Logomarca do periódico: Anais Brasileiros de Dermatologia

Open-access Anais Brasileiros de Dermatologia

Publicação de: Sociedade Brasileira de Dermatologia
Área: Ciências Da Saúde
Versão impressa ISSN: 0365-0596
Versão on-line ISSN: 1806-4841
Título anterior: Anais Brasileiros De Dermatologia E Sifilografia
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Sumário

Anais Brasileiros de Dermatologia, Volume: 89, Número: 6, Publicado: 2014

Anais Brasileiros de Dermatologia, Volume: 89, Número: 6, Publicado: 2014

Document list
Continuing Medical Education
Dermatitis herpetiformis: pathophysiology, clinical presentation, diagnosis and treatment Clarindo, Marcos Vinícius Possebon, Adriana Tomazzoni Soligo, Emylle Marlene Uyeda, Hirofumi Ruaro, Roseli Terezinha Empinotti, Julio Cesar

Resumo em Inglês:

Researches on DH have shown that it is not just a bullous skin disease, but a cutaneous-intestinal disorder caused by hypersensitivity to gluten. Exposure to gluten is the starting point of an inflammatory cascade capable of forming autoantibodies that are brought to the skin, where they are deposited, culminating in the formation of skin lesions. These lesions are vesico-bullous, pruritic, and localized especially on elbows, knees and buttocks, although atypical presentations can occur. Immunofluorescence of perilesional area is considered the gold standard for diagnosis, but serological tests help in cases where it is negative. Patients who follow glutenfree diets have better control of symptoms on the skin and intestine, as well as lower risks of progression to lymphoma. Dapsone remains the main drug for treatment, but it requires monitoring of possible side effects, some potentially lethal.
Investigation
Lower facial remodeling with botulinum toxin type A for the treatment of masseter hypertrophy Klein, Fernanda Homem de Mello de Souza Brenner, Fabiane Mulinari Sato, Maurício Shigeru Robert, Fernanda Manfron Batista Rosas Helmer, Karin Adriane

Resumo em Inglês:

BACKGROUND: Masseter hypertrophy has been treated with botulinum toxin injections because of esthetic complaints especially in Asians. OBJECTIVES: The goal of the present study was to evaluate the efficacy of abobotulin toxin use in masseter hipertrophy treatment in Brazilians. METHODS: Ten Brazilian female patients with masseter hypertrophy were subjected to injections of 90U of abobotulinum toxin A applied on each side respecting the safety zone stabilished in literature and were followed up for 24 weeks. RESULTS: When analyzing the coefficients between measures of middle and lower third of the face obtained from standardized photographs, an increase was observed, with statistical significance at 2 weeks (p=0.005) and 12 weeks (p=0.001). The progression of lower third reduction was 3.94%, 5.26%, 11.99%, and 5.47% (2, 4, 12, and 24 weeks respectively). All patients showed improvement in bruxism after treatment. Observed adverse effects were masticatory fatigue, smile limitation, and smile asymmetry. CONCLUSION: The use of abobotulinum toxin A for masseter hypertrophy is effective in Brazilians and reached its maximum effect of facial thinning at 12 weeks. Smile limitation had a higher incidence compared to that reported in the literature and may result from risorius muscle blockage caused by toxin dissemination. Despite its side effects, 80% of the patients would like to repeat the treatment.
Investigation
Immunofluorescence testing in the diagnosis of autoimmune blistering diseases: overview of 10-year experience Arbache, Samia Trigo Nogueira, Tarsila Gasparotto Delgado, Lívia Miyamoto, Denise Aoki, Valéria

Resumo em Inglês:

BACKGROUND: Immunofluorescence testing is an important tool for diagnosing blistering diseases. OBJECTIVE: To characterize the immunofluorescence findings in patients diagnosed with autoimmune blistering skin diseases. METHODS: We retrospectively analyzed immunofluorescence results encompassing a 10-year period. RESULTS: 421 patients were included and divided into 2 groups: group 1- intraepidermal blistering diseases (n=277) and 2- subepidermal blistering diseases (n=144). For group 1, positive DIF findings demonstrated: predominance of IgG intercellular staining (ICS) and C3 for pemphigus foliaceus-PF (94% and 73% respectively), pemphigus vulgaris-PV (91.5%-79.5%) and paraneoplastic pemphigus-PNP (66%-33%); ICS IgA in 100% of IgA pemphigus cases, and IgG deposits in the basement membrane zone (BMZ) along with ICS in one Hailey-Hailey patient. The IIF findings revealed mean titers of 1:2.560 for PV and 1:1.280 for PF. For paraneoplastic pemphigus, IIF was positive in 2 out of 3 cases with rat bladder substrate. In group 2, positive DIF findings included multiple deposits at basement membrane zone for epidermolysis bullosa acquisita-EBA (C3-89%,IgG-79%,IgA-47%,IgM-21%) mucous membrane pemphigoid-MMP (C3,IgG,IgA,IgM-80%) and bullous pemphigoid-BP (C3-91%,IgG-39%,IgA-11%,IgM-6%), and IgA at basement membrane zone for IgA linear disease (99%) and dermatitis herpetiformis-DH (dermal papillae in 84.6%). For lichen planus pemphigoides, there was C3 (100%) and IgG (50%) deposition at basement membrane zone. indirect immunofluorescence positive findings revealed basement membrane zone IgG deposits in 46% of BP patients, 50% for EBA, 15% for IgA linear dermatosis and 50% for LPP. Indirect immunofluorescence positive results were higher for BP and EBA with Salt-Split skin substrate. CONCLUSION: Our results confirmed the importance of immunofluorescence assays in diagnosing autoimmune blistering diseases, and higher sensitivity for indirect immunofluorescence when Salt-split skin technique is performed.
Investigation
Expression of lymphatic markers and lymphatic growth factors in psoriasis before and after anti-TNF treatment Moustou, Aikaterini Evangelia Alexandrou, Paraskevi Stratigos, Alexander J Giannopoulou, Ioanna Vergou, Theognosia Katsambas, Andreas Antoniou, Christina

Resumo em Inglês:

BACKGROUND: Angiogenesis is an early stage of psoriatic lesion development, but less is known about lymphagiogenesis and its role in the development of psoriasis. OBJECTIVE: To examine the expression of specific lymphatic markers and lymphatic growth factors in untreated psoriatic skin, in the unaffected skin of patients and skin of healthy volunteers, as well as their alteration after treatment with an anti-TNF agent. METHODS: Immunohistochemistry for the lymphatic markers D2-40 and LYVE-1, in addition to the VEGF-C and VEGF-D growth factors, was performed in the skin biopsies of psoriatic lesions and adjacent non-psoriatic skin of 19 patients before and after treatment with etanercept, as well as in the skin biopsies of 10 healthy volunteers. RESULTS: The expressions of D2-40, VEGF-C and VEGF-D on lymphatic vessels underwent statistically significant increases in untreated psoriatic skin compared with non-lesional skin, in contrast to LYVE-1, which did not involve significant increase in expression in psoriatic skin. VEGF-C expression on lymphatic vessels diminished after treatment with etanercept. Moreover VEGF-C and VEGF-D staining on fibroblasts presented with higher expression in lesional skin than in non-lesional adjacent skin. CONCLUSION: Remodeling of lymphatic vessels possibly occurs during psoriatic lesion development, parallel to blood vessel formation. The exact role of this alteration is not yet clear and more studies are necessary to confirm these results.
Investigation
Phototherapy promotes healing of cutaneous wounds in undernourished rats Leite, Saulo Nani Andrade, Thiago Antônio Moretti de Masson-Meyers, Daniela dos Santos Leite, Marcel Nani Enwemeka, Chukuka S. Frade, Marco Andrey Cipriani

Resumo em Inglês:

BACKGROUND: Various studies have shown that phototherapy promotes the healing of cutaneous wounds. OBJECTIVE: To investigate the effect of phototherapy on healing of cutaneous wounds in nourished and undernourished rats. METHODS: Forty rats, 20 nourished plus 20 others rendered marasmus with undernourishment, were assigned to four equal groups: nourished sham, nourished Light Emitting Diode treated, undernourished sham and undernourished Light Emitting Diode treated. In the two treated groups, two 8-mm punch wounds made on the dorsum of each rat were irradiated three times per week with 3 J/cm2 sq cm of combined 660 and 890nm light; wounds in the other groups were not irradiated. Wounds were evaluated with digital photography and image analysis, either on day 7 or day 14, with biopsies obtained on day 14 for histological studies. RESULTS: Undernourishment retarded the mean healing rate of the undernourished sham wounds (p < 0.01), but not the undernourished Light emission diode treated wounds, which healed significantly faster (p < 0.001) and as fast as the two nourished groups. Histological analysis showed a smaller percentage of collagen in the undernourished sham group compared with the three other groups, thus confirming our photographic image analysis data. CONCLUSION: Phototherapy reverses the adverse healing effects of undernourishment. Similar beneficial effects may be achieved in patients with poor nutritional status.
Investigation
Piercings in medical students and their effects on the skin Purim, Kátia Sheylla Malta Rosario, Bernardo Augusto Rosario, Cristine Secco Guimarães, Ana Tereza Bittencourt

Resumo em Inglês:

BACKGROUND: Piercings are body embellishments commonly seen in young people, however their inherent risk of infection and scarring disorders are less divulged. OBJECTIVE: To evaluate the prevalence of body piercings among medical students and their possible dermatologic consequences. METHODS: Cross-sectional study with 58 medical students, by means of a structured questionnaire covering socio-demographic characteristics, technical issues related to the piercing and characteristics of the dermatologic complications. RESULTS: The sample was predominantly female (86.2%), with mean age 24 ± 3 years. The placement of the first piercing occurred during adolescence (median age 15), without medical supervision (91.4%) or knowledge of parents/guardians (74%). Most piercings were made of metal alloy/stainless steel, in a dumbbell model (51.7%), inserted in the umbilical area (53.5%) or ear (41.4%), with frequent cutaneous reactions in the first six months post-piercing. Hypertrophic scarring, pain, swelling and infection (p<0.05) had significantly higher frequencies among those with navel piercings. CONCLUSION: Piercing insertion occurred during adolescence. Local inflammatory and infectious reactions were common. Scarring disorders and dermatitis appeared in the long term. There is need for preventive and educational activities, starting with those in the academic environment.
Investigation
Long-term results of oxybutynin use in treating facial hyperhidrosis Wolosker, Nelson Teivelis, Marcelo Passos Krutman, Mariana Campbell, Taiz Pereira Dozono de Almeida Kauffman, Paulo Campos, José Ribas de Puech-Leão, Pedro

Resumo em Inglês:

BACKGROUND: Facial hyperhidrosis can lead to serious emotional distress. Video-assisted thoracic sympathectomy resolves symptoms effectively, though it may be associated with compensatory hyperhidrosis, which may be more common in patients undergoing resection of the second thoracic ganglion. Oxybutynin has been used as a pharmacological approach to facial hyperhidrosis but the long-term results of this treatment are unclear. OBJECTIVE: To evaluate the use of low oxybutynin doses in facial hyperhidrosis patients for at least six months. METHODS: 61 patients were monitored for over six months and assessed according to the following variables: impact of hyperhidrosis on quality of life (QOL) before treatment and after six weeks, evolution of facial hyperhidrosis after six weeks and at the last consultation, complaints of dry mouth after six weeks and on last return visit, and improvement at other hyperhidrosis sites. RESULTS: Patients were monitored for 6 to 61 months (median=17 months). Thirty-six (59%) were female. Age ranged from 17-74 (median:45). Pre-treatment QOL was poor/very poor in 96.72%. After six weeks, 100% of patients improved QOL. Comparing results after six weeks and on the last visit, 91.8% of patients maintained the same category of improvement in facial hyperhidrosis, 3.3% worsened and 4.9% improved. Dry mouth complaints were common but not consistent throughout treatment. More than 90% of patients presented moderate/great improvement at other hyperhidrosis sites. CONCLUSION: Patients who had a good initial response to treatment maintained a good response long-term, did not display tachiphylaxis and experienced improvement on other hyperhidrosis sites.
Epidemiology And Biostatistics Applied To Dermatology
Field work I: selecting the instrument for data collection Bastos, Joao Luiz Duquia, Rodrigo Pereira González-Chica, David Alejandro Mesa, Jeovany Martínez Bonamigo, Renan Rangel

Resumo em Inglês:

The selection of instruments that will be used to collect data is a crucial step in the research process. Validity and reliability of the collected data and, above all, their potential comparability with data from previous investigations must be prioritized during this phase. We present a decision tree, which is intended to guide the selection of the instruments employed in research projects. Studies conducted along these lines have greater potential to broaden the knowledge on the studied subject and contribute to addressing truly socially relevant needs.
Review
Update on cutaneous tuberculosis Dias, Maria Fernanda Reis Gavazzoni Bernardes Filho, Fred Quaresma, Maria Victória Nascimento, Leninha Valério do Nery, José Augusto da Costa Azulay, David Rubem

Resumo em Inglês:

Tuberculosis continues to draw special attention from health care professionals and society in general. Cutaneous tuberculosis is an infection caused by M. tuberculosis complex, M. bovis and bacillus Calmette-Guérin. Depending on individual immunity, environmental factors and the type of inoculum, it may present varied clinical and evolutionary aspects. Patients with HIV and those using immunobiological drugs are more prone to infection, which is a great concern in centers where the disease is considered endemic. This paper aims to review the current situation of cutaneous tuberculosis in light of this new scenario, highlighting the emergence of new and more specific methods of diagnosis, and the molecular and cellular mechanisms that regulate the parasite-host interaction.
Review
Surgical treatment of axillary hyperhidrosis by suction-curettage of sweat glands Rezende, Rebeca Maffra de Luz, Flávio Barbosa

Resumo em Inglês:

Suction curettage is a dermatologic surgery technique for the treatment of axillary hyperhidrosis, which is becoming more popular. Objective: The purpose of this study is to describe the current technique of removal of axillary sweat glands, and evaluate its efficacy and safety. Conclusion: Suction-curettage of sweat glands is a minimally invasive surgical technique that is easy to perform, safe, has high rates of success and relatively few side-effects. It is generally well tolerated by patients and requires shorter time away from daily activities, when compared with other surgical modalities.
Dermatopathology
Targetoid hemosiderotic hemangioma - Case report Kakizaki, Priscila Valente, Neusa Yuriko Sakai Paiva, Daniele Loureiro Mangueira Dantas, Fernando Luiz Teixeira Gonçalves, Sheila Viana Castelo Branco

Resumo em Inglês:

Targetoid Hemosiderotic Hemangioma, also known as Hobnail Hemangioma, is a lesion of vascular origin, probably lymphatic. The most common clinical feature is a solitary violaceous papule surrounded by a pale, thin area and a peripheral ecchymotic ring, simulating a target. Histopathologically, there is a biphasic pattern, with dilated vessels in the superficial dermis and pseudoangiosarcomatous pattern in the deep dermis, and endothelial cells with hobnail morphology. A simple excision is curative. We report a rare case of Targetoid Hemosiderotic Hemangioma.
Case Report
Cutaneous involvement as the initial presentation of metastatic breast adenocarcinoma - Case report Siqueira, Verônica Riquet de Frota, Aline Salmito Maia, Israel Leitão Queiroz, Hercília Maria Carvalho Valença Júnior, Jose Telmo Accioly Filho, José Wilson

Resumo em Inglês:

Cutaneous metastasis is an uncommon manifestation of visceral malignancy. It occurs late in the course of the disease but can be a sign of an unknown neoplasm. A case of local cutaneous metastasis by contiguity with breast adenocarcinoma is reported. It presented as initial manifestation and main complaint of a 68-year-old woman, with no family history and negative screening tests for the disease. Biopsies of ulcers which do not heal, persistent hardened erythema and cutaneous nodules of unknown cause must be performed, since the evidence of cutaneous metastasis can be of extreme importance for the diagnosis, staging and prognosis of an internal cancer. In this scenario, the dermatologist plays a fundamental role and should be always attentive to this diagnostic possibility.
Case Report
Tumor of follicular infundibulum with unique features Haddad, Natalie Oliveira Filho, Jayme de Reis, Mariana Junqueira Lacerda Michalany, Alexandre Ozores Nasser, Kassila da Rosa Corbett, Ana Maria França

Resumo em Inglês:

Tumor of the follicular infundibulum is a rare benign cutaneous adnexal neoplasm with variable clinical presentation. In most cases the diagnosis is made with the help of histopathology, due to lack of a characteristic clinical presentation. The most common form is a solitary lesion, but it can be multiple or eruptive, then called infundibulomatose. This case report illustrates a patient with multiple lesions of tumor of the follicular infundibulum with bizarre aspect and atypical location.
Case Report
Skin gangrene as an extraintestinal manifestation of inflammatory bowel disease Komatsu, Yumi Cristina Capareli, Gabriela Cunha Boin, Maria Fernanda Feitosa de Camargo Lellis, Rute Freitas, Thaís Helena Proença de Simone, Karine

Resumo em Inglês:

Inflammatory bowel diseases can commonly present many cutaneous lesions which can contribute to the diagnosis of the disease or its activity. The most frequent cutaneous or mucocutaneous manifestations suggesting ulcerative rectocolitis activity are erythema nodosum (3-10%), pyoderma gangrenosum (5-12%) and aphthous stomatitis (4%). Other reactive skin manifestations related to immunological mechanisms associated with the inflammatory bowel disease are: Sweet's syndrome, arthritis-dermatitis syndrome associated with inflammatory bowel disease and leukocytoclastic vasculitis. We describe the case of a young man with diagnosis of ulcerative rectocolitis, which presented an extensive cutaneous gangrene secondary to microvascular thrombosis. The case represents a dermatologic rarity and should be recognized as a cutaneous manifestation related to the hypercoagulability state observed in the disease's activity.
Case Report
Malignant syphilis in an immunocompetent female patient Requena, Camila Bueno Orasmo, Cínthia Rosane Ocanha, Juliana Polizel Barraviera, Silvia Regina Catharino Sartore Marques, Mariangela Esther Alencar Marques, Silvio Alencar

Resumo em Inglês:

Malignant syphilis is an uncommon manifestation of secondary syphilis, in which necrotic lesions may be associated with systemic signs and symptoms. Generally it occurs in an immunosuppressed patient, mainly HIV-infected, but might be observed on those who have normal immune response. Since there is an exponential increase in the number of syphilis cases, more diagnoses of malignant syphilis must be expected. We report a case in an immunocompetent female patient.
Case Report
American tegumentary leishmaniasis - a case of therapeutic challenge Couto, Daíne Vargas Hans Filho, Gunter Medeiros, Marcelo Zanolli Vicari, Carolina Faria Santos Barbosa, Aline Blanco Takita, Luiz Carlos

Resumo em Inglês:

American Tegumentary Leishmaniasis (ATL) is a chronic, non-contagious, infectious disease affecting millions of people worldwide. The timely and proper treatment is of great importance to prevent the disease from progressing to destructive and severe forms. Treatment for ATL recommended by the Brazilian Ministry of Health is similar for the whole country, regardless of the species of Leishmania. It is known that the response to treatment may vary with the strain of the parasite, the immune status of the patient and clinical form. We report the case of a healthy patient, coming from Manaus, Amazonas state, Brazil, who presented resistance to treatment with N-methyl-glutamine and liposomal amphotericin B, only being healed after using pentamidine.
Case Report
Rigid swelling of sublingual caruncle area due to the salivary gland duct obstruction by a sialolith Bernardes Filho, Fred Martins, Gustavo Alves, Andreia Oliveira Costa, José Ronaldo Vieira da Azulay, David Rubem Azulay-Abulafia, Luna

Resumo em Inglês:

Sialolithiasis is the presence of calculus within the ductal system of a salivary gland. Among the diagnostic methods are inspection, palpation, checking the amount of saliva secreted and the identification of a sialolith. The authors present the case of a 37-year-old female patient with edema of the submandibular area and a bulging sublingual caruncle due to a calculus that obstructed the salivary gland ostium.
Case Report
Refractory pemphigus vulgaris treated with rituximab and mycophenolate mofetil Biot, Stephanie Del Rio Navarrete Franco, Joanna Pimenta de Araujo Lima, Ricardo Barbosa Pereira, Henrique Novo Costa Marques, Luiz Paulo José Martins, Carlos José

Resumo em Inglês:

The main treatment for pemphigus vulgaris are systemic corticosteroids and immunosuppressive agents, but due to adverse reactions and therapeutic failure, new drugs such as rituximab and mycophenolate mofetil have been used. In this case report are described two cases of severe pemphigus vulgaris refractory to various treatments, with resolution after use of rituximab and mycophenolate mofetil, associated with corticosteroids. A higher-than-usual dose of rituximab was employed, without the occurrence of serious adverse reactions. Mycophenolate mofetil was added as adjunctive therapy due to lack of response to azathioprine.
Case Report
Herpes zoster-associated acute urinary retention in immunocompetent patient Marques, Silvio Alencar Hortense, Juliana

Resumo em Inglês:

Herpes zoster-associated urinary retention is an uncommon event related to virus infection of the S2-S4 dermatome. The possible major reasons are ipsilateral hemicystitis, neuritis-induced or myelitis-associated virus infection. We report a case of a 65-year-old immunocompetent female patient who presented an acute urinary retention after four days under treatment with valacyclovir for gluteal herpes zoster. The patient had to use a vesical catheter, was treated with antibiotics and corticosteroids and fully recovered after eight weeks.
Imaging In Dermatology
Three-dimensional aspects of superficial disseminated porokeratosis with scanning electron microscopy Almeida Jr., Hiram Larangeira de Abreu, Luciana Boff de Rampon, Greice Silva, Ricardo Marques e Rocha, Nara Moreira

Resumo em Inglês:

The three-dimensional findings of the surface and from a cross section from a case of disseminated superficial porokeratois using scanning electron microscopy are reported. On the surface of the skin, irregular keratin with a serpiginous distribution was seen. A gross aspect of keratin in the hyperkeratotic wall was also observed and compared to the normal area, in which the release of corneocytes seemed normal. The cross-sectional imaging easily identified the cornoid lamella, with compact keratin surrounded by normal stratum corneum.
Imaging In Dermatology
Goya and tinea favosa Vallarelli, Andrelou Fralete Ayres

Resumo em Inglês:

A case of a tinea favosa involving the scalp of a child represented in the painting "Boys climbing a tree" (Muchachos trepando a un árbol), by Francisco Goya y Lucientes, with pictorial representation of favic scutula and consequent alopecia.
Imaging In Tropical Dermatology
"Sign of the kiss" in dermatitis caused by vesicant beetles ("potós" or Paederus sp.) Haddad Junior, Vidal

Resumo em Inglês:

The cosmopolitan beetles of the Paederus genus (potós) cause a severe dermatitis when the insect is crushed against the skin of exposed areas (the cervical region is the most affected). Toxins (pederin and others) from the hemolymph of the insect cause plaques and/or bizarre, linear lesions with erythema, edema, blisters, pustules, crusts and exulcerations. There may be a burning sensation and severe conjunctivitis. Lesions disappear after 10 days and may leave hyperchromic macules. Treatment is made with topical corticosteroids and intensive washing.
What Is Your Diagnosis?
Case for diagnosis Boza, Juliana Catucci Dorn, Timotio Volnei Oliveira, Fabiana Bazanella de Bakos, Renato Marchiori

Resumo em Inglês:

The Osler-Weber-Rendu syndrome or Hereditary Hemorrhagic Telangiectasia (HHT) is a systemic fibrovascular dysplasia characterized by defects in the elastic and vascular walls of blood vessels, making them varicose and prone to disruptions. Lesions occur in different organs and can lead to hemorrhage in the lungs, digestive tract and brain. We describe the case of a patient with cutaneous manifestations and severe impairment of the digestive tract. It is important for the dermatologist to recognize this syndrome, since the cutaneous lesions may play a key role in diagnosis.
What Is Your Diagnosis?
Case for diagnosis Antonio, João Roberto Lucca, Larissa Cannizza Pacheco de Borim, Mariana Perez Rossi, Natália Cristina Pires Oliveira, Guilherme Bueno de

Resumo em Inglês:

Graham-Little-Piccardi-Lassueur Syndrome is a rare form of Lichen Planus, characterized by the presence of the triad: non-scarring hair loss in the inguinal and axillary regions and follicular spinous or disseminated acuminate papules; typical, cutaneous or mucous LP; and scarring alopecia of the scalp with or without atrophy. These features do not have to be present simultaneously.
Syndrome In Question
Syndrome in question Peixoto, Isy Lima Carreno, Ana Maria Prazeres, Vania Mesquita Gadelha Chirano, Caroline Albuquerque Rodrigues Ihara, Gabriel Maroja Akel, Patricia Bandeira de Melo

Resumo em Inglês:

Costello syndrome (CS) is a rare genetic disorder, first described by Costello in 1971, caused by mutations in the HRAS proto-oncogene. Clinical findings include facial dysmorphism, skin disorders, cognitive impairment, cardiac and musculoskeletal defects. There is an increased risk of malignancies in these patients, due to the proto-oncogene mutation, and also sudden death secondary to heart disease. We report a case with characteristic phenotype, highlighting the peculiar skin changes.
Special
The value of trichoscopy in the differential diagnosis of scalp lesions in pemphigus vulgaris and pemphigus foliaceus Sar-Pomian, Marta Kurzeja, Marta Rudnicka, Lidia Olszewska, Malgorzata

Resumo em Inglês:

BACKGROUND: Trichoscopy is becoming increasingly popular in diagnosing hair and scalp diseases. Scalp involvement in pemphigus is common. The scalp may be the first or only site of clinical manifestation of the disease. OBJECTIVE: The aim of this study was to analyze whether trichoscopy may be useful in aiding differential diagnosis of scalp lesions in patients with pemphigus vulgaris and pemphigus foliaceus. METHODS: Trichoscopy was performed in 19 patients with scalp lesions in the course of pemphigus (9 patients with pemphigus vulgaris and 10 with pemphigus foliaceus). In all patients, the diagnosis of scalp pemphigus was confirmed by histopathology. The working magnification was 20-fold and 70-fold. RESULTS: The most frequently observed trichoscopy features of pemphigus lesions were: extravasations (18/19; 94.7%) and yellow hemorrhagic crusts (11/19; 57.9%). Yellow dots with whitish halo were observed in 6/19 (31.6%) patients with pemphigus. White polygonal structures were observed in pemphigus foliaceus (6/10; 60%), but not in pemphigus vulgaris. Vascular abnormalities were more frequent in pemphigus vulgaris, when compared to pemphigus foliaceus, and were associated with a severe course of disease. Linear serpentine vessels were the most frequent vascular abnormality in patients with pemphigus vulgaris and pemphigus foliaceus (77.8% and 30%, respectively). CONCLUSION: Trichoscopy may serve as a useful supplementary method in the differential diagnosis of pemphigus, especially in cases of desquamative or exudative lesions limited to the scalp. Extravasations, yellow hemorrhagic crusts, yellow dots with whitish halo, white polygonal structures and linear serpentine vessels are trichoscopy features which may suggest the diagnosis of pemphigus.
Communication
Distribution of Brazilian dermatologists according to geographic location, population and HDI of municipalities: an ecological study Schmitt, Juliano Vilaverde Miot, Hélio Amante

Resumo em Inglês:

This study investigated the geographic distribution of dermatologists in Brazilian municipalities in relation to the population, regions of the country and human development index. We conducted an ecological study based on data from the 2010 census, the 2010 human development index, and the records of the Brazilian Society of Dermatology. 5565 municipalities and 6718 dermatologists were surveyed. Only 504 (9.1%) municipalities had dermatologists, and accounted for 56.2% of the Brazilian population. The smallest population size and lowest HDI rate that best discriminated municipalities that did not have dermatologists were found to be 28,000 and 0.71, respectively. The average population density of dermatologists in cities was 1/23.000 inhabitants, and variations were independently associated with the HDI, the population of the municipalities and the region of the country.
Communication
Two cases of renal cell cancer during immunobiologic therapy for psoriasis Zarur, Fabiana Palmieri d'Almeida, Luiza Ferreira Vieira Mafort, Monique Samy Pamplona Gusmão, Paula Regazzi de Avelleira, João Carlos Regazzi

Resumo em Inglês:

Immunobiologic therapy is indicated for severe forms of psoriasis, resistant to conventional therapy. There is growing concern about their safety profile and possible association with cancer development. This article documents two cases of renal cell cancer during treatment with biologic therapy, reviewing what is described in the literature . The risk of solid tumors as a complication of using TNF-alpha inhibitors is controversial. No conclusion can be drawn from the data in the literature, however, we believe that special attention should be given to those with known risk factors for a specific neoplasm.
Communication
T-cell-predominant lymphoid hyperplasia in a tattoo Souza, Erica Sales Rocha, Bruno de Oliveira Batista, Everton da Silva Oliveira, Rodrigo Ferreira de Farre, Lourdes Bittencourt, Achilea Lisboa

Resumo em Inglês:

Cutaneous lymphoid hyperplasia (CLH) can be idiopathic or secondary to external stimuli, and is considered rare in tattoos. The infiltrate can be predominantly of B or T-cells, the latter being seldom reported in tattoos. We present a case of a predominantly T CLH, secondary to the black pigment of tattooing in a 35-year-old patient, with a dense infiltrate of small, medium and scarce large T-cells. Analysis of the rearrangement of T-cells receptor revealed a polyclonal proliferation. Since the infiltrate of CLH can simulate a T lymphoma, it is important to show that lesions from tattoos can have a predominance of T-cells.
Letters
Chronic ulcers: considerations about contaminant flora, infection and antimicrobial treatment Abbade, Luciana Patrícia Fernandes Miot, Hélio Amante
Letters
Replay Gelatti, Luciane Cristina Bonamigo, Renan Rangel
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