Resumo em Inglês:

Leprosy is a chronic infectious condition caused by Mycobacterium leprae(M. leprae). It is endemic in many regions of the world and a public health problem in Brazil. Additionally, it presents a wide spectrum of clinical manifestations, which are dependent on the interaction between M. leprae and host, and are related to the degree of immunity to the bacillus. The diagnosis of this disease is a clinical one. However, in some situations laboratory exams are necessary to confirm the diagnosis of leprosy or classify its clinical form. This article aims to update dermatologists on leprosy, through a review of complementary laboratory techniques that can be employed for the diagnosis of leprosy, including Mitsuda intradermal reaction, skin smear microscopy, histopathology, serology, immunohistochemistry, polymerase chain reaction, imaging tests, electromyography, and blood tests. It also aims to explain standard multidrug therapy regimens, the treatment of reactions and resistant cases, immunotherapy with bacillus Calmette-Guérin (BCG) vaccine and chemoprophylaxis.

Resumo em Inglês:

BACKGROUND: One of the most stigmatizing physical sequelaeof leprosy in cured patients is the development of chronic lower extremity ulcers. The bacterial diversity present in ulcers is considered one of the factors that can delay the healing process, as well as serve as a focus for severe secondary infections. OBJECTIVE: To identify the microbiota and antimicrobial resistance profile of bacteria isolated from skin ulcers in patients cured of leprosy. METHODS: After obtaining informed consent, material was collected from ulcers of 16 patients treated at the Outpatient Public Health Dermatology Clinic of Rio Grande do Sul and Hospital Colônia Itapuã. Sampleswere collected during dressing, and the material sent to the Microbiology Laboratory of the Federal University of Health Sciences of Porto Alegre for microbiological culture. Methicillin-resistant Staphylococcus aureus (MRSA) was characterized by two molecular methods, including detection of the mecA gene by PCR and SCCmecgene typing. RESULTS: Cultures revealed microorganisms in all ulcers: Gram-negative bacilli in 80%, Gram-positive cocci in 63%, and mixed microflora in 36%. Staphylococcus aureus and Pseudomonas aeruginosa were the most prevalent bacteria. Assessment of the antimicrobial resistance profile was notable for the presence of MRSA. Molecular analysis of this isolate revealed presence of the mecA gene contained in a type IV staphylococcal cassette chromosome mec (SCCmec). CONCLUSIONS: In patients with leprosy, laboratory culture of skin ulcers is essential for correct antibiotic selection and to control emerging pathogens, such as MRSA carrying SCCmec type IV.

Resumo em Inglês:

BACKGROUND: Cryosurgery is an efficient therapeutic technique used to treat benign and malignant cutaneous diseases. The primary active mechanism of cryosurgery is related to vascular effects on treated tissue. After a cryosurgical procedure, exuberant granulation tissue is formed at the injection site, probably as a result of angiogenic stimulation of the cryogen and inflammatory response, particularly in endothelial cells. OBJECTIVE: To evaluate the angiogenic effects of freezing, as part of the phenomenon of healing rat skin subjected to previous injury. METHODS: Two incisions were made in each of the twenty rats, which were divided randomly into two groups of ten. After 3 days, cryosurgery with liquid nitrogen was performed in one of incisions. The rats' samples were then collected, cut and stained to conduct histopathological examination, to assess the local angiogenesis in differing moments and situations. RESULTS: It was possible to demonstrate that cryosurgery, in spite of promoting cell death and accentuated local inflammation soon after its application, induces quicker cell proliferation in the affected tissue and maintenance of this rate in a second phase, than in tissue healing without this procedure. CONCLUSIONS: These findings, together with the knowledge that there is a direct relationship between mononuclear cells and neovascularization (the development of a rich system of new vessels in injury caused by cold), suggest that cryosurgery possesses angiogenic stimulus, even though complete healing takes longer to occur. The significance level for statistical tests was 5% (p<0,05).

Resumo em Inglês:

BACKGROUND: Venous ulcers have a significant impact on patient quality of life, and constitute a worldwide public health problem. Treatment is complex, with high failure rates. OBJECTIVES: To identify clinical and therapeutic factors that influence healing of venous ulcers. METHODS: Retrospective cohort study of patients with venous ulcers. Ulcer area was measured at the first visit (T0) and after 6 months (T6) and 1 year (T12). A reduction in ulcer area of 50% or more at T6 and T12 was the outcome of interest, weighted by clinical, demographic and treatment aspects. RESULTS: Ninety-four patients were included (137 ulcers). A reduction in ulcer area of 50% or more was seen in 40.1% of patients (95%CI 31.9 to 48.4%) at T6 and 49.6% (95%CI 41.2 to 58.1%) at T12. Complete healing occurred in 16.8% (95%CI 10.5 to 23.1%) at T6 and 27% (95%CI 19.5 to 39.5%) at T12. The lowest ulcer area reductions at T6 were associated with longstanding ulcer (RR=0.95; 95%CI 0.91 to 0.98), poor adherence to compression therapy (RR=4.04; 95%CI 1.31 to 12.41), and infection episodes (RR= 0.42; 95%CI 0.23 to 0.76). At T12, lower reductions were associated with longstanding ulcer (RR=0.95; 95%CI 0.92 to 0.98), longer topical antibiotic use (RR=0.93; 95%CI 0.87 to 0.99), and systemic antibiotic use (RR=0.63; 95%CI 0.40 to 0.99). CONCLUSIONS: Longstanding ulcer, infection, poor adherence to compression therapy, and longer topical and systemic antibiotic use were independently correlated with worse healing rates.

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BACKGROUND: Previous studies have shown that some viral infections may be triggers for autoimmune diseases. The role of viral infections in the etiopathogenesis of pemphigus has also been investigated. OBJECTIVES: To investigate the relationship between pemphigus and the hepatitis B and C virus infections. METHODS: This retrospective study included 62 patients with pemphigus and 50 healthy controls of matching ages and genders. The control group included relatives who accompanied the orthopedic patients to the hospital but had no history of systemic and/or autoimmune diseases. RESULTS: The group of patients with pemphigus was composed of 43 (69.3%) females and 19 (29.7%) males, and the mean age was 48.08 ± 15.38. The hepatitis C virus antibody was negative in all of the patients. Hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), or both, were studied in 44 of the 62 patients. Two (4.3%) of these patients were positive for HBsAg and found to have HBV infection. Fourteen of them were HBsAb positive. Two (4%) of the 50 control subjects showed hepatitis C virus antibody positivity, while only 1 (2%) patient with pemphigus displayed HBsAg positivity. There was no statistically significant difference between the two groups for hepatitis B and C virus infections. CONCLUSIONS: This study does not support an association between pemphigus and hepatitis B and/or C virus infections.

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BACKGROUND: Acne is a common disease in adolescents, but there are no epidemiological data for acne in Brazil. OBJECTIVES: To estimate the prevalence and degree of acne in adolescents from Sao Paulo and study socio-demographic factors, family history and lifestyle, associated with the disease. METHODS: Cross-sectional study with 452 adolescents aged between 10 and 17 (mean=13.3 years), students from elementary and high school, examined by 3 independent evaluators. RESULTS: 62.4% were female, 85.8% white and 6.4% were aged 14. The prevalence was 96.0% and increased with age - all students over 14 had acne. The most prevalent form of acne was comedonal (61.1%), followed by mild (30.6%) and moderate (7.6%) papular-pustular, which affected mostly the face (97.5%). About half of the adolescents reported family history for acne in mother or father, and 20.6% reported previous treatment for acne. There was a higher chance of presenting non-comedonal acne with increased age (p<0.001). DISCUSSION: The prevalence of acne in adolescents varies widely due to the clinical features and diagnostic methods used. Adolescents whose brothers/sisters had acne (OR=1.7-p=0.027) and those over 13 (OR=8.3-p<0.001), were more likely to have non-comedonal acne. CONCLUSION: This study showed high prevalence of acne in adolescents from Sao Paulo, predominantly the comedonal form on the face, with a higher chance of presenting non-comedonal acne with increased age.

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BACKGROUND: Psoriasis is a chronic immune-mediated disease, characterized by increased levels of TNFα. Anti-TNFα agents have revolutionized the treatment of severe psoriasis by targeting an important molecule involved in its pathogenesis. OBJECTIVES: We report the experience of a state referral center that uses anti-TNFα agents for psoriasis. METHODS: We conducted a retrospective case series. Seventy-four out of 120 patients met the inclusion criteria. Clinical and laboratory data was analyzed using the chi-squared, Wicoxon and McNemar's tests. Associations were considered statistically significant when p-value<0.05. RESULTS: Forty-one subjects (55.40%) were male, with a mean age of 47.69±14.99 years. Median disease duration and pre-treatment PASI were 14.0 months (IQR 9.0-20.0), and 13.55 points (IQR 8.5-20.32). Sixty patients (81.10%) had arthropathic psoriasis. Forty-six subjects (62.20%) had comorbidities; the most frequent was dyslipidemia (25.70%). In 55.40% of patients, insufficient response to conventional therapies was the principal indication for using anti-TNFα drugs. Clinical improvement occurred in 93.20% of cases, and the post-treatment PASI median was 0.0 points (IQR 0.0-0.0). Adverse effects occurred in 6.80% of patients. Infections and elevation of transaminases occurred in 28.40% and 8.10% of cases, respectively. CONCLUSION: Post-treatment reduction in PASI was satisfactory and the occurrence of adverse effects was minor, mostly mild infusion effects and local reactions at drug administration sites.

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BACKGROUND: Cutaneous melanoma is a skin cancer with low incidence but high mortality rates. Several factors are associated with increased risk of melanoma, such as excessive sun exposure, fair skin, and family history, among others. Little is known about the spatial distribution of this cancer in Brazil. OBJECTIVE: To identify, through the use of geostatistical tools, spatial clusters of municipalities in the state of São Paulo based on their incidence of cutaneous melanoma. METHODS: This was an ecological and exploratory study of data on new cases obtained from Fundação Oncocentro for the period 1 January 2006-31 December 2011. Cases were separated by gender and rates per 100,000 inhabitants were calculated and used to compile thematic maps, Moran maps and kernel maps, using TerraView software. RESULTS: There were 3,172 new cases of cutaneous melanoma in the study period. High rates were identified in the North, Northwest, Southwest, and Southeast regions of São Paulo state. Global Moran's I values were statistically significant (p<0.05) at 0.12, 0.08, and 0.16, respectively, for males, females, and all cases. Areas such as the Southeast, North, and Northwest of São Paulo were identified as being of high priority for intervention. CONCLUSION: Spatial clusters of municipalities with high incidence rates of cutaneous melanoma in the state of São Paulo were identified. These data can serve as an important input for public health agencies.

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BACKGROUND: Herpes simplex virus (HSV) infection is an endemic disease and it is estimated that 6095% of the adult population are infected with symptoms that are usually self-limiting, though they can be serious, extensive and prolonged in immunocompromised individuals, highlighted by the emergence of drug-resistant strains. The study of the wild-type HSV strains based on the cytopathogenic features and its antiviral sensitivity are important in the establishment of an antivirogram for controlling the infection. OBJECTIVE: This study sought to isolate and examine the cytopathological characteristics of circulating strains of the Herpes simplex virus, from clinical specimens and their sensitivity to commercially available antiherpesvirus drugs, acyclovir, phosphonophormic acid and trifluridine. METHODS: Herpes simplex virus isolation, cytopathological features and antiviral sensitivity assays were performed in cell culture by tissue culture infectious dose or plaque forming unit assay. RESULTS: From twenty-two clinical specimens, we isolated and adapted nine strains. Overall, the cytopathic effect was detected 24 h post-infection (p.i.) and the presence of syncytia was remarkable 48 h p.i., observed after cell staining. Out of eight isolates, four developed plaques of varying sizes. All the isolates were sensitive to acyclovir, phosphonophormic and trifluridine, with the percentage of virus inhibition (%VI) ranging from 49.7-100%. CONCLUSIONS: The methodology for HSV isolation and characterization is a straightforward approach, but the drug sensitivity test, regarded as being of great practical importance, needs to be better understood.

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In the context of declining leprosy endemicity worldwide, keeping the interest in knowledge and expertise in leprosy alive has been a matter of concern. Approaching the problem only in primary care, without the proper integration with other levels of care in the health system fails to account for the complexity of the disease. Training professionals to work at different levels of health care is a current challenge. The objective of this review was to look for experiences related to the teaching of leprosy both in undergraduate courses in the field of health sciences and in training programs for professionals who work in patient care. We highlight the role of the dermatologist in the management of control programs, diagnosis and treatment of the disease, as well as in the continuous education of other health professionals.

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Vitiligo is a chronic stigmatizing disease, already known for millennia, which mainly affects melanocytes from epidermis basal layer, leading to the development of hypochromic and achromic patches. Its estimated prevalence is 0.5% worldwide. The involvement of genetic factors controlling susceptibility to vitiligo has been studied over the last decades, and results of previous studies present vitiligo as a complex, multifactorial and polygenic disease. In this context, a few genes, including DDR1, XBP1 and NLRP1 have been consistently and functionally associated with the disease. Notwithstanding, environmental factors that precipitate or maintain the disease are yet to be described. The pathogenesis of vitiligo has not been totally clarified until now and many theories have been proposed. Of these, the autoimmune hypothesis is now the most cited and studied among experts. Dysfunction in metabolic pathways, which could lead to production of toxic metabolites causing damage to melanocytes, has also been investigated. Melanocytes adhesion deficit in patients with vitiligo is mainly speculated by the appearance of Köebner phenomenon, recently, new genes and proteins involved in this deficit have been found.

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Several variants of dermatofibroma have been described. They are essentially distinguished by their clinical and histopathological features. To review the mainfeaturesof these variants, a retrospective study of skin biopsies and tissue excisions of dermatofibromasperformed in the dermatology and venereology service at the Hospital Garcia de Orta between May 2007 and April 2012 was carried out. During that period, 192 dermatofibromas were diagnosed in 181 patients, the lesions being more common in women. Median age of the study population was 48 years. The most common lesion site was the limbs (74% of patients). The histopathological types found were common fibrous histiocytoma (80%) and the aneurysmal (5.7%),hemosiderotic (5.7%), epithelioid (2.6%), cellular (2.1%), lipidized (2.1%), atrophic (1.0) and clear cell (0.5%) variants. Based on these findings, this review focuses on the clinical and histological features of the various variants of dermatofibroma in terms of their clinical presentation, distinct histopathological features, differential diagnosis and prognosis.

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A case of abscess resulting from Mycobacterium kansasii, in the left thigh of a 53-year-old woman infected with the Human Immunodeficiency virus, is reported. Curiously, there was no pulmonary or systemic involvement as is usual with these Mycobacterium infections. The patient had CD4 T lymphocyte count of 257 cells/µL and a viral load of 60,154 copies. Despite presenting a relatively preserved immunity, the patient also presented Criptococcic meningoencephalitis and Esophageal candidiasis. The patient responded satisfactorily to treatment for infections and after 51 days was discharged.

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Leprosy skin lesions are described as hypochromic or erythematous macules, pale erythematous or reddish-brown plaques, papules, nodules, and diffuse cutaneous infiltration, depending on the clinical form of the disease. They may be accompanied by hypo or anesthesia, alopecia, and hypo or anhidrosis. Verrucous lesions are now quite uncommon in leprosy. The literature is sparse, with only 25 reported cases of this association, especially in the lepromatous pole of the disease. This work is a report on two cases of lepromatous leprosy of long evolution, coursing with vegetant verrucous lesions.

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Incontinentia pigmenti is a rare X-linked genodermatosis that affects mainly female neonates. The first manifestation occurs in the early neonatal period and progresses through four stages: vesicular, verruciform, hyperpigmented and hypopigmented. Clinical features also manifest themselves through changes in the teeth, eyes, hair, central nervous system, bone structures, skeletal musculature and immune system. The authors report the case of a patient with cutaneous lesions and histological findings that are compatible with the vesicular stage, emphasizing the importance of early diagnosis and appropriate therapeutic management.

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The yellow nail syndrome is a rare disorder characterized by the classic triad of yellow and dystrophic nails, lymphedema and pleural effusion. We report in this paper a case of yellow nail syndrome, presenting the classic triad of the disease, associated with an unusual lymph accumulation in the abdomen region.

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Basal cell and squamous cell carcinomas are the main neoplasms of lip and perioral location. We describe different techniques of successful surgical reconstruction, including flaps or simple incision and suture. Using the latter technique satisfactory results were demonstrated, although the incision made removed more than a third of the lip, contrary to the literature. Our goal is to emphasize that the common sense and experience of the surgeon should prevail in the choice of reconstructive method. Moreover, even if the priority is complete excision of the lesion, we cannot ignore the aesthetic and functional recovery objective.

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Pityriasis Rubra Pilaris (PRP) is a chronic and rare papulosquamous disorder. Treatment of Pityriasis Rubra Pilaris is based on empiric evidence because of several doubts regarding its etiology and also because of its relative rarity, making randomized studies difficult to perform. Some factors suggest that the metabolism of vitamin A is involved in pathogenesis. We report a case of Pityriasis Rubra Pilaris associated with autoimmune hypothyroidism which presented rapid and complete response after thyroid hormone replacement, without any association with other systemic treatment. In literature there are only three other reports of significant improvement of the lesions after hormonal correction. Deficiency of thyroid hormone inhibits the conversion of carotene into vitamin A, which would be responsible for the occurrence of Pityriasis Rubra Pilaris in this patient.

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Ewing sarcoma is a primitive neuroectodermal tumor rarely occurs in the skin and sobcutaneous tissues. Generally Ewing's sarcoma is a primary bone tumor, but when present in soft tissues it characterizes an extremely uncommon clinical picture. It usually involves the deep subcutaneous tissue or muscles, and more rarely occurs like a primary skin cancer. Most patients are white, women, and in the second decade of life. The clinical features are a superficial mass, in average measuring 2-3 cm, of soft consistency, freely mobile and sometimes painful. The more affected locations are upper and lower extremities, trunk, head, neck or multiple lesions. The presence of metastases is very rare.

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Eccrine syringofibroadenoma is a rare benign neoplasia derived from acrosyryngium cells of the eccrine sudoriferous glands. It affects the extremities of elderly individuals as solitary tumors, or may also present as multiple lesions. There are controversies about the pathogenesis and differentiation of the tumor. Eccrine syringofibroadenoma has been associated with subjacent conditions, such as for example, hypohidrotic ectodermic dysplasias. The authors describe a case report of a patient with Clouston Syndrome, who presented papules and nodules in extremities, clinically and histologically compatible with eccrine syringofibroadenoma. There are only three cases described in the literature, associated with Clouston Syndrome, and this is the fourth case.

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Confluent and reticulated papillomatosis of Gougerot and Carteaud is a dermatosis that despite showing characteristic clinical signs is often poorly recognized and diagnosed. The authors present a case with extensive skin involvement, discuss its association with obesity and describe dermoscopic findings making the histopathological correlation.

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Little is known about the use of dermoscopy in skin grafting. We describe the case of a patient with skin grafting and surrounding pigmentation on acral region. The dermoscopic findings were similar to those of benign acral lesions (lattice-like pattern) and reactive pigmentations (fine striae). Histopathology revealed pigment leakage and increased number of melanocytes. It is believed that this phenomenon occured as the result of an inflammatory stimulus.

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We report the case of a 47-year-old homeless male with a massive infestation of Pediculus humanus corporis on his entire body. Dermoscopy helped to diagnose pediculosis by showing the involvement of scalp, beard and the genital region in this disease.

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The record of the first cases of leprosy in Rio de Janeiro dates from the seventeenth century. The first local host of leprosy patients was created from 1741, and the first colonies hospitals were built in the early twentieth century, in order to avoid contagion of the population. The first structures dedicated to research also date from this time: the Leprosy International Institute, the Leprology Institute, and the Leprosy Laboratory of the Oswaldo Cruz Foundation, where the most prestigious leprologists of Rio de Janeiro worked. Currently, investigations are focused on the Oswaldo Cruz Foundation; additionally, leprosy patients are treated at municipal health centers and state hospitals, and former colony hospitals only accept patients with severe disabilities.

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We report the case of an 11-year-old male patient with a histopathological and immunohistochemical diagnosis of dermatofibroma with an atypical clinical presentation on the right forearm. Although dermatofibroma is considered a benign skin tumor, some of its differential diagnoses, such as dermatofibrosarcoma protuberans and malignant fibrous histiocytoma, are truly aggressive. Lesions with atypical clinical aspects and topology associated with specific histopathological variants are some of the criteria for complete tumor excision.

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Degos disease, also known as malignant atrophic papulosis, is a rare occlusive vasculopathy of unknown etiology characterized by infarcts in the dermis, gastrointestinal tract, central nervous system, and other organs. It is characterized by papules, which become umbilicated and evolve with a depressed porcelain-white central area, with an erythematous halo with telangiectasias. Histological findings include wedge-shaped dermoepidermal necrosis and blood vessel thrombosis. Approximately 50-60% of patients with systemic symptoms die within 2-3 years, most due to gastrointestinal perforation. We report a typical case, with lethal outcome, in a 45-year-old woman.

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Granular cell tumour is a rare tumour of neural origin usually located on the face and the neck. The biological behaviour is usually benign. However, certain clinical and histopathological features should alert physicians to a malignant behaviour. This case report describes the occurrence of a granular cell tumour in the inguinal area that resembled a malignant tumour. The histopathological study revealed typical features of granular cell tumour and an extension study confirmed the absence of metastasis. This case highlights the importance of considering this disorder in the differential diagnosis of ulcerated nodules and of managing atypical granular cell tumor appropriately.

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A 48-year-old male patient with chronic alcoholism presented with a soft, bulky, asymptomatic, and slow-growing mass in the posterior region of the neck, as well as nodules in the deltoid region and posterior triangle of the sternocleidomastoid muscle. Needle aspiration confirmed the diagnosis of lipoma. Multiple symmetric lipomatosis (Madelung's disease) is a rare proliferation of adipocytes, of unknown etiology, most common in middle-aged men and mainly associated with alcoholism. It predominantly affects the neck and upper trunk, causing compressive symptoms or a imparting a pseudoathletic appearance. Surgical resection or liposuction is the most effective treatment, despite frequent recurrence.

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Recent reports have shown increased sensitization to Methylchloroisothiazolinone/methylisothiazolinone. We report a retrospective study conducted at the Hospital das Clínicas - UFMG, based on the results of patch tests with the Brazilian standard series, performed on referred patients. The positive results in 359 patients from November 2009 to October 2012 were analyzed and compared with the previous data collected from March 2006 to October 2009 (447 patients). The data showed 11.14% sensitization to Methylchloroisothiazolinone/ methylisothiazolinone during 2009-2012, contrasting with the previous period (3.35%). A positive association was found between its positivity and the period of 2009-2012.

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There are few populational studies to estimate the dimension of dermatological diseases. We performed a survey with 515 employees from UNESP campus, Botucatu (SP), exploring demographic data, medical appointments and dermatological diagnoses. Additionally, we induced questions about prevalent diseases. Appointments to the dermatologist were reported by 77% of subjects. The main dermatoses spontaneously reported were mycoses, allergies, nevi and viral warts. There were association of juvenile acne and males (OR=2.3), melasma and females (OR=8.0), and onychomycosis with older age (OR=1.05). Surveys are important to know the demand for dermatology care, besides directing formulation of public health policy and medical education.

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Histoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum.Primary infection occurs through inhalation of spores from the air. Immunocompetent individuals are usually asymptomatic, but may develop pulmonary disease. Immunocompromised patients tend to present systemic histoplasmosis with cutaneous lesions occurring by secondary invasion. In this case report, we describe a probable primary cutaneous histoplasmosis (PCH) in a patient with adult onset Still's disease under immunosuppression.