrm=iso&tlng=es Abstract: Background: Myeloid leukemia cutis is the terminology used for cutaneous manifestations of myeloid leukemia. Objective: The purpose of this study was to study the clinical, histopathological and immunohistochemical features of myeloid leukemia cutis. Methods: This was a retrospective study of clinical and pathological features of 10 patients with myeloid leukemia cutis. Results: One patient developed skin lesions before the onset of leukemia, seven patients developed skin infiltration within 4-72 months after the onset of leukemia, and two patients developed skin lesions and systemic leukemia simultaneously. Of these patients, five presented with generalized papules or nodules, and five with localized masses. The biopsy of skin lesions showed a large number of tumor cells within the dermis and subcutaneous fat layer. Immunohistochemical analysis showed strong reactivity to myeloperoxidase (MPO), CD15, CD43 and CD45 (LCA) in most cases. NPM1 (nucleophosmin I) and FLT3-ITD (Fms-like tyrosine kinase 3-internal tandem duplication) mutations were identified in one case. Five patients with acute myelogenous leukemia and one patient with chronic myelomonocytic leukemia died within two months to one year after the onset of skin lesions. Study limitations: This was a retrospective and small sample study. Conclusions: In patients with myelogenous leukemia, skin infiltration usually occurs after, but occasionally before, the appearance of hemogram and myelogram abnormalities, and the presence of skin infiltration is often associated with a poor prognosis and short survival time. myeloid leukemia cutis often presents as generalized or localized nodules or masses with characteristic pathological and histochemical findings. <![CDATA[Metabolic syndrome, C-reactive protein and cardiovascular risk in psoriasis patients: a cross-sectional study]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200222&lng=es&nrm=iso&tlng=es Abstract: Background: Psoriasis has been associated with co-morbidities and elevated cardiovascular risk. Objectives: To analyze the relationships among metabolic syndrome, cardiovascular risk, C-reactive protein, gender, and Psoriasis severity. Methods: In this cross-sectional study, plaque Psoriasis patients (n=90), distributed equally in gender, were analyzed according to: Psoriasis Area and Severity Index, cardiovascular risk determined by the Framingham risk score and global risk assessment, C-reactive protein and metabolic syndrome criteria (NCEPT-ATP III). Results: Metabolic syndrome frequency was 43.3% overall, without significance between genders (P=0.14); but women had higher risk for obesity (OR 2.56, 95%CI 1.02-6.41; P=0.04) and systemic arterial hypertension (OR 3.29, 95%CI 1.39-7.81; P=0.006). The increase in the Psoriasis Area and Severity Index also increased the risk for metabolic syndrome (OR 1.060, 95%CI 1.006-1.117; P=0.03). Absolute 10-year cardiovascular risk was higher in males (P=0.002), but after global risk assessment, 51.1% patients, 52.2% women, were re-classified as high-intermediate cardiovascular risk; without significance between genders (P=0.83). C-reactive protein level was elevated nearly six-fold overall, higher in metabolic syndrome (P=0.05), systemic arterial hypertension (P=0.004), and high-intermediate 10-year cardiovascular risk patients (P&lt;0.001); positively correlated to: Framingham risk score (P&lt;0.001; r=0.60), absolute 10-year cardiovascular risk (P&lt;0.001; r=0.58), and age (P=0.001; r=0.35); but not to Psoriasis Area and Severity Index (P=0.14; r=0.16); increased the 10-year cardiovascular risk (R2=33.6; P&lt;0.001), MetS risk (OR 1.17, 95%CI 0.99-1.37; P=0.05) and with age (P=0.001). HDL-cholesterol level was higher in normal C-reactive protein patients (t=1.98; P=0.05). Study limitations: Restricted sample, hospital-based and representative of a single center and no specification of psoriatic arthritis. Conclusions: Psoriasis, metabolic syndrome, systemic arterial hypertension and age share the increase in C-reactive protein, which could implicate in additional burden for increasing the cardiovascular risk and be an alert for effective interventions. <![CDATA[Sclerodermiform basal cell carcinoma: how much can we rely on dermatoscopy to differentiate from non-aggressive basal cell carcinomas? Analysis of 1256 cases]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200229&lng=es&nrm=iso&tlng=es Abstract: Background: The behaviour of each basal cell carcinoma is known to be different according to the histological growth pattern. Among these aggressive lesions, sclerodermiform basal cell carcinomas are the most common type. This is a challenging-to-treat lesion due to its deep tissue invasion, rapid growth, risk of metastasis and overall poor prognosis if not diagnosed in early stages. Objective: To investigate if sclerodermiform basal cell carcinomas are diagnosed later compared to non-sclerodermiform basal cell carcinoma Method: All lesions excised from 2000 to 2010 were included. A pathologist classified the lesions in two cohorts: one with specimens of non-aggressive basal cell carcinoma (superficial, nodular and pigmented), and other with sclerodermiform basal cell carcinoma. For each lesion, we collected patient's information from digital medical records regarding: gender, age when first attending the clinic and the tumor location. Results: 1256 lesions were included, out of which 296 (23.6%) corresponded to sclerodermiform basal cell carcinoma, whereas 960 (76.4%) were non-aggressive subtypes of basal cell carcinoma. The age of diagnosis was: 72.78±12.31 years for sclerodermiform basal cell and 69.26±13.87 years for non-aggressive basal cell carcinoma (P&lt;.0001). Sclerodermiform basal cell carcinomas are diagnosed on average 3.52 years later than non-aggressive basal cell carcinomas. Sclerodermiform basal cell carcinomas were diagnosed 3.40 years and 2.34 years later than non-aggressive basal cell carcinomas in younger and older patients respectively (P=.002 and P=.03, respectively). Study limitations: retrospective design. Conclusion: The diagnostic accuracy and primary clinic conjecture of sclerodermiform basal cell carcinomas is quite low compared to other forms of basal cell carcinoma such as nodular, superficial and pigmented. The dermoscopic vascular patterns, which is the basis for the diagnosis of non-melanocytic nonpigmented skin tumors, may not be particularly useful in identifying sclerodermiform basal cell carcinomas in early stages. As a distinct entity, sclerodermiform basal cell carcinomas show a lack of early diagnosis compared to less-aggressive subtypes of BCC, and thus, more accurate diagnostic tools apart from dermatoscopy are required to reach the goal of early-stage diagnosis of sclerodermiform basal cell carcinomas. <![CDATA[Suppression of wheal and flare in histamine test by the main H1 antihistamines commercialized in Brazil]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200233&lng=es&nrm=iso&tlng=es Abstract: Background: Several dermatoses are mediated by histamine, such as urticaria, angioedema, and papular urticaria. There are no Brazilian studies comparing the potency of antihistamines. Objectives: To evaluate the tolerability and efficacy of the main commercial brand and generic H1 antihistamines, regarding the suppression of the wheal and flare to the histamine test. Methods: A quasi-experimental, open study with 10 healthy adults submitted to the histamine test on the ventral aspect of the forearms. After 20 minutes, wheal and flares were measured. The tests were performed after two hours of intake of dexchlorpheniramine, hydroxyzine, levocetirizine, fexofenadine, cetirizine, loratadine, ebastine, desloratadine, epinastine and rupatadine, as well as generics of loratadine, cetirizine and fexofenadine. Results: All antihistamines presented a reduction in the wheal compared to the control (p &lt;0.02), as well as in the flare, except for rupatadine (p = 0.70). In the internal comparison, cetirizine, fexofenadine, epinastine, levocetirizine, dexchlorpheniramine and hydroxyzine were the most potent, with no difference between them (p &gt; 0.1). As for halo, cetirizine, epinastine, hydroxyzine and fexofenadine were the most potent, with no difference between them (p &gt; 0.1). The most common adverse effect was drowsiness, which was more prevalent among first-generation drugs (p &lt; 0.01). Generic loratadine, fexofenadine and cetirizine halos were higher than their controls (p &lt;0.03).. Study limitations: A single-center study evaluating only aspects related to histamine. Conclusions: Brazilian commercial antihistamines presented different profiles of inhibition of wheal and flares in the histamine test, as well as adverse effects. Generic loratadine, fexofenadine and cetirizine presented larger flares than brand drugs. <![CDATA[Blocking or enhancing effects of some basic emollients in UVA penetration]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200238&lng=es&nrm=iso&tlng=es Abstract: Background: Topical agents used in combination with phototherapy or photochemotherapy may have both blocking or enhancing effects in ultraviolet rays. Objective: In this in vivo study, the effects of topical petrolatum, basis cream, glycerine, and olive oil on the transmission of ultraviolet A radiation were investigated. Methods: A test was performed to determine the minimal phototoxic dose on 29 volunteers with only psoralen plus ultraviolet A (PUVA) and then the same test was repeated with white petrolatum, basis cream, glycerine, olive oil, and sunscreen (0.3cc/25cm2). The effects of each agent on the minimal phototoxic dose were determined after 72 h. Results: When compared to pure PUVA, there was a statistically significant increase in the mean minimal phototoxic dose values by the application of white petrolatum (P = 0.011), but there was no significant increase or decrease in the mean minimal phototoxic dose values after the application of basis cream (P = 0.326), glycerine (P = 0.611) or olive oil (P = 0.799). Study limitations: Low number of patients Conclusion: The application of white petrolatum, which has a blocking effect, and also of basis cream immediately before PUVA therapy should not be recommended. Although we specify that glycerine and maybe olive oil can be used before photochemotherapy, there is a need for further research in larger series. <![CDATA[Innate immunity and effector and regulatory mechanisms involved in allergic contact dermatitis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200242&lng=es&nrm=iso&tlng=es Abstract: Skin's innate immunity is the initial activator of immune response mechanisms, influencing the development of adaptive immunity. Some contact allergens are detected by Toll-like receptors (TLRs) and inflammasome NLR3. Keratinocytes participate in innate immunity and, in addition to functioning as an anatomical barrier, secrete cytokines, such as TNF, IL-1β, and IL-18, contributing to the development of Allergic Contact Dermatitis. Dendritic cells recognize and process antigenic peptides into T cells. Neutrophils cause pro-inflammatory reactions, mast cells induce migration/maturation of skin DCs, the natural killer cells have natural cytotoxic capacity, the γδ T cells favor contact with hapten during the sensitization phase, and the innate lymphoid cells act in the early stages by secreting cytokines, as well as act in inflammation and tissue homeostasis. The antigen-specific inflammation is mediated by T cells, and each subtype of T cells (Th1/Tc1, Th2/Tc2, and Th17/Tc17) activates resident skin cells, thus contributing to inflammation. Skin's regulatory T cells have a strong ability to inhibit the proliferation of hapten-specific T cells, acting at the end of the Allergic Contact Dermatitis response and in the control of systemic immune responses. In this review, we report how cutaneous innate immunity is the first line of defense and focus its role in the activation of the adaptive immune response, with effector response induction and its regulation. <![CDATA[Skin manifestations of tick bites in humans]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200251&lng=es&nrm=iso&tlng=es Abstract: Ticks are blood-sucking arthropods that attach to human skin through oral devices causing diverse initial cutaneous manifestations, and may also transmit serious infectious diseases. In certain situations, the Health Teams (and especially dermatologists) may face difficulties in identifying the lesions and associating them to the parasites. To assist them in clinical diagnosis, we suggest a classification of the skin manifestations in primary lesions, which occur by the attachment the tick to the host (for toxicity and the anticoagulant substances in the saliva and/or marked inflammation by the penetration and permanence of the mouthparts) and secondary lesions that are manifestations of infections caused by rickettsia, bacteria, protozoa and fungi inoculated by the ticks. <![CDATA[Lymphoepithelioma-like carcinoma of the skin]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200256&lng=es&nrm=iso&tlng=es Abstract: Primary cutaneous lymphoepithelioma-like carcinoma is a rare disease with low metastatic potential. Its morphologic and pathological features are similar to those of nasopharyngeal lymphoepithelial carcinoma. We report the case of a 60-year-old man with an infrapalpebral pearly papule, measuring 0.6 cm in diameter. The lesion was excised with a clinical hypothesis of basal cell carcinoma or squamous cell carcinoma. Histopathological analysis revealed a malignant neoplasm with syncytial arrangement of cells with vesicular nuclei, associated with dense lymphocytic infiltrate. Immunohistochemistry revealed cytokeratin-positive cells (AE1/AE3) and p63 protein, indicating epithelial histogenesis and squamous differentiation. A negative Epstein-Barr virus test result was achieved by immunohistochemistry. Primary lymphoepithelioma-like carcinoma of the skin is a differential diagnosis of lesions with prominent inflammatory infiltrates. <![CDATA[What does the 4<sup>th</sup> edition of the World Health Organization Classification of Head and Neck Tumors (2017) bring new about mucosal melanomas?]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200259&lng=es&nrm=iso&tlng=es Abstract: The recently published 4th Edition of the World Health Organization Classification of Head and Neck Tumors addresses the most relevant and updated aspects of tumor biology, including clinical presentation, histopathology, immunohistochemistry, and prognosis of head and neck tumors. The objective of the present study is to compare these updates to the 3rd edition of that book with regard to mucosal melanomas and to highlight the potential factors that differ those tumors from cutaneous melanomas. We observed progress in the understanding of oral and sinonasal mucosal melanomas, which also present themselves, in the molecular scope, differently form cutaneous melanomas. <![CDATA[Cutaneous leiomyosarcoma on the face]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200262&lng=es&nrm=iso&tlng=es Abstract: Leiomyosarcoma is a rare skin tumor, most common in white men in the fifth to eighth decades of life. Primary tumors are classified in dermal or subcutaneous, that differ by clinical and prognostic features. They may appear on any site of the body, but are rare on the face. A 54-year-old female was admitted with a 5cm exophytic nodular lesion of 8 months duration on the right cheek, site of previous chronic radiodermatitis. Histopathology revealed spindle-shaped cell neoplasia, positive for smooth muscle actin on immunohistochemistry. Cutaneous leiomyosarcomas on the face are rare and may occur in previously irradiated areas. Immunohistochemistry is mandatory for an accurate diagnosis. Its similarity with other tumors may complicate the diagnosis, with delay expansion of the tumor. <![CDATA[Atypical Gianotti-Crosti syndrome]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200265&lng=es&nrm=iso&tlng=es Abstract: We report the case of a male 22-month-old child, with atypical presentation of Gianotti-Crosti syndrome after infection with Epstein-Barr virus. <![CDATA[Multiple dermatomyofibromas]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200268&lng=es&nrm=iso&tlng=es Abstract: This study describes a case of a 19-year-old patient with seven asymptomatic lesions on the chest, measuring between 0.5 to 1cm in diameter, with no history of trauma in the region. The immunohistochemical evaluation was positive for vimentin and smooth muscle actin, determining Dermatomyofibroma as definitive diagnosis. Dermatomyofibroma is a benign skin tumor, with a myofibroblastic origin, prevalent in young women. It usually presents as a single lesion, with very few reports of multiple lesions. <![CDATA[Oral mucosa lesions as atypical manifestation of adult-onset Still´s disease]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200271&lng=es&nrm=iso&tlng=es Abstract: Adult-onset Still's disease is a systemic inflammatory disorder of unknown etiology, characterized by skin rash, spiking fever, arthralgias or arthritis, and leukocytosis. The typical skin rash is evanescent, salmon-pink, nonpruritic and maculopapular, predominantly on the extremities. It is considered one of the major Yamaguchi's criteria in adult-onset Still's disease. However, atypical skin lesions are also described. Here, a 61-year-old woman with sore throat, spiking fever, polyarthritis and evanescent salmon-pink nonpruritic maculopapular skin rash on the extremities was diagnosed with adult-onset Still's disease. In addition, atypical brown macules on oral mucosa, localized on the inner lips and tongue were also observed. Biopsy revealed a neutrophilic infiltrate. Despite treatment and improvement of the adult-onset Still's disease, the atypical oral mucosal lesions persisted. <![CDATA[Coexistence of chronic cutaneous lupus erythematosus and frontal fibrosing alopecia]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200274&lng=es&nrm=iso&tlng=es Abstract: Lupus erythemathosus is a chronic, relapsing disease with acute, subacute, and chronic lesions. Effluvium telogen occurs in the setting of systemic activity of the disease, and cicatricial alopecia results from discoid lesionsin on the scalp. Other types of alopecia, like alopecia areata, may rarely be found in lupus. Frontal fibrosing alopecia is characterized by frontotemporal hairline recession and eybrow loss. Histophatologically, it cannot be differentiated from lichen planopilaris.It is controversial whether frontal fibrosing alopecia is a subtype of lichen planopilaris.. A pacient with chronic lichenoid lupus erythematosus is described with clinical, histophatological and dermoscopic features of frontal fibrosing alopecia.We have not been able to find in the literature cases of frontal fibrosing alopecia as a clinical manifestation of lupus. <![CDATA[Atypical crusted scabies in a patient with chronic liver disease caused by hepatitis B and D viruses]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200277&lng=es&nrm=iso&tlng=es Abstract: Crusted scabies is a less common variant of scabies that is highly contagious, difficult to treat and involves infestation by Sarcoptes scabiei var. hominis. The classical clinical presentation includes crusted, scaly and generally non-pruritic lesions usually located on the head, neck, palmar, plantar and periungual region. It was first described in Norway in 1848 in patients with leprosy who presented with crusted lesions. In this study, we report the case of a patient with crusted scabies with florid clinical manifestations and chronic liver disease due to hepatitis B and delta virus infection. <![CDATA[Lobomycosis: a therapeutic challenge]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200279&lng=es&nrm=iso&tlng=es Abstract: Lobomycosis or lacaziosis is a chronic granulomatous fungal infection caused by Lacazia loboi. Most cases are restricted to tropical regions. Transmission is believed to occur through traumatic inoculation in the skin, mainly in exposed areas. It is characterized by keloid-like nodules. There are only a few hundred cases reported. The differential diagnoses include many skin conditions, and treatment is difficult. The reported case, initially diagnosed as keloid, proved to be refractory to surgical treatment alone. It was subsequently approached with extensive surgery, cryotherapy every three months and a combination of itraconazole and clofazimine for two years. No signs of clinical and histopathological activity were detected during follow-up. <![CDATA[An unusual variant of atrophic dermatofibrosarcoma protuberans]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200282&lng=es&nrm=iso&tlng=es Abstract: Dermatofibrosarcoma protuberans is an uncommon neoplasm that is most often seen in young adults. The most common clinical presentation is the protruding form; however, other subtypes are known, such as the atrophic. In 2012 there were only 33 reports of this variant in the literature. Many cases of Dermatofibrosarcoma protuberans in children are only discovered in adulthood because they were not diagnosed early. Due the high morbidity, we raise the need for attention from the dermatologist to recognize uncommon neoplasms in the clinical practice. We report a case of a 15-year-old patient diagnosed with atrophic Dermatofibrosarcoma protuberans on the back. <![CDATA[Acute prurigo simplex in humans caused by pigeon lice]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200285&lng=es&nrm=iso&tlng=es Abstract: Pigeon lice are insects that feed on feathers of these birds; their life cycle includes egg, nymph and adult and they may cause dermatoses in humans. Four persons of the same family, living in an urban area, presented with widespread intensely pruritic erythematous papules. A great number of lice were seen in their house, which moved from a nest of pigeons located on the condenser of the air-conditioning to the dormitory of one of the patients. Even in urban environments, dermatitis caused by parasites of birds is a possibility in cases of acute prurigo simplex. Pigeon lice are possible etiological agents of this kind of skin eruption, although they are often neglected, even by dermatologists. <![CDATA[Dermoscopy of inflammatory breast cancer]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200289&lng=es&nrm=iso&tlng=es Abstract: Inflammatory breast cancer is an aggressive and infiltrative malignancy that is often misdiagnosed as an infection because of its symptoms and signs of inflammation, delaying proper diagnosis and treatment. We report a case of inflammatory breast cancer showing correlation between dermoscopic and histopathological diagnoses. We highlight the utility of dermoscopy for skin biopsy site selection. <![CDATA[Case for diagnosis. Multinucleated cell angiohistiocytoma]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200291&lng=es&nrm=iso&tlng=es Abstract: Multinucleate cell angiohistiocytoma is a rare idiopathic benign fibrohistiocytic and vascular proliferation usually presenting as multiple asymptomatic papules, red to violaceous in colour, primarily located on the extremities of middle-aged females. This entity is probably underdiagnosed due to the lack of recognition by clinicians and pathologists. We describe a patient with a multinucleate cell angiohistiocytoma of the face, a less frequent localization, in order to increase awareness of this entity and elucidate its clinical, histopathological, and immunohistochemistry features. <![CDATA[Most frequent dermatoses at a vulvar pathology outpatient clinic]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200294&lng=es&nrm=iso&tlng=es Abstract: The vulva corresponds to the external female genitalia. Special features of this region favor a wide range of diseases, whose knowledge allows for better clinical management, impacting on the quality of life. This is a cross-sectional and descriptive study carried out at a vulvar pathology outpatient clinic, between May and December/ 2015. Data obtained from a standard form included demographic parameters, habits, and vulvar dermatosis and allowed to identify the epidemiological profile of patients with vulvar dermatosis treated in this outpatient clinic and to determine the most prevalent dermatoses. Our results, partially concordant with the literature, provide original data that should stimulate further studies <![CDATA[Ultrasonographic findings in primary umbilical endometriosis]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200297&lng=es&nrm=iso&tlng=es Abstract: Primary cutaneous endometriosis is a rare condition. It appears without a prior history of surgical procedure and the umbilicus is the most frequently involved area. Primary umbilical endometriosis, or Villar's nodule, usually presents as a painful nodule. Its differential diagnosis may be challenging. Although histopathological assessment represents the gold standard for diagnosis, cutaneous ultrasonography may be useful in guiding the surgical treatment. Ultrasonographic features of cutaneous endometriosis have not yet been fully explored in the literature. Hence, we report peculiar ultrasonographic findings of primary umbilical endometriosis <![CDATA[Diphencyprone as a therapeutic option in cutaneous metastasis of melanoma. A single-institution experience]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200299&lng=es&nrm=iso&tlng=es Abstract: Diphencyprone has been reported as a local immunotherapy for cutaneous melanoma metastases. We aim to report cases of melanoma patients treated with diphencyprone in a single Brazilian institution and highlight their outcomes. Since 2012, we have treated 16 melanoma patients with cutaneous metastases with topical diphencyprone. To date, we have had 37.5% of complete response, 25% of partial responses, and 31.25% patients without any response. Treatment was well tolerated and local toxicity was easily controlled. We believe topical diphencyprone is a feasible treatment that can be another option for treating melanoma patients, especially in cases of in-transit or extensive disease. <![CDATA[Vitiligo patients show significant up-regulation of aryl hydrocarbon receptor transcription factor]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200302&lng=es&nrm=iso&tlng=es Abstract: IL-22 has been implicated in the pathogenesis of vitiligo. However, the role of aryl hydrocarbon receptor transcription factor that acts as a master regulator of IL-22-producing Th22 cells is not fully understood. The goal of this study was to investigate the expression pattern of aryl hydrocarbon receptor in peripheral blood mononuclear cells of patients with vitiligo and in normal controls. Transcript levels were determined by a reverse transcription quantitative real-time polymerase chain reaction. Aryl hydrocarbon receptor mRNA expression was drastically increased in patients with vitiligo compared to healthy controls (P = 0.000). Th22 cells may contribute to abnormal immune responses underlying vitiligo. <![CDATA[Urticaria and angioedema as possible reactions of omalizumab]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200304&lng=es&nrm=iso&tlng=es Abstract: IL-22 has been implicated in the pathogenesis of vitiligo. However, the role of aryl hydrocarbon receptor transcription factor that acts as a master regulator of IL-22-producing Th22 cells is not fully understood. The goal of this study was to investigate the expression pattern of aryl hydrocarbon receptor in peripheral blood mononuclear cells of patients with vitiligo and in normal controls. Transcript levels were determined by a reverse transcription quantitative real-time polymerase chain reaction. Aryl hydrocarbon receptor mRNA expression was drastically increased in patients with vitiligo compared to healthy controls (P = 0.000). Th22 cells may contribute to abnormal immune responses underlying vitiligo. <![CDATA[Diphenciprone as a therapeutic alternative to exuberant periungual warts]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200305&lng=es&nrm=iso&tlng=es Abstract: IL-22 has been implicated in the pathogenesis of vitiligo. However, the role of aryl hydrocarbon receptor transcription factor that acts as a master regulator of IL-22-producing Th22 cells is not fully understood. The goal of this study was to investigate the expression pattern of aryl hydrocarbon receptor in peripheral blood mononuclear cells of patients with vitiligo and in normal controls. Transcript levels were determined by a reverse transcription quantitative real-time polymerase chain reaction. Aryl hydrocarbon receptor mRNA expression was drastically increased in patients with vitiligo compared to healthy controls (P = 0.000). Th22 cells may contribute to abnormal immune responses underlying vitiligo. <![CDATA[Metastatic pleomorphic dermal sarcoma: an uncommon skin tumour]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200307&lng=es&nrm=iso&tlng=es Abstract: IL-22 has been implicated in the pathogenesis of vitiligo. However, the role of aryl hydrocarbon receptor transcription factor that acts as a master regulator of IL-22-producing Th22 cells is not fully understood. The goal of this study was to investigate the expression pattern of aryl hydrocarbon receptor in peripheral blood mononuclear cells of patients with vitiligo and in normal controls. Transcript levels were determined by a reverse transcription quantitative real-time polymerase chain reaction. Aryl hydrocarbon receptor mRNA expression was drastically increased in patients with vitiligo compared to healthy controls (P = 0.000). Th22 cells may contribute to abnormal immune responses underlying vitiligo. <![CDATA[Atypical aquagenic keratoderma treated with oxybutynin chloride]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200308&lng=es&nrm=iso&tlng=es Abstract: IL-22 has been implicated in the pathogenesis of vitiligo. However, the role of aryl hydrocarbon receptor transcription factor that acts as a master regulator of IL-22-producing Th22 cells is not fully understood. The goal of this study was to investigate the expression pattern of aryl hydrocarbon receptor in peripheral blood mononuclear cells of patients with vitiligo and in normal controls. Transcript levels were determined by a reverse transcription quantitative real-time polymerase chain reaction. Aryl hydrocarbon receptor mRNA expression was drastically increased in patients with vitiligo compared to healthy controls (P = 0.000). Th22 cells may contribute to abnormal immune responses underlying vitiligo. <![CDATA[Lingual melanotic macule - the first case report in an adult patient]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200310&lng=es&nrm=iso&tlng=es Abstract: IL-22 has been implicated in the pathogenesis of vitiligo. However, the role of aryl hydrocarbon receptor transcription factor that acts as a master regulator of IL-22-producing Th22 cells is not fully understood. The goal of this study was to investigate the expression pattern of aryl hydrocarbon receptor in peripheral blood mononuclear cells of patients with vitiligo and in normal controls. Transcript levels were determined by a reverse transcription quantitative real-time polymerase chain reaction. Aryl hydrocarbon receptor mRNA expression was drastically increased in patients with vitiligo compared to healthy controls (P = 0.000). Th22 cells may contribute to abnormal immune responses underlying vitiligo. <![CDATA[Intralesional betamethasone as a therapeutic option for alopecia areata]]> http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962018000200311&lng=es&nrm=iso&tlng=es Abstract: IL-22 has been implicated in the pathogenesis of vitiligo. However, the role of aryl hydrocarbon receptor transcription factor that acts as a master regulator of IL-22-producing Th22 cells is not fully understood. The goal of this study was to investigate the expression pattern of aryl hydrocarbon receptor in peripheral blood mononuclear cells of patients with vitiligo and in normal controls. Transcript levels were determined by a reverse transcription quantitative real-time polymerase chain reaction. Aryl hydrocarbon receptor mRNA expression was drastically increased in patients with vitiligo compared to healthy controls (P = 0.000). Th22 cells may contribute to abnormal immune responses underlying vitiligo.