Notalgia paresthetica: treatment using intradermal botulinum toxin A.

INTRODUCTION: Notalgia paresthetica is a sensory mononeuropathy that affects dorsal segments T2 to T6. It can have a significant effect on quality of life. Numerous treatments have been used with variable results. MATERIAL AND METHODS: Five patients diagnosed with notalgia paresthetica were treated with intradermal botulinum toxin A. None had achieved relief of the pruritus with previous treatments. RESULTS: Variable results were observed after the administration of intradermal botulinum toxin. Complete resolution of the pruritus was not achieved in any of the patients. CONCLUSIONS: Botulinum toxin A appears to be a safe therapeutic option for patients with notalgia paresthetica. However, data currently available come from small patient series, making it difficult to draw definitive conclusions regarding the true efficacy and long-term effects of this treatment.

Clinical diagnosis of toenail onychomycosis is possible in some patients: cross-sectional diagnostic study and development of a diagnostic rule.

BACKGROUND: Suspected toenail onychomycosis is a frequent problem. Clinical diagnosis has been considered inadequate. OBJECTIVES: To assess the diagnostic accuracy of clinical findings for detecting fungi in toenails, and to develop and validate a clinical diagnostic rule aimed at improving dermatologists' diagnosis of onychomycosis. METHODS: A cross-sectional diagnostic study was performed including a total of 277 patients seen by 12 dermatologists. The gold standard was the presence of dermatophytes on culture or a positive nail plate biopsy. For each sign we described prevalence, sensitivity, specificity, positive and negative predictive values, and likelihood ratios for positive and negative results. We developed a diagnostic clinical rule and validated it in a subsample. RESULTS: Helpful findings to predict the presence of fungi are: previous diagnosis of fungal disease; abnormal plantar desquamation (affecting > 25% of the sole); onychomycosis considered the most probable diagnosis by a dermatologist; and presence of interdigital tinea. When dermatologists considered onychomycosis the most probable diagnosis and plantar desquamation was present (13% of patients), the positive predictive value for presence of fungi was 81%. When both signs were absent (34% of patients), the positive predictive value for absence of fungi was 71%. In other situations, clinical diagnosis might not give enough information to decide on therapy. CONCLUSIONS: In 13% of the patients (a large number in absolute terms), when dermatologists consider onychomycosis the most probable diagnosis and plantar desquamation is present, therapy should be started without any further test, as clinical diagnosis is at least as accurate as laboratory tests. In other situations, an optimal management strategy should be defined.

Notalgia paresthesica successfully treated with narrow-band UVB: report of five cases.

BACKGROUND: Notalgia paresthesica is a disorder of unknown origin characterized by pruritus localized to the patients' back. Local pain, burning or paresthesias have also been described. No definite treatments have been found for this disorder and most of those reported to date are anecdotal. Topical capsaicin is the option most widely used among dermatologists. Transcutaneous electrical nerve stimulation, gabapentin, oxcarbazepine and botulinum toxin have recently shown promising effects. UVB has been used for decades to treat different pruritic skin diseases, but its benefits in the management of NP have not been stated to date. OBJECTIVES: To test the effects of UVB in notalgia paresthesica. Methods We used a course of UVB narrow band to treat five patients with notalgia paresthesica. The treatment was administered following a phototype protocol in a UV 7002 cabinet. RESULTS: We provide the results of a course of UVB narrow-band phototherapy in five patients. Phototherapy contributed substantially to improve pruritus in all of them. CONCLUSION: Given the benefits achieved, we stress the interest of UVB narrow-band as a safe and well tolerated alternative treatment for notalgia paresthetica.

[Short term efficacy and safety of etanercept in psoriasis]. / Eficacia y seguridad a corto plazo de etanercept en la psoriasis.

Psoriasis is a chronic disease that occurs in episodes and which, in a certain moment of its evolution or in some patients, may affect a large portion of the body surface with serious physical and psychological repercussions. The treatment used in this type of patient is associated to many side effects and requires numerous clinical and laboratory controls. We present a clinical case of severe psoriasis that presented a rapid and complete response to etanercept. Based on this case, we performed a bibliographic review aimed at the short-term safety and efficacy aspects, less than 12 weeks of treatment, in psoriatic patients treated with this molecule.

Observer agreement in toenail disorders: implications for diagnosis and clinical research.

BACKGROUND: Toenail disorders are frequent, especially onychomycosis. The interobserver variability of nail signs needs to be known before these signs can be confidently applied for diagnosis. OBJECTIVES: To describe observer agreement in toenail findings as described by dermatologists in standard clinical practice, focusing on signs that could be useful for diagnosis of onychomycosis. METHODS: Prospective cross-sectional study in five dermatology departments. Eighty-six patients with abnormal toenails that could have onychomycosis as a differential diagnosis were independently examined by a pair of dermatologists using a predefined questionnaire, to describe the presence of 10 findings on previous history and 14 physical signs. RESULTS: Agreement was fine for previous history findings: it was very good (kappa > 0.81) for previous diagnosis of diabetes, smoking and use of public dressing rooms or swimming pools. Agreement was good (kappa 0.61-0.80) for immune suppression (drugs or cancer), previous diagnosis of fungal disease and worsening in the last year. It was moderate (kappa 0.41-0.60) for previous diagnosis of arterial disease, trauma induced by work or sports, and distal vs. proximal or lateral vs. central start of the lesion. Agreement was worse for physical signs: we found good agreement for the presence of the same disease in fingernails, abnormal plantar desquamation, deformity causing nail trauma, and subungual hyperkeratosis. It was moderate for the presence of nail destruction, tinea interdigitalis, onycholysis, and the type of material obtained by subungual curettage (dust vs. hard). Agreement was fair (kappa 0.21-0.40) for the presence of longitudinal or transverse striae, trachyonychia, pachyonychia, and change in colour of the nail plate. Pitting was too infrequent to allow for kappa calculation. Chance expected agreement was between 51% and 84% for all signs except pitting. CONCLUSIONS: Agreement is adequate for most signs. It is low for the presence of longitudinal or transverse striae, trachyonychia, and change in colour of the nail plate. Pitting is rare in toenails.

Pelo lanoso posnatal: clave diagnóstica en la neuropatía axonal gigante / Postnatal Woolly Hair: A Key to Diagnosis in Giant Axonal Neuropathy

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Apocrine carcinoma with signet ring cells and histiocytoid features. A potentially confusing axillary tumor.

A case of carcinoma of the axillary apocrine gland in a 42-year-old man is reported. The cytomorphic features of this tumor on fine-needle aspiration closely resemble invasive lobular carcinoma of the breast. Both in situ, and invasive apocrine gland carcinoma were present within the excision specimen, and metastatic tumor was found in the axillary lymph nodes. On histologic, immunohistochemical and ultrastructural examination, the tumor was similar to invasive lobular carcinoma of the breast. The tumor cells analyzed by cytometry displayed a diploid pattern. Serial sections of the whole resected specimen failed to reveal breast parenchyma. To the best of our knowledge, this is the first case presented in axilla of an unusual variant of carcinoma of the skin, very similar or identical to six other cases located on the eyelids. The descriptive term "apocrine carcinoma with signet ring cells and histiocytoid features" is proposed in order to emphasize that these tumors are easily confused with benign conditions, mammary cancer and other metastatic carcinomas.