Preventing melasma recurrence: prescribing a maintenance regimen with an effective triple combination cream based on long-standing clinical severity.

BACKGROUND: The relapsing nature of melasma emphasizes the need to maintain efficacy achieved after acute treatment. OBJECTIVE: To compare clinical efficacy and safety of two 6-month Triple Combination (TC; containing fluocinolone acetonide, hydroquinone and tretinoin) maintenance regimens in subjects with moderate to severe melasma, after daily treatment up to 8 weeks. METHODS: This randomized, investigator-blinded, controlled study had a maintenance phase of 6 months. Sixteen centres in Brazil and Mexico enrolled 242 subjects 18 years or older attaining no or mild melasma after 8 weeks of daily TC applications. Subjects were randomized to receive TC in a twice weekly or tapering regimen [3/week (1st month), 2/week (2nd month), 1/week (4th month)]. Efficacy and safety measurements included median time to relapse and relapse-free rate, Global Severity Score, Melasma Area and Severity Index score (MASI), subject's assessment, quality of life questionnaire (MelasQol), and adverse events. RESULTS: The majority (78.8%) had no or mild melasma (GSS ≤ 1) at week 8 and entered maintenance phase. After 6 months, 53% of patients remained relapse-free with improved quality of life, and time to relapse was similar between groups (about 190 days). Melasma severity at study entry, not maintenance baseline, influenced relapse rate. The twice weekly regimen tended to show better effectiveness in postponing relapse in severe melasma. Both regimens were safe. CONCLUSIONS: After resolution of melasma with TC, maintenance therapy over 6 months was successful in preventing relapse in over half of the patients who entered maintenance phase. Prescribing medicines should be adapted to patients based on melasma severity.

Trichophyton raubitschekii: a new agent of dermatophytosis in Brazil?

A microbiological and ultrastructural study of Trichophyton raubitschekii recovered from a patient with tinea faciei is presented. This is the second case of isolation of this fungus in Sao Paulo and the sixth case in Brazil. Upon culture, the morphological pattern and the physiological tests performed confirmed the identification of T. raubitschekii. The ultrastructural study of T. raubitschekii showed the presence of a membrane-like structure located in the outer portion of the hyphal walls. This structure was bi-stratified and very like the one observed in T. rubrum. Is T. raubitschekii a new fungus emerging in Brazil or is it a T. rubrum variant?

[Neurocutaneous melanosis. Case report of a malignant melanoma of the central nervous system]. / Melanose neurocutânea. Relato de caso com melanoma maligno do sistema nervoso central.

The neurocutaneous melanosis is a rare syndrome in which the congenital melanocytic nevi and excessive melanosis are the main features. The syndrome seems to be a morphogenesis error of the embryonic neuroectoderm. A clinical case with necroscopy in a 19 year-old man who had developed malign melanoma in his central nervous system is reported.

[Primary cutaneous malignant melanoma: retrospective studyfrom 1963 to 1997 at Hospital do Servidor Público Estadual de São Paulo]. / Melanoma maligno cutâneo primário: estudo retrospectivo de 1963 a 1997 no Hospital do Servidor Público Estadual de São Paulo.

OBJECTIVES: A retrospective study on the Primary Cutaneous Malignant Melanoma in the Hospital do Servidor Público Estadual de São Paulo (HSPE-SP) analyzing its distribution according to age, sex, race and cutaneous site. METHODOLOGY: We studied 222 patients with Primary Cutaneous Malignant Melanoma as diagnosed at Hospital do Servidor Público Estadual de São Paulo, Brazil between the period from 1963 to 1997. A retrospective study was performed. Data were expressed as inance of caucasians (98.19%) over afro-americans (1.81) and of the female sex (69.36%) over the male sex (30.63%) was found. The predominant age on the occasion of the diagnosis was between 50 and 60 years for the women (25.32%) and between 60 and 69 years for the men (22.52%). The most frequent site of the cancer in men was the back region (29.41%) and in the lower members in the women (38.31%). The most frequent level of the tumor invasion (Clark) was IV (39.77%), and the average of tumor thickeness (Breslow) was < 0.75 mm (28.4%). A 5 years survival was observed in 73.3% of the patients. CONCLUSIONS: At our Hospital the incidence of Primary Cutaneous Malignant Melanoma has shown an increase in recent years; these results are compatible with the most recent international surveys.

[Urticaria and systemic diseases]. / Urticária e doenças sistêmicas.

Chronic urticaria and concurrent angioedema are disappointing problems for both physicians and patients. The disease can result from multiple causes and probably does not have a single etiology. Several factors have been identified that appear to be important in the pathogenesis of individual cases, some drugs, food additives, physical factors and internal diseases. In some cases no pathogenesis are identified and those cases are classified as idiopathic. In recent years several articles has emphasized autoimmunity and infections due to Helicobacter pylori. Our article reviewed the etiology of chronic urticaria at current concepts.

[Erythema cinitiensis perstans]. / Erythema cinitiensis perstans.

The authors report a case of Erythema Cinitiensis Perstans, in a thirty-one years old white man. This dermatosis, reported in the literature also es Ashy Dermatitis and Erythema Dyschromicum Perstans, is here in Brazil exceptional. Clinically this dermatosis is characterized by the presence of gray patches in a sometimes surrounded by an erythematous active border. The lesions may occur on any area of the integument, sparing the hair scalp, palms, soles and nails. The therapy has been ineffective in all the cases, but one reported by Stevenson and Miura and in our case, where the patients have improved after Dithiazanine iodide treatment due to intestinal parasitoses by the Tricocephalus trichiurus.

[Yellow nail syndrome; Samman-Emerson syndrome]. / Sindrome da unha amarela. Sindrome de Samman-Emerson.

The authors make a description of a case of the yellow nail syndrome. They look over the literature about such cases again and they agree with the denomination suggested by Rabello of Samman and Emerson syndrome.

[Apocrine hidrocystoma]. / Hidrocistoma apocrino.

One case of multiple apocrine hidrocystomas is reported with localization at the eyelids. The authors emphasises the character of multiple lesions, once the apocrine hidrocystoma is generally solitary. Surgical treatment is indicated with excellent results.

[Large cell acanthoma]. / Acantoma de células grandes.

The authors relate a clinical case of large cell acanthoma with multiple lesions that predominate on the inferior limbs. They comment the nosological position, the clinical aspects and, concerning the histopathology, emphasize the enlarged dimensions of the cellular nuclei in acanthoma and the differential diagnosis. Probably, the large cell acanthoma is a much more frequent entity that has not been diagnosed due to the little knowledge of this pathology.

[Treatment of chromomycosis with liquid nitrogen]. / Tratamento da cromomicose pelo nitrogenio liquido.

Five patients with chromomycosis have been treated by liquid nitrogen application. The evolution of disease has been of one to twenty five years, with 4 patients with verrucous patches and one patient with sarcoid-like lesion. In all cultures grows-up Fonseca pedrosi. The authors believe that this method of treatment has advantage to be more economic, to avoid hospitalization and surgical acts with anesthesia, and also could be realized at ambulatory level. The efficacy of this method has been proved by the follow-up the patients during a period between two to four years, without any recurrency.

[Malignant melanoma (review of 68 cases)]. / Melanoma maligno (revisão de 68 casos).

A clinica pathologic revision was performed about 68 patients with malignant melanoma of the Hospital dos Servidores Publicos do Estado de São Paulo. The authors had checked the data concerning to color, age and sex of the patients, localisation, clinical aspect of the lesions and clinical evolution of the cases. They made comments on the histopathology related to Clark's levels, the depth of tumors (Breslow), solar elastosis and inflammatory infiltrate, in relation with the clinical evolution of the cases.

[Poikiloderma congenitale of the Kindler type associated with multiple seborrheic warts]. / Poiquilodermia congênita tipo Kindler associada a verrugas seborreicas múltiplas.

A case an eleven year old girl with congenital poikiloderma, generalized xerosis and cutaneous atrophy, recurrent blister in extremities, sclerosis of the fingers and toes diffuse hyperkeratosis of palms and soles and webbing between some toes is reported here. Multiple seborrheic keratosis were also found, an association hitherto not mentioned with congenital poikiloderma.

[Clinico-pathological evaluation of keloids treated with intralesional injections of corticoid]. / Avaliação clinico-patológica de quelóides tratados por infiltrações intra-lesionais de corticóide.

37 keloid patients were treated with triamcinolone intralesionally every 15 days, in all 6 inoculations. Histologically after the treatment we observed alterations in dermal vascularization, in morphology, in color characteristics and in the arrangement of the collagen bundles. The disappearance of mucin and the presence of palisade granulomas was observed in some cases probably because of the corticoid deposited. There was regression of pruritus and pain in all the patients. We believe that the intralesionally infiltration of corticoid is even today one of the best methods of treatment, and it may also be effected together with other technics.

[Incidence pityriasis rosea of Gibert in the Dermatology Service of the Hospital do Servidor Público in the state of São Paulo]. / Incidência da Pitiriase Rósea de Gibert no Servico de Dermatologia do Hospital do Servidor Público do Estado de São Paulo.

The authors present a retrospective study on the incidence of Pitiriase Rosea in the Dermatology Department of the Hospital do Servidor Público do Estado de São Paulo, covering a 17 years span. Figures concerning race, sex, age, mensal and anual incidence as well the distribution in the seasons of the year are analysed.

[Congenital Horner syndrome]. / Síndrome de Horner congénita.

The authors report a case of congenital Horner's syndrome. Through ophthalmological tests, it is realized a comparative study between a patient with congenital Horner's syndrome and a patient who is a carrier of this syndrome acquired by a cervical sympathectomy. We have come to the conclusion that possibly there is a congenital lesion ea the third sympathetic neuron.

[Lichen striatus. Epidemiologic study]. / Lichen striatus. Estudo epidemiológico.

The authors are showing a retrospective study of 53 cases of lichen striatus concerning sex, colour, age, place of lesions, associated diseases and period of the year of occurrence of the dermatosis. There was a larger number of cases in females of white race and age-between 2 and 5 years old. A greater occurrence was observed in the months of September and March which correspond to spring and summer. Adding the fact that there have been more cases in children, at times in brothers and the trend to spontaneous involution, the authors suggest the possibility of a virus as etiology to this entity.

[Atrophodermia vermiculata]. / Atrofodermia vermiculata.

The authors present a case of Atrophodermia vermiculata, a very uncommon disease. The authors also suggest the inclusion of the disease in the group of "Keratosis pilaris atrophicans" or shortly an the "Keratosis pilaris".

Keratosis lichenoides chronica: report of a case developing after erythroderma.

A 66-year-old male presented with keratosis lichenoides chronica after a presumed drug-induced erythroderma. After resolution of the erythroderma, slightly scaly erythematous and violaceous papules in a reticular arrangement over the trunk and limbs developed in association with hoarseness, palmoplantar keratoderma, onycholysis and subungual keratosis. Histology from a lichenoid lesion showed pseudo-epitheliomatous hyperplasia, hyperorthokeratosis, parakeratosis, dyskeratosis, neutrophil exocytosis and focal vacuolar degeneration of the basal layer of the epidermis. There was a band-like chronic inflammatory infiltrate in the upper dermis. The skin improved with prednisone 40 mg/day for 15 days, leaving atrophic hypopigmented scars. A diagnosis of keratosis lichenoides chronica was made.

Lichen sclerosus--a keratotic variant.

We describe an unusual case of keratotic lichen sclerosus with extragenital and genital lesions in a 34-year-old Brazilian man. The disease was characterized by several erythematous and brownish keratotic papules on the man's back, trunk and extensor areas of the limbs; histologic findings were typical of lichen sclerosus. Others atypical extragenital forms of lichen sderosus are discussed.