Cumulative incidence and risk factors for cutaneous squamous cell carcinoma metastases in organ transplant recipients: The Skin Care in Organ Transplant Patients in Europe-International Transplant Skin Cancer Collaborative metastases study, a prospective multicenter study.

INTRODUCTION: Solid organ transplant recipients (SOTRs) are believed to have an increased risk of metastatic cutaneous squamous cell carcinoma (cSCC), but reliable data are lacking regarding the precise incidence and associated risk factors. METHODS: In a prospective cohort study, including 19 specialist dermatology outpatient clinics in 15 countries, patient and tumor characteristics were collected using standardized questionnaires when SOTRs presented with a new cSCC. After a minimum of 2 years of follow-up, relevant data for all SOTRs were collected. Cumulative incidence of metastases was calculated by the Aalen-Johansen estimator. Fine and Gray models were used to assess multiple risk factors for metastases. RESULTS: Of 514 SOTRs who presented with 623 primary cSCCs, metastases developed in 37 with a 2-year patient-based cumulative incidence of 6.2%. Risk factors for metastases included location in the head and neck area, local recurrence, size > 2 cm, clinical ulceration, poor differentiation grade, perineural invasion, and deep invasion. A high-stage tumor that is also ulcerated showed the highest risk of metastasis, with a 2-year cumulative incidence of 46.2% (31.9%-68.4%). CONCLUSIONS: SOTRs have a high risk of cSCC metastases and well-established clinical and histologic risk factors have been confirmed. High-stage, ulcerated cSCCs have the highest risk of metastasis.

Basal cell carcinoma in a 17 year-old organ transplant recipient.

Skin cancer is among the most frequent cancers in pediatric organ transplant recipients. We report a 17-year-old Caucasian girl who had had a kidney transplant 6 years before and was referred to our outpatient clinic for a basal cell carcinoma of the scalp. This case emphasizes the importance of teaching sun-protective behavior to transplant recipients and their parents and having a high index of suspicion and arrange for early referral for dermatologic care if skin changes are observed.

Kaposi Sarcoma of the eyelid as an initial manifestation of AIDS.

Kaposi sarcoma (KS) is a multifocal systemic disease that originates in the vascular endothelium related to Human Herpes Virus 8 (HHV-8). In the early 1980s the first series of cases of disseminated Kaposi Sarcoma in HIV infected patients were reported. However, with the advent of highly active antiretroviral therapy (HAART) since 1997, these cases are less frequently observed by clinicians. We report the case of a 40-year-old woman, presenting with two asymptomatic purpuric nodules localized in the superior and inferior left eyelids, occluding the palpebral fissure, which were present for 4 months prior to presentation. The eyelid nodules were determined to represent KS, but there were no additional cutaneous lesions. Pulmonary and gastric KS involvement was documented. Antiretroviral therapy was initiated along with pegylated liposomal doxorubicin. The nodules gradually disappeared and her immune status eventually improved. Ocular and periorbital involvement of KS associated with HIV-1 infection as the initial clinical manifestations is a rare advent. This case is important as it illustrates that disseminated KS was not to be predicted by the number or the extension of cutaneous lesions.

Clinical and Epidemiological Characteristics of Mpox in HIV-Infected and Uninfected Men Who Have Sex with Men: A Retrospective Study in Lisbon.

The resurgence of Mpox, predominantly among men who have sex with men (MSM), has prompted an analysis of its clinical manifestations and epidemiological patterns, particularly in individuals living with human immunodeficiency virus (HIV). This retrospective study aims to delineate and compare the clinical presentations and epidemiological characteristics of Mpox among HIV-positive and HIV-negative individuals. A total of 58 confirmed Mpox cases from a dermatology department in Lisbon were analyzed, focusing on mucocutaneous manifestations, systemic symptoms, and laboratory parameters. Our findings indicate no significant difference in disease severity and presentation between HIV-positive and HIV-negative groups, suggesting that HIV status may not be a determinant of Mpox severity, but rather an indicator of increased sexual risk behaviors, a recognized risk factor for Mpox transmission.

Secondary syphilis mimicking inflammatory bowel disease.

This study reports the case of a 15-year-old male patient with extensive anal inflammation, cobblestone-like mucosa and areas of ulceration, loose bloody stool and weight loss for 8 weeks, suggestive of inflammatory bowel disease. Genital lesions of syphilides were later observed and Venereal Disease Research Laboratory test was positive, thus benzyl penicillin treatment was prescribed with total resolution of genital and bowel symptoms.

Molluscum contagiosum eyelid lesions in an HIV-patient.

Molluscum contagiosum (MC) lesions on the face are mainly observed in HIV patients and are related to low CD4 cells counts. We report a 41-year-old female patient infected with human immunodeficiency virus who had a CD4 count of 22 cells/mm³. She developed molluscum contagiosum lesions at the right upper eyelid. Skin biopsy was performed to exclude other serious conditions, such as dimorphic fungal infections. A good response was observed with three sessions of curettage and topical application of 70 percent trichloroacetic acid. Facial molluscum contagiosum lesions can be a cutaneous marker of severe immunosuppression in HIV patients and skin biopsy is important in ruling out the diagnosis of dimorphic fungal infections.

Emerging treatments for bullous pemphigoid.

Bullous pemphigoid (BP) is the most common autoimmune blistering disease. It is characterized by an immune response against the hemidesmosomal anchoring proteins BP180 and BP230. BP mainly affects elderly patients, with an increasing incidence over the past two decades. High potency topical and/or systemic corticosteroids as well as immunosuppressants are the current mainstay of treatment. However, long-term systemic immunosuppression may result in significant morbidity and mortality. Recent advances in the understanding of the pathogenesis of BP have enabled the investigation of newer therapies that specifically work against a variety of pro-inflammatory mediators associated with BP. These new treatments hold promise to be highly efficient and safer alternatives and are expected to be shortly available for the treatment of BP. This review discusses current evidence on the use of novel targeted therapeutic approaches in the treatment of BP.

Human monkeypox coinfection with acute HIV: an exuberant presentation.

Human monkeypox (MPX) is a zoonotic endemic disease in regions of Africa caused by the monkeypox virus, with a recent outbreak in several non-African countries. We report a case of a 24-year-old male patient with a concurrent diagnosis of MPX and acute HIV infection who presented to our Emergency Care Dermatology Clinic with disseminated papules throughout the trunk, face and genital area. On the perianal area, several grouped umbilicated whitish papules in a kissing lesion configuration could be seen. Laboratory workups were consistent with recent HIV infection, and swab samples from the lesion surfaces were positive for monkeypox virus. We provide novel information on the clinical presentation of MPX, expanding the data pool of the clinical manifestations of which health workers should be aware.

Monkeypox infection and bacterial cellulitis: a complication to look for.

Human monkeypox (MPX) is an endemic zoonotic disease in regions of Africa caused by the monkeypox virus, with recent outbreaks in several non-African countries. In this study, we present two cases of patients with MPX infection complicated by a deep skin infection. Both patients presented to our dermatology clinic with a clinical syndrome characteristic of MPX. The diagnosis was confirmed based on swabs of skin lesions. Both patients later returned to our clinic with erythema, pain, and edema at the site of previous papules and were diagnosed with deep skin bacterial infection. In this study we provide information on what we believe was an underreported MPX infection complication and give some advice on preventing cases of cellulitis in these patients.

Monkeypox Diagnosis by Cutaneous and Mucosal Findings.

A monkeypox outbreak has been reported in several countries since early May 2022. Human monkeypox (MPX) diagnosis is based on a clinical suspicion supported by typical skin and mucosal lesions, confirmed with molecular testing. We present the results of all MPX confirmed patients presenting to our department until July 15 of 2022, describing the characteristics of the lesions at diagnosis. In total, 47 patients were included, all men and 44.7% (n = 21) were HIV-positive. Skin lesions were noted in all patients. The most commonly affected area was the genital region (63.8%), followed by the anorectal region (46.8%). Extra anogenital mucosal (oral or conjunctival mucosa) involvement was reported in three patients. Typical skin findings included erythematous papules, whitish, umbilicated papules, some with a necrotic center and an elevated whitish border. Most patients had lesions in multiple phases presenting simultaneously. Correct identification of MPX skin and mucosal lesions is crucial to avoid late diagnosis and prevent further spreading, ensuring less worldwide morbidity.

Hydrochlorothiazide treatment and risk of non-melanoma skin cancer: Review of the literature. / Terapêutica com hidroclorotiazida e risco de cancro cutâneo não melanoma: revisão da literatura.

Non-melanoma skin cancer is the most prevalent malignancy in fair-skinned people and its incidence is increasing. Recently, studies have suggested that antihypertensive drugs may increase the risk of these tumors, particularly hydrochlorothiazide, due to its photosensitizing properties. The Portuguese National Authority for Medicines and Health Products, INFARMED, has issued an alert to healthcare professionals concerning the increased risk of non-melanoma skin cancer in patients exposed to cumulative doses of this drug. However, study results have been heterogeneous and sometimes conflicting. The high incidence of non-melanoma skin cancer and the large number of patients under chronic hydrochlorothiazide therapy may thus have important public health consequences. In this article, the authors review the published evidence and conclude that there may be an association between hydrochlorothiazide use and the risk of non-melanoma skin cancer, but also point out some limitations of the studies in the literature. It is important to promote preventive strategies against sun exposure, regular skin examinations, and individual assessment of the benefits of hydrochlorothiazide use, particularly in patients with previous skin cancer.

Acquired perforating dermatosis: clinicopathologic study of a 10-year period at a tertiary teaching hospital.

BACKGROUND: Acquired perforating dermatosis (APD) comprises an uncommon group of skin disorders that develop in adulthood in association with systemic diseases. The aim of this study was to characterize clinicopathologic features and treatment outcomes in a series of patients diagnosed with APD. METHODS: Retrospective study of all patients diagnosed with an APD over a 10-year period (2009-2018) at a tertiary teaching hospital in Lisbon, Portugal. RESULTS: Fifty-seven patients with APD were identified. Thirty-five patients presented lesions in multiple anatomic areas (61.4%), and the lower limbs were the most common location. Forty-six patients reported pruritus (80.7%), which was classified as severe in 21 of them (36.8%). An underlying systemic disease was identified in 53 patients (93.0%). Diabetes mellitus (DM) and chronic kidney disease (CKD) were the most common associated systemic diseases, but psychiatric disorders, malignancies, and chronic infections were present in a significant number of patients. The combination of topical steroids with antihistamines was the most prescribed initial treatment, but only 37.8% of the patients had a complete response. Acitretin, systemic steroids, and phototherapy were the treatments associated with the best outcome. CONCLUSION: Acquired perforating dermatosis can be associated with many systemic disorders that have pruritus as a common factor. Chronic viral infections and an occult malignancy should be sought, particularly in the absence of DM and CKD. The management of APD is challenging and is best achieved with the control of the underlying systemic diseases.

Successful Treatment with Fusidic Acid in a Patient with Folliculitis Decalvans.

Dear Editor, Folliculitis decalvans (FD) is a rare form of primary neutrophilic cicatricial alopecia. It is a highly distressing disease that affects young and middle-aged adults, with a slight male predominance (1). The most frequent clinical manifestations are follicular pustules and diffuse and perifollicular erythema that heal with centrifugal scarring. Follicular tufting, erosions, and hemorrhagic crusts can also be present, and this alopecia is most often located at the vertex and occipital area. Patients frequently complain about pain, itching, or burning sensations, and the involvement of other body areas is rare (2). The pathogenesis of this disease remains unclear. Staphylococcus aureus and other hair follicle bacteria can often be isolated from the pustules, suggesting the role of a bacterial infection in its etiology. A defect in the host's immune response can also be postulated by reports of familial cases and the appearance of FD in patients with immunity dysfunctions. Other mechanical factors have been suggested, such as structural abnormalities of the follicle or local inflammation (2). Management of this alopecia is difficult and its course is typically chronic and relapsing. The treatment aim is to stop inflammation and further irreversible destruction of hair follicles. Antibiotics remain the first-line therapy, due both to their anti-inflammatory and antimicrobial properties (1). Although topical fusidic acid is widely used as adjuvant treatment, there are few data regarding its oral use. We report a case of folliculitis decalvans successfully treated with oral fusidic acid. Our patient was a 41-year old Cape Verdean woman with a two month history of alopecia with painful, purulent discharge at the vertex of the scalp. The patient was diagnosed with human immunodeficiency virus type 1 (HIV-1) infection 5 years prior and was stable on her regimen of efavirenz, tenofovir, and emtricitabine, with undetectable viral load. She denied application of topical or capillary products. Dermatological examination revealed a patch of cicatricial alopecia with crusts and follicular pustules (Figure 1). Direct microscopic examination and mycological culture showed no fungal element. A diagnosis of folliculitis decalvans was established and the patient was started on oral fusidic acid at a dose of 500 mg three times a day. Betamethasone dipropionate 0.05% and salicylic acid 3% lotion as well as azelaic acid 5% lotion were also applied to the affected area once daily. After two months of treatment, the patient showed clinical improvement, with less erythema and suppuration of the affected scalp. A partial hair regrowth was noted, mainly at the periphery. Subsequently the patient maintained only topical therapy, and no recurrences were observed after 6-months of follow-up. Fusidic acid is useful in the treatment of skin and soft tissue infections, particularly those due to S. aureus, as shown by randomized controlled studies (3). The clinical efficacy of fusidic acid in the treatment of folliculitis decalvans has been reported previously. Bogg was the first to describe this useful effect (4). Sutter also reported good results with fusidic acid used both topically and orally (500 mg three times a day) (5). However, both failed to report the treatment duration or the outcome on discontinuation. Abeck described three patients that responded to a three week oral course of fusidic acid (500 mg three times a day) and to a maintenance treatment with zinc sulfate (4). During the following year, recurrence was observed in only one patient after ending zinc sulfate therapy. Oral antibiotics are frequently used to treat folliculitis decalvans. Tetracyclines and the combination of clindamycin with rifampicin are the most commonly used (2). However, the disease usually progresses when treatment is stopped. Fusidic acid is an anti-staphylococcal drug with few adverse effects. It is highly bioavailable orally, and has a long plasma half-life. Despite years of clinical use in numerous countries, resistance rates remain at low levels to date (6). Since clinical series or cases including ours have shown good results, this drug should not be forgotten when considering treatment options for folliculitis decalvans.

Skin Diseases in the Era of Highly Active Antiretroviral Therapy: A Retrospective Study of 534 Patients.

BACKGROUND: With the increasing number of HIV-infected patients receiving highly active antiretroviral therapy (HAART), the shift in their dermatologic profile becomes less characteristic of AIDS-defining illnesses. METHODS: Retrospective review of mucocutaneous pathology among patients seen at HIV-Dermatology Clinic from January 2009 to December 2013. RESULTS: Among 534 patients, there were 68.4% males and 31.6% females, with 8.7-year average duration of infection; 82.8% were receiving HAART. Kaposi sarcoma was the only relatively frequent AIDS-defining disease. Fungal and viral infections were common, with human papilloma virus (HPV) as the most frequent overall. Benign and premalignant tumors were associated with HAART and CD4 >200/mm3 ( P < .05). Psoriasis was prevalent among patients without HAART ( P < .05). Prurigo was associated with lower CD4 count ( P < .001). CONCLUSION: Patients receiving HAART are faced with chronic skin problems such as benign and premalignant tumors, and HPV infection adds to their neoplastic predisposition. Further research is recommended to develop protocols for treating psoriasis and screening for HPV-associated neoplasia among patients.

[Skin Diseases in Africans]. / Dermatoses em Africanos.

Nowadays, due to the increasingly frequent migratory circuits in Europe and the increment of the migrant population in Portugal, mainly in the Lisbon metropolitan area, it is more and more common to find several dermatological conditions and disorders in Africans seen in our health care system. There are few studies on dermatoses in these populations. It is important to know the biologic and physiologic differences of black skin in order to understand both the pathophysiology and manifestations of dermatoses. The recognition of many of them represents a challenge to any clinician due to the specific characteristics of their skin. It is thus essential to know the different patterns and frequencies of skin diseases in Africans, in order to optimize the diagnosis, approach and treatment.

Atualmente, devido aos circuitos migratórios cada vez mais frequentes na Europa e consequente aumento da população migrante em Portugal, principalmente na área metropolitana de Lisboa, é cada vez mais comum depararmo-nos com diversas patologias dermatológicas nos indivíduos africanos que recorrem ao sistema de saúde. Existem poucos estudos sobre dermatoses nesta população.É importante conhecer as diferenças biológicas e fisiológicas da pele negra, de modo a compreender a fisiopatologia e a manifestação das dermatoses. O diagnóstico de muitas delas constitui um desafio para qualquer clínico devido às características especificas da sua pele. É essencial conhecer os diferentes padrões e frequências das doenças cutâneas em africanos, de modo a otimizar os seus diagnóstico, abordagem e tratamento.

Hepatitis C virus infection: 'beyond the liver'.

There are rare reports of association between hepatitis C virus (HCV) infection and dermatomyositis although cause and effect remains to be proven. We present a clinical case with a probable cause and effect association between these two entities. A 71-year-old woman developed an erythematous exanthem with pruritic and scaly lesions located at the torso and upper limbs associated with heliotrope and Gottron's papules. At the same time, she notice a significant loss of muscular strength. Skin and muscular biopsies made the diagnosis of dermatomyositis and the patient started with prednisolone (60 mg/day) with poor symptoms control. Paraneoplastic syndrome, HIV, hepatitis B virus and syphilis infections were excluded. HCV serology was positive, with a viral load of 58 159 IU/mL (genotype 1a). Therefore, the patient underwent a 12-week treatment with grazoprevir 100 mg and elbasvir 50 mg achieving a sustained virological response with regression of skin lesions and complete recovery of muscular strength (photodocumented before/after treatment). Additionally it was possible to reduce prednisolone dosage to 5 mg/day.

Nonvenereal Penile Dermatoses: A Retrospective Study.

CONTEXT: A variety of nonvenereal diseases can affect the penis and diminish quality of life. Many present similar clinical features and a cutaneous biopsy may be necessary to clarify the diagnosis. AIMS: To characterize nonvenereal penile dermatoses with histological confirmation in a southwestern Europe hospital during a 9-year period. MATERIALS AND METHODS: A retrospective study was conducted. We reviewed all penile biopsies performed between January 1, 2007 and December 31, 2015 and studied the causes of the nonvenereal penile dermatoses. RESULTS: The sample included a total of 108 patients, aged 62.9 (±17.8) years, between 16 years and 96 years of age. Eighteen dermatoses were identified. Inflammatory diseases were present in 65. 7% of patients (71/108) and neoplastic dermatoses in 34. 3% (37/108). Concerning inflammatory dermatoses, the most frequent were Zoon balanitis (27.8%, 30/108), followed by lichen sclerosus (15.7%, 17/108), psoriasis (11.1%, 12/108), and lichen planus (4.6%, 5/108). In patients with psoriasis, 10 had lesions only in the penis, similarly to all patients with lichen planus. The most frequent malignant tumor was squamous cell carcinoma (SCC) (15.7%, 17/108). The most common in-situ tumor was erythroplasia of Queyrat (8.3%, 9/108). A case of basal cell carcinoma (BCC) was found. Kaposi sarcoma and mycosis fungoides on penis were also diagnosed, as an additional form of presentation to their generalized disease. CONCLUSIONS: In this study, inflammatory diseases were the most frequently diagnosed dermatoses, while SCC was the most common malignant tumor found. In the majority of psoriasis and lichen planus cases, clinical lesions were only present in the genital area.