Resumo em Inglês:

The evolution in the knowledge of tuberculosis' physiopathology allowed not only a better understanding of the immunological factors involved in the disease process, but also the development of new laboratory tests, as well as the establishment of a histological classification that reflects the host's ability to contain the infectious agent. At the same time, the increasing bacilli resistance led to alterations in the basic tuberculosis treatment scheme in 2009. This article critically examines laboratory and histological investigations, treatment regimens for tuberculosis and possible adverse reactions to the most frequently used drugs.

Resumo em Inglês:

BACKGROUND: Pemphigusis a bullous, rare and chronic autoimmune disease. There are two major forms of pemphigus: vulgaris and foliaceus. Epidemiological data and clinical outcome in patients diagnosed in the Brazilian Amazon states are still rare. OBJECTIVES: To study the occurrence of the disease during the study period and analyze the epidemiological profile of patients, the most common subtype of pemphigus, and the clinical evolution of patients. METHODS: Retrospective analysis of medical records of hospitalized patients with pemphigus foliaceus and pemphigus vulgaris in the period from 2003 to 2010 in Dermatology Service of Hospital Fundação Santa Casa de Misericórdia do Pará, Belém, Northern Brazil. RESULTS: We found a total of 20 cases of pemphigus during the study period, 8 of which were of foliaceus pemphigus and 12 of vulgaris pemphigus. Pemphigus foliaceus had the predominance of male patients (75%), showed satisfactory clinical evolution, and was characterized by absence of pediatric cases. Pemphigus vulgaris affected more women (66.7%), showed mean hospital stay of 1 to 3 months (50%), and there were three cases of death (25%). The prescribed immunosuppressive drugs included prednisone with or without combination of azathioprine and/or dapsone. Sepsis was associated with 100% of the deaths. CONCLUSIONS: The occurrence of the disease is rare, there are no familiar/endemic outbreaks in the sample. Evolution is usually favorable, but secondary infection is associated with worse prognosis. The choice of best drugs to treat pemphigus remains controversial.

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BACKGROUND: squamous cell carcinoma is the second most common type of skin malignancy and may evolve to regional lymph node and distant metastases. OBJECTIVE: The objective of this study was to evaluate patients with head and neck cutaneous squamous cell carcinoma to identify its clinical and histopathological characteristics, as well as the frequency of local recurrence and metastasis. METHODS: A retrospective cohort of patients with head and neck cutaneous squamous cell carcinoma. Inclusion criteria: histopathological confirmation, follow-up for longer than one year after diagnosis. Exclusion criteria: immunosuppression; lip and oral cavity squamous cell carcinoma; and non-surgical resection of the lesion. We evaluated demographic, clinical and anatomopathologic findings and explored their associations. RESULTS: Sixty-one patients with 79 tumors and followed by 4.8±3.0 years were selected. The average age was 67.1 years, and 63% of tumors had up to two centimeters. Seven tumors (8.9%) recurred and two of them had positive margins. Recurrence was associated with higher Broders' grade (p<0.01). Two patients (3.3%) had regional lymph node metastases. There were no distant metastases. Seventy tumors were considered to be usual tumors (89.7%), and 68 (87.2%) were classified as Broders' grade 1 and 2. Additionally, 64.1% of tumors had a depth of invasion below four millimeters. Thirteen tumors (16.7%) had positive histological margins. CONCLUSIONS: Most patients had good prognosis in the first year of follow-up, confirming that head and neck cutaneous squamous cell carcinoma has a better prognosis than squamous cell carcinoma of other regions such as mucosa, oral cavity, and internal organs.

Resumo em Inglês:

BACKGROUND: notalgia paresthetica is a subdiagnosed sensory neuropathy presenting as a condition of intense itching and hyperchromic macule on the back that interferes with daily habits. OBJECTIVES: To determine the efficacy of treatment of notalgia paresthetica using oral gabapentin, assessing the degree of improvement in itching and influence on quality of life. Moreover, to evaluate the signs and symptoms associated with notalgia paresthetica. METHODS: We conducted an experimental, non-randomized, parallel, non-blinded study including 20 patients with clinical and histopathological diagnosis of notalgia paresthetica. After application of the visual analogue scale of pain adapted for pruritus and of the questionnaire of dermatology life quality index (DLQI), ten patients with visual analogue scale > 5 were given treatment with gabapentin at the dose of 300 mg/day for four weeks. The other ten were treated with topical capsaicin 0.025% daily for four weeks. After the treatment period, patients answered again the scale of itching. RESULTS: The use of gabapentin was responsible for a significant improvement in pruritus (p=0.0020). Besides itching and hyperchromic stain on the back, patients reported paresthesia and back pain. It was observed that the main factor in the worsening of the rash is heat. CONCLUSION: Gabapentin is a good option for the treatment of severe itching caused by nostalgia paresthetica.

Resumo em Inglês:

BACKGROUND: Acne vulgaris has high prevalence, disturbing quality of life during adolescence. OBJECTIVES: To measure dissastifaction and acne in 18-year-old male individuals and its associated factors. METHODS: A questionnaire was applied by trained interviewers to all boys during selection for the military service. Dissatisfaction and acne was evaluated using a self-administered face scale. Facial, prestrernal and dorsal acne were evaluated separately. RESULTS: A total of 2,200 adolescents, aged 18 years, were interviewed. Among these, 1,678 had acne on the face and 974 (54.05%) showed some degree of dissatisfaction. Regarding the impact of acne located on the chest, 326 out of 686 adolescents (47.52%) reported dissatisfaction. For acne located on the back, 568 out of 1,103 affected individuals (51.50%) showed dissatisfaction. Facial / dorsal acne and dissatisfaction were statistically associated with lower income, lower education levels and with non-whites. Presternal acne and dissatisfaction were statistically asssociated with lower income and lower education levels. CONCLUSION: This population-based study found a high prevalence of acne on the face, back and chest, with high rates of dissatisfaction.

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BACKGROUND: Onychomycosis or nail fungal infection is the most common nail disease. Despite the wide range of studies on this condition, it remains difficult to establish the correct diagnosis and effective treatment. OBJECTIVES: To evaluate the efficacy of classical laboratory methods for the diagnosis of onychomycosis, and the in vitro susceptibility of the its main etiological agent to antifungals used in routine. METHODS: Nail samples of 100 patients with clinically suspected feet onychomycosis were collected to confirm the diagnosis by direct mycological examination and fungal culture. In vitro antifungal susceptibility testing was performed against strains of the main dermatophyte isolated by microdilution, according to the standardized protocol (M38-A2 - CLSI) RESULTS: Clinical diagnosis of onychomycosis was confirmed by laboratory analysis in 59% of patients. Of these, 54.2% were positive only in direct mycological examination, 44.1% in direct mycological examination and culture, and one case (1.7%) was positive only in culture, resulting in weak agreement between these tests (Kappa = 0.385; p <0.001) High minimum inhibitory concentration values of fluconazole and itraconazole were observed in 66.7% and 25.0% of isolates of T. rubrum tested. Additionally, high MIC values of terbinafine and ciclopirox was detected in only one isolate, and this was one of the strains in which in vitro activity of itraconazole and fluconazole has not been proven. CONCLUSIONS: Poor agreement was observed between direct mycological examination and culture for the diagnosis of onychomycosis, with direct mycological examination being significantly more sensitive. Except for fluconazole, the other three antifungals tested showed good in vitro activity against clinical isolates of T. rubrum.

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BACKGROUND: Road running is a growing sport. OBJECTIVES: To determine the prevalence of sports-related dermatoses among road runners. METHODS: Cross-sectional study of 76 road runners. Assessment was performed by means of a questionnaire, interview, and clinical examination. The chi-square and linear trend tests were used for analysis. RESULTS: Most athletes were men (61%), aged 38±11 years, who ran mid- or long-distance courses (60.5%) for 45 to 60 minutes (79%), for a total of 25-64 km (42.1% ) or more than 65 km (18.4%) per week. The most prevalent injuries were blisters (50%), chafing (42.1%), calluses (34.2%), onychomadesis (31.5%), tinea pedis (18.4%), onychocryptosis (14.5%), and cheilitis simplex (14.5%). Among athletes running >64 km weekly, several conditions were significantly more frequent: calluses (p<0.04), jogger's nipple (p<0.004), cheilitis simplex (p<0.05), and tinea pedis (p<0.004). There was a significant association between the weekly running distance and the probability of skin lesions. Of the athletes in our sample, 57% trained before 10 a.m., 86% wore clothing and accessories for sun protection, 62% wore sunscreen, and 19.7% experienced sunburn. Traumatic and environmental dermatoses are common in practitioners of this outdoor sport, and are influenced by the weekly running distance. CONCLUSION: In this group of athletes, rashes, blisters, sunburn, and nail disorders were recurrent complaints regardless of running distance. Calluses, athlete's foot, chapped lips, and jogger's nipple predominated in individuals who ran longer routes.

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BACKGROUND: Cancer is a multifactorial disease and skin carcinomas are the most common type of cancer. Assessing quality of life and self-esteem outcomes in skin cancer patients is important because these are indicators of the results of the treatment, translating how patients face their lives and their personal relationships. OBJECTIVE: To assess the late impact of the surgical treatment of head and/or neck skin carcinomas on quality of life and self-esteem of the patients. METHODS: Fifty patients with head or neck skin carcinomas were enrolled. Their age ranged between 30 and 75 years, 27 were men and 23 were women. Patients were assessed with regard to quality of life and self-esteem, preoperatively and five years postoperatively. Validated instruments were used: the MOS 36-item Short-form Health Survey (SF-36) and the Rosenberg Self-esteem/EPM-UNIFESP Scale. The Wilcoxon signed-rank test was used for the statistical analysis. RESULTS: Twenty-two patients completed the five-year follow-up, 54.5% women and 45.5% men. Compared to the preoperative assessment, patients had an improvement in mental health (p=0.011) and in self-esteem (p=0.002). There was no statistical difference with regard to the other domains of the SF-36. CONCLUSION: Patients submitted to surgical treatment of skin carcinoma improved mental health and self-esteem in the late postsurgical testing.

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BACKGROUND: Measuring the quality of life measure of patients with dermatologic diseases is an important concern. The instruments to evaluate it are commonly originally written in English and need to be translated and validated to be used in different cultures. OBJECTIVE: The purpose of this paper is to translate and validate the Skindex-29 questionnaire to Brazilian Portuguese to be used in our country as a quality of life assessment instrument in dermatologic patients. METHODS: The first step was the translation from English to Brazilian Portuguese and the back-translation by two native speakers. The translated version was then used for the second step, when three questionnaires were applied to 75 patients (43 of whom were classified as lightly affected and 32 as heavily affected by their dermatologic conditions): an identification questionnaire, the translated version of Skindex-29, and the Brazilian Portuguese version of Dermatologic Life Quality Index (DLQI). Additionally, the generic questionnaire Short Form 36 (SF-36) was applied to 41 of these patients. The last step to evaluate reproducibility was repeating the Skindex-29 questionnaire by the same researcher one week later in 44 patients. RESULTS: Reliability was observed in global Skindex-29 scale (α=0.934), and its domains emotions (α=0.926), symptoms (α=0,702), and psycosocial functioning (α=0.860). The reproducibility showed high intraclass correlations. High intra class correlations was observed, thus validating reliability. CONCLUSIONS: The Skindex-29 quality of life questionnaire was properly translated and validated to Brazilian Portuguese.

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The importance of estimating sample sizes is rarely understood by researchers, when planning a study. This paper aims to highlight the centrality of sample size estimations in health research. Examples that help in understanding the basic concepts involved in their calculation are presented. The scenarios covered are based more on the epidemiological reasoning and less on mathematical formulae. Proper calculation of the number of participants in a study diminishes the likelihood of errors, which are often associated with adverse consequences in terms of economic, ethical and health aspects.

Resumo em Inglês:

Several studies demonstrate the benefits of low-power light therapy on wound healing. However, the use of LED as a therapeutic resource remains controversial. There are questions regarding the equality or not of biological effects promoted by LED and LASER. One objective of this review was to determine the biological effects that support the use of LED on wound healing. Another objective was to identify LED´s parameters for the treatment of wounds. The biological effects and parameters of LED will be compared to those of LASER. Literature was obtained from online databases such as Medline, PubMed, Science Direct and Scielo. The search was restricted to studies published in English and Portuguese from 1992 to 2012. Sixty-eight studies in vitro and in animals were analyzed. LED and LASER promote similar biological effects, such as decrease of inflammatory cells, increased fibroblast proliferation, stimulation of angiogenesis, granulation tissue formation and increased synthesis of collagen. The irradiation parameters are also similar between LED and LASER. The biological effects are dependent on irradiation parameters, mainly wavelength and dose. This review elucidates the importance of defining parameters for the use of light devices.

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Self-medication is the selection and use of drugs without medical prescription, to treat diseases or for symptomatic relief. This article is a systematic review on self-medication in skin diseases. A search was conducted on Virtual Health Library and PubMed databases using predetermined descriptors. Two researchers performed the article selection process independently, with the degree of inter-observer agreement measured by the kappa index. The prevalence of self-medication ranged from 6.0 to 45.0%. Topical corticosteroids were the most commonly used therapeutic strategies for self-medication, as found in the reviewed articles. This study revealed that published data on self-medication in dermatology are scarce, although the findings showed that it was a common practice.

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The graft-versus-host disease is the major cause of morbidity and mortality in patients who have undergone hematopoietic stem cell transplantation. Aiming at contributing to the understanding of the role of myeloid and plasmacytoid dendritic cells, and natural killer cells in chronic graft-versus-host disease, we examined biopsies of jugal mucosa of 26 patients with acute myeloid leukemia who had undergone allogenic hematopoietic stem cell transplantation. Half of these patients developed oral chronic graft-versus-host disease. Microscopic sections were immunohistochemically stained for anti-CD1a, anti-CD123 and anti-CD56. We calculated the number of immunostained cells in the corium per square millimeter and applied the Mann-Whitney test. Results showed a statistically significant increase of myeloid dendritic cells (CD1a+; p=0,02) and natural killer cells (CD56; p=0,04) in patients with oral chronic graft-versus-host disease. CD123 immunostaining showed no statistical difference between groups. It was concluded that myeloid dendritic cells and natural killer cells participate in the development of oral chronic graft-versus-host disease.

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The platelet-rich plasma (PRP) has proved promising regarding its applicability in dermatology, especially in the healing of chronic ulcers. The autologous platelet-rich plasma is obtained by centrifuging the blood, so that the components are separated by density gradient. The final product is a gel rich in growth factors that act in tissue repair by activating fibroblasts and inducing extracellular matrix remodeling.

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Chronic mucocutaneous candidiasis is a rare disorder characterized by persistent and recurrent infections by Candida due to changes in cellular immunity and may be associated with autoimmune endocrine disorders. It is refractory to the usual antifungal treatments, which merely control it with imidazole derivatives. This reports the case of a 50-year-old female patient who referred vaginal discharge associated with vulvar ulcerated lesions and whitish plaques on oral and genital mucous membranes of onset in adolescence besides cutaneous horns in nipples. The clinical picture, family history, culture and anatomopathological studies were consistent with chronic infection by candida. Treatment with systemic antifungals obtained partial response of lesions characterizing a clinical picture of Chronic Mucocutaneous Candidiasis.

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Schistosomiasis is best known in its visceral form but it can attack the skin, its ectopic cutaneous manifestation being rare and clinically difficult to diagnose. It is characterized by isolated or coalescent papules, erythematous, pruritic or asymptomatic, with zosteriform distribution, often located on the trunk. The authors report a case of a 28-year-old female patient with lesions on the abdomen, with positive stool results for Schistosoma and absence of active symptoms of visceral disease. The case reveals rare exuberant cutaneous manifestation and the importance of the diagnosis of this entity in patients from endemic regions.

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Phaeohyphomycosis is a disease caused by dematiaceous fungi with a worldwide geographic distribution and broad spectrum. It is most commonly found in adult individuals of both genders and all races. We report the case of a 57-year-old woman with phaeohyphomycosis in the ungual apparatus.

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Psoriasis is a chronic inflammatory, immune-mediated disease that affects 1% to 2% of the world's population. Immunobiological medications are prescribed for certain patients with severe forms of psoriasis, however, these drugs increase the risk of reactivation of viral diseases such as hepatitis B. We report the case of a patient with severe psoriasis with positive serology for the Hepatitis B virus, who received ustekinumab (a human monoclonal antibody against interleukin 12 and 23). In this patient, the use of ustekinumab did not reactivate the Hepatitis B virus. Given the high prevalence of chronic viral infections in patients who are candidates for biologic therapy, as well as the potential for reactivate chronic viral illness, randomized controlled studies are needed to assess the risks and benefits of such therapy in these populations.

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We report the case of a 48-year-old, Caucasian female who presented with slowly progressing asymptomatic poikilodermatous changes of the extensor aspects of the forearms. She also had typical Poikiloderma of Civatte on the V of the neck and erythemato-telangiectatic rosacea of the central face. The patient had been practicing aroma-therapy for many years. Histologic examination revealed findings consistent with PC. Patch-testing revealed positive reactions to Fragrance mix and Nickel sulphate. Based on clinical and histological findings, a diagnosis of extracervical PC was suggested. PC with extra-cervical or extra-facial involvement is rare. In addition, this case supports the theory that contact sensitization to fragrances may contribute to the development of PC.

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Acne fulminans is a rare and serious condition characterized by the sudden onset of nodular and ulcerative acne lesions associated with systemic symptoms. It has been recognized a subset of patients with a sudden worsening of acne, often during treatment with oral isotretinoin, but without the strong presence of systemic involvement. Recognized by some authors as "pseudo-acne fulminans" or " acne fulminans sine fulminans," we report a case with these features in order to draw attention to the recognition and early management of this manifestation.

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Sarcoidosis is a multisystem granulomatous disease of unknown cause. The osteoarticular involvement in sarcoidosis is rare and is often associated with cutaneous and long-standing chronic multisystem disease. More common in black women, osseous sarcoidosis is difficult to diagnose, with an incidence of 3 to 13%. The most characteristic radiological clinical picture evidences rounded, well-defined cysts, with no periosteal reaction and without peripheral sclerosis. The small bones of hands and feet are the most frequently involved sites. This report aims to demonstrate a rare case of osteoarticular sarcoidosis with characteristic clinical presentation, and highlight the importance of detecting osteoarticular involvement in this pathology.

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Furuncular myiasis occurs after larvae penetrate on the skin. The disease is characterized by the presence of a nodule with a central hole through which there is serosanguinous exudate drainage. The authors present a case of furuncular myiasis by Dermatobia hominis in which late diagnosis made it necessary to have the orifice margins surgically enlarged in order to extract the larva. They also emphasize that dermoscopy is a useful auxiliary tool in this diagnosis.

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Melanoma is a malignant melanocytic neoplasm with high mortality rate, and steadily and universally increasing incidence rates. Polypoid melanoma is considered an exophytic variant of the nodular subtype. The incidence of polypoid melanoma is extremely variable, most likely because of the different criteria used for its characterization. We presented a rare case of polypoid melanoma and superficial spreading melanoma in the same lesion.

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We present an interesting case report of two sarcoid-like lesions on a port-wine stain (PWS) birthmark in a Brazilian patient which on investigation proved to be cutaneous leishmaniasis.

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Idiopathic Atrophoderma of Pasini and Pierini (IAPP) is a rare, exclusively cutaneous disease. It is more frequent in females, with incidence peak in the second and third decades of life. The etiopathogenesis remains unknown. IAPP most commonly affects the back, abdomen and proximal regions of the limbs. Lesions may be rounded, oval or circular; single or multiple. The evolution is variable and the course is initially progressive. Collagen changes such as atrophy, thinning, condensation and sclerosis may be observed in the papillary dermis. This paper describes a case of Idiopathic Atrophoderma of Pasini and Pierini with histopathologic findings.

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We report the case of a 81-year-old female patient who had a two-year history of violet-colored erythematous tumors on both legs. Histopathological and immunohistochemical examinations confirmed the diagnosis of primary cutaneous large B-cell lymphoma, leg type. This rare, cutaneous lymphoma affects predominantly elderly females. Clinically, patients present with tumoral lesions on one or both legs (worst prognosis). Diagnosis is based on clinical, histopathological and immunohistochemical findings. The strong expression of BCL2, BCL6, MUM-1 and CD20, and the positivity for Ki67 antigen confirm the diagnosis. R-CHOP chemotherapy regimen (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) is the most widely accepted treatment.

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Intravascular papillary endothelial hyperplasia is a benign vascular lesion caused by proliferation of endothelium. It is reactive to thrombotic or inflammatory stimuli in the vessel wall.We report the case of a 14-yearold male patient with a violet-colored erythematous tumoral lesion of progressive growth in the occipital region. The diagnosis of intravascular papillary endothelial hyperplasia (IPEH) was confirmed by clinical and histopathological findings. Total lesion exeresis was performed with no recurrence up to date. IPEH presents clinical importance due to its clinical and histological resemblance to angiosarcoma. In order to differentiate it from angiosarcoma, distinguishing features of the benign disease should be considered, such as lack of cellular atypia and rare mitotic activity.Prognosis is good.

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Rendu-Osler-Weber Syndrome also known as Hereditary Hemorrhagic Telangiectasia is a rare systemic fibrovascular dysplasia, with dominant autosomal inheritance. It is characterized by recurrent epistaxis, mucocutaneous telangiectasia, visceral arteriovenous malformation and positive family history. There may be hematologic, neurologic, dermatologic and gastrointestinal complications. Therapy is supportive and aimed at preventing complications. In this article we report a case of Rendu-Osler-Weber in a 64 year-old man, with history of mucocutaneous telangiectasia since the third decade of life, recurrent epistaxis, positive family history and vascular ectasia in the gastrointestinal tract.

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Vitiligo is a dermatosis requiring complex treatment. In clinically stable cases, melanocyte autologous grafting has shown good results, using different methodologies for obtaining the donor area: dermatomes, punches, blisters. However, these techniques are complex and require specific instruments. This study presents a simple technique for melanocyte harvest that has been performed in our service for more than ten years and includes epidermal curettage of the donor area, grafting of the obtained material, which was homogenized with saline or hyaluronic acid, on the achromic area, and the application of a semipermeable dressing that is removed 1 week later.

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Alopecia areata is a common autoimmune disorder that leads to nonscarring hair loss. Black dots, also called comedo-like cadaver hairs, can be found in almost 50% of alopecia areata patients and indicate disease activity. Trichostasis spinulosa is a follicular disorder resulting from the retention of numerous hairs surrounded by a keratinous sheath in dilated follicles. Trichostasis spinulosa is a relatively common but underdiagnosed disorder of hair follicles. Here, we describe a man with alopecia areata of the eyebrows, androgenetic alopecia and trichostasis spinulosa at the vertex and show how dermoscopy can be useful in distinguishing black dots from Trichostasis spinulosa lesions.

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Porphyria cutanea tarda is prevalent in connective tissue disease, common in systemic lupus erythematosus. However, the co-existence of primary sjogren's syndrome and porphyria cutanea tarda is rare and poses diagnostic and therapeutic challenges. We report a case of porphyria cutanea tarda associated with primary sjogren's syndrome.