Evaluation of serum levels of C-reactive protein, D-Dimer and Autologous Serum Skin Test in patients with Chronic Spontaneous Urticaria in a Brazilian tertiary center : a cross-sectional study.

BACKGROUND: The pathophysiology of urticaria is still poorly understood. Recent studies demonstrate that the activation of coagulation is correlated with the clinical activity of Chronic Spontaneous Urticaria. Coagulation and inflammation are strongly linked. OBJECTIVES: To correlate the severity and activity of Chronic Spontaneous Urticaria with the levels of D-dimer, C-reactive protein, and autologous serum test in patients with Chronic Spontaneous Urticaria. METHODS: The study included 55 patients diagnosed with chronic spontaneous urticaria. D-dimer levels were measured using enzyme-linked fluorescent assay and C-reactive protein levels were measured using the nephelometric method; autologous serum testing was performed on patients who discontinued antihistamine therapy. The severity of the disease was assessed using the urticaria activity score. RESULTS: patients with severe, spontaneous, and difficult-to-control chronic urticaria had elevated serum levels of D-dimer, as well as a positive autologous serum test. Little correlation was demonstrated between the severity of chronic spontaneous urticaria and the levels of C-reactive protein. CONCLUSION: The authors concluded that patients with severe Chronic Spontaneous Urticaria showed signs of activated fibrinolysis. Most patients with high clinical scores had high D-dimer values. Patients with positive results for the autologous serum test also had more severe Chronic Spontaneous Urticaria and needed more drugs to control the disease. Finally, little correlation was found between C-reactive protein levels and disease severity. STUDY LIMITATIONS: The main limitation was the small sample of patients. In the present patients, it was demonstrated that serum D-dimer levels and the autologous serum test can act as predictive markers of severity and activity of Chronic Spontaneous Urticaria.

What lessons can we learn? Clinical and epidemiological retrospective analysis of 267 patients with urticaria in a Brazilian tertiary center.

BACKGROUND: There are few epidemiological studies of urticaria, published in the indexed literature (PubMed/Medline). OBJECTIVE: The study aimed to evaluate the epidemiological and clinical data among patients with urticaria/angioedema attending a reference clinic in Brazil. METHODS: Two hundred sixty-seven patients were evaluated retrospectively considering demographic data, time course of the disease, triggering symptoms, the presence of angioedema, complementary laboratory tests including total blood count, reactive-C protein, erythrocyte sedimentation rate, IgE serum levels, and other, as necessary. RESULTS: The most commonly diagnosed type of urticaria was chronic spontaneous urticaria (56.93%). Angioedema was associated with chronic urticaria in 108 patients (40.08%). STUDY LIMITATIONS: Unicentered and retrospective. CONCLUSION: Some relevant findings in this study are the observation of a female prevalence of cases (4-females: 1-man), a result more elevated than demonstrated in previous studies in Europe and Asia, the median age was 43-years old and the delay of time between the diagnosis of urticaria and the admission for treatment in a specialized center was approximately 2-years. Other multicenter studies can better establish these differences in Brazilian patients.

Keep it simple. A ten-year experience in reconstructions after Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery is worldwide used for treating skin cancers. After obtaining tumor-free margins, choosing the most appropriate type of closure can be challenging. OBJECTIVES: Our aim was to associate type of surgical reconstructions after Mohs micrographic surgery with the characteristics of the tumors as histological subtype, anatomical localization and especially number of surgical stages to achieve complete excision of the tumour. METHODS: Transversal, retrospective analyses of medical records. Compilation of data such as gender, age, tumor location, histological subtype, number of stages to achieve clear margins and type of repair used. RESULTS: A total of 975 of facial and extra-facial cases were analyzed. Linear closure was the most common repair by far (39%) and was associated with the smallest number of Mohs micrographic surgery stages. This type of closure was also more common in most histological subtypes and anatomical locations studied. Using Poisson regression model, nose defects presented 39% higher frequency of other closure types than the frequency of primary repairs, when compared to defects in other anatomic sites (p < 0.05). Tumors with two or more stages had a 28.6% higher frequency of other closure types than those operated in a single stage (p < 0.05). STUDY LIMITATIONS: Retrospective study with limitations in obtaining information from medical records. The choice of closure type can be a personal choice. CONCLUSIONS: Primary closure should not be forgotten especially in surgical defects with fewer stages and in non-aggressive histological subtypes in main anatomic sites where Mohs micrographic surgery is performed.

Clinical variability of the GJB4:c.35G > A gene variant: a study of a large Brazilian erythrokeratodermia pedigree.

BACKGROUND: Erythrokeratodermas are a heterogeneous group of keratinization disorders. They are inherited in both autosomal dominant and autosomal recessive pattern. Erythrokeratoderma variabilis et progressive (EKVP) is a disorder caused by variations in genes that codify connexins (GJA1, GJB3, GJB4). The distinction between different phenotypes is not always simple. Age of presentation varies from birth to adulthood; stationary or migratory erythematous plaques associated with nonmigratory hyperkeratosis are characteristic of this disorder. Nails, hair, and teeth are not affected. METHODS: In order to describe the clinical phenotypes and molecular findings in a large Brazilian pedigree affected by erythrokeratoderma, we performed a clinical evaluation of four patients with different presentations of erythrokeratoderma from the same family, in which there are 35 affected members distributed in six generations. Genomic DNA evaluation by Sanger sequencing of GJB3 and GJB4 was performed in two affected family members with different phenotypes. RESULTS: Clinical heterogeneity in affected patients was remarkable. In patients investigated with genetic testing, a heterozygous pathogenic gene variant in the GJB4 (gap junction protein beta-4) gene was found positive for GJB4:c.35G>A (rsrs80358211). One patient also presented a synonymous variant in GJB3:c.357C>T (rs41310442). CONCLUSION: Variants in GJB4 are classically associated with Erythrokeratodermia variabilis, but there is remarkable clinical heterogeneity. Our observation that the same variant caused different phenotypes within the same family corroborates clinical heterogeneity and suggests that other genes that compose the genetic background exert some influence on the disease phenotype.

Dosages of androgenic hormones in adolescent patients with severe acne.

OBJECTIVE: Acne vulgaris in female adolescents, when severe or accompanied by other signs of androgenization, may represent a sign of hyperandrogenemia often underdiagnosed, which will have harmful consequences for adult life. The objective of this cross-sectional and retrospective study was to demonstrate the incidence of hormonal changes in the cases of female adolescents with severe or extensive acne, with or without other signs of hyperandrogenism, and propose a hormonal research pattern which should be indicated in order to detect early hyperandrogenemia. METHODS: The medical records of 38 female patients aged between 9 and 15 years old with grade II and/or III acne were analyzed. The dehydroepiandrosterone sulfate, dehydroepiandrostenedione, and androstenedione, total testosterone, and dihydrotestosterone sulfate hormones were required prior to initiation of treatment. The hormonal dosages were performed in the serum after at least 3 hours of fasting by means of radioimmunoassay tests. RESULTS: Of the 38 patients included, 44.7% presented changes in androgen levels (hyperandrogenemia), and the two most frequently altered hormones were DHEA and androstenedione, with the same incidence (23.6%). CONCLUSIONS: The correct and early diagnosis provides an effective and agile approach, including antiandrogen therapy, with the purpose of avoiding the reproductive and metabolic repercussions, besides controlling the inflammatory picture and avoid aesthetic complications.

Plantar fibromatosis: Surgical approach of a giant bilateral case.

BACKGROUND: Plantar fibromatosis or Ledderhose disease is characterized by a benign fibroblastic proliferation of the plantar fascia. It is an illness with unknown etiology and a complex treatment in its most intense manifestation. OBJECTIVE: The authors describe a surgical option for extensive cases where conservative treatments are not successful. Surgical techniques may vary according to the site and extent of the lesions. METHODS: Surgical treatment with wide resection of the lesion and second intention healing using a hydrocolloid dressing. RESULTS: After a 3-year follow-up with no recurrence, the authors demonstrated an excellent result, which led to an important improvement in the patient's quality of life. CONCLUSION: Surgical treatment can be a good option for plantar fibromatosis. Giant lesions can be treated with wide excisions and second intention healing, with low risk of aesthetic and functional complications.

Dosages of androgenic hormones in adolescent patients with severe acne

SUMMARY OBJECTIVE Acne vulgaris in female adolescents, when severe or accompanied by other signs of androgenization, may represent a sign of hyperandrogenemia often underdiagnosed, which will have harmful consequences for adult life. The objective of this cross-sectional and retrospective study was to demonstrate the incidence of hormonal changes in the cases of female adolescents with severe or extensive acne, with or without other signs of hyperandrogenism, and propose a hormonal research pattern which should be indicated in order to detect early hyperandrogenemia. METHODS The medical records of 38 female patients aged between 9 and 15 years old with grade II and/or III acne were analyzed. The dehydroepiandrosterone sulfate, dehydroepiandrostenedione, and androstenedione, total testosterone, and dihydrotestosterone sulfate hormones were required prior to initiation of treatment. The hormonal dosages were performed in the serum after at least 3 hours of fasting by means of radioimmunoassay tests. RESULTS Of the 38 patients included, 44.7% presented changes in androgen levels (hyperandrogenemia), and the two most frequently altered hormones were DHEA and androstenedione, with the same incidence (23.6%). CONCLUSIONS The correct and early diagnosis provides an effective and agile approach, including antiandrogen therapy, with the purpose of avoiding the reproductive and metabolic repercussions, besides controlling the inflammatory picture and avoid aesthetic complications.

RESUMO OBJETIVO A acne vulgar em adolescentes do sexo feminino, quando grave ou acompanhada de outros sinais de androgenização, pode representar um sinal de hiperandrogenemia muitas vezes subdiagnosticado, que acarretará consequências danosas para a vida adulta. O objetivo deste estudo transversal e retrospectivo foi demonstrar a incidência das alterações hormonais nos casos de adolescentes do sexo feminino com acne grave ou extensa, acompanhada ou não de outros sinais de hiperandrogenismo e propor um padrão de pesquisa hormonal que deve ser indicado com o intuito de detectar precocemente o quadro de hiperandrogenemia. MÉTODOS Foram analisados os prontuários de 38 pacientes do sexo feminino com idades entre 9 e 15 anos, portadoras de quadro de acne grau II e/ou III. Os hormônios sulfato de dehidroepiandrostenediona, dehidroepiandrostenediona, androstenediona, testosterona total e dehidrotestosterona foram solicitados antes do início do tratamento. As dosagens hormonais foram realizadas no soro após pelo menos 3 horas de jejum por meio de exames de radioimunoensaio. RESULTADOS Das 38 pacientes incluídas, 44,7% apresentaram alterações dos níveis de andrógenos (hiperandrogenemia), sendo que os dois hormônios mais frequentemente alterados foram o DHEA e androstenediona, com a mesma incidência (23,6%). CONCLUSÕES O diagnóstico correto e precoce propicia uma abordagem efetiva e ágil, incluindo a terapia antiandrogênica, com a finalidade de evitar as repercussões reprodutivas e metabólicas, além de controlar o quadro inflamatório e evitar complicações estéticas.

Epidermal curettage technique (ECT) for tissue harvest from the donor area for melanocyte autologous grafting in cases of vitiligo.

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.

A study of clinical profiles of vitiligo in different ages: an analysis of 669 outpatients.

INTRODUCTION: Vitiligo is a skin disorder characterized by achromic macules (white) on the skin and/or mucous membranes, which affects 0.5-2% of the population. Few publications address a vitiligo epidemiological profile worldwide. In Brazil there are only studies in children. OBJECTIVE: To assess the clinical and epidemiological profile of individuals affected by vitiligo and to evaluate behavior of the disease in different age groups. MATERIALS AND METHODS: We conducted a retrospective cross-sectional study in 669 patients with vitiligo from January 2001 to May 2006, who attended the Faculty of Medicine of ABC, located in the metropolitan region of São Paulo, Brazil. RESULTS: There was a predominance of females (62.2%) and adult age group (62.5%), with higher prevalence peaks between the second and third decades of life (18.3% and 16.9%, respectively). The most frequent phototype in skin was III (49.9%). Lesions began on the face most commonly in children and adolescents (32.6%) and the elderly (23.3%), and on hands in adults (24.0%). There was a higher prevalence of segmental vitiligo in children and adolescents (36.4%), compared with adults (11.3%) and the elderly (6.7%), and vitiligo with stable evolution was proportionately more frequent in childhood and adolescents (46.2%) than in adults (32.5%) and elderly (36.7%). CONCLUSIONS: Our findings are similar to other countries, mainly regarding the higher prevalence of segmental vitiligo and vitiligo with stable development among children and adolescents.

Necrose cutânea do tecido enxertado decorrente de tabagismo / Necrosis of skin graft entailed by smoking habits

A cicatrização adequada das feridas cirúrgicas é influenciada pela técnica operatória, pela presença de intercorrências pós-cirúrgicas e pelos hábitos de vida do paciente. Relatamos caso de paciente submetido a exérese de carcinoma basocelular por cirurgia micrográfica de Mohs e reconstrução com enxertia cutânea palpebral. No pós-operatório houve necrose do enxerto devido má perfusão do leito cirúrgico imputada ao tabagismo. O tabagismo interfere na embebição plasmática e neovascularização do enxerto, além de promover estresse oxidativo e disfunção endotelial. O cirurgião deve orientar a suspensão do tabagismo por pelo menos quatro semanas antes do procedimento, a fim de evitar maiores riscos de complicações.

Adequate healing of surgical wounds is influenced by the operative technique, the presence of postoperative complications, and the patient's life style. The authors of the present paper report the case of a patient who underwent excision of a basal cell carcinoma by Mohs micrographic surgery and reconstruction with palpebral skin grafting. The graft necrosed in the postoperative period due to poor perfusion of the surgical bed, correlated to smoking habits. Smoking interferes with plasma perfusion and graft neovascularization, and promotes oxidative stress and endothelial dysfunction. Surgeons should recommend the cessation of smoking for at least 4 weeks prior to the procedure in order to avoid further risks of complications.

Action of topical mometasone on the pigmented halos of micrografting in patients with vitiligo.

BACKGROUND: Vitiligo is a prevalent skin pigmentation disorder worldwide. The treatments available still offer limited results to some patients. For patients with clinically stable vitiligo, melanocyte transplantation is an appropriate treatment option, and the technique of autologous punch grafting shows good repigmentation. OBJECTIVE: To evaluate the effect of topical mometasone on the halos of repigmentation after autologous punch grafting in patients with clinically stable vitiligo. METHODS: Between 2009 and 2010, 11 patients with clinically stable vitiligo (7 generalized, 2 focal and 2 segmental) underwent autologous punch grafting in the achromic patches. According to the clinical type of vitiligo, patients were instructed to use the corticosteroid ointment during 6 months, only on a few grafted lesions. In the first month, the mometasone ointment was used twice a day and after that just once. They were reassessed 1, 3 and 6 months after the procedure. Grafted halos were photographed and recorded using the software fotofinder. After 6 months, all the treated and untreated areas of the repigmentation halos were measured and analyzed comparatively. RESULTS: The median area of the repigmentation halos after 6 months of treatment with mometasone was larger (25,96 mm(2)) than the one of the untreated halos (13,86 mm(2)), showing a statistically significant difference (p = 0,026). CONCLUSION: In this study, the use of mometasone ointment increased the area of the repigmentation halos after punch grafting. However, this should be further investigated in larger samples in order to validate this positive action in the treatment of stable vitiligo.

Comparative dermatology: blue nevus.

There are elements in nature that may be compared to some dermatological lesions, such as the black pearl, which is very similar to a cellular blue nevus observed in the gluteus region of a 31-year-old male patient.

Aplicação de ácido poli-l-lático para o tratamento da flacidez corporal / Poly-L-lactic acid injections in sagging body skin

Introdução: O tratamento da flacidez cutânea corporal constitui grande desafio, pois poucos são os procedimentos destinados a melhorá-la. O ácido poli-L-lático é polímero sintético injetável da família dos alfa-hidroxiácidos, cuja injeção na derme profunda ou hipoderme superficial induz reação local e gradual, com síntese de novo colágeno pelos fibroblastos e consequente aumento da espessura dérmica. Objetivo: Avaliar os efeitos do ácido poli-L-lático na flacidez da pele do corpo. Métodos: Quatorze pacientes que apresentavam flacidez de região glútea foram tratadas com duas aplicações de ácido poli-L-lático com intervalos de 45 dias entre elas. Foram realizadas avalição clínica inicial e seis meses após a segunda aplicação, fotos prévias e seis meses após o tratamento, bem como foram aplicados questionários às pacientes e ao médico avaliador, e realizado exame ultrassonográfico de todas as pacientes para verificação do aumento de espessura dérmica. Foram avaliados também os efeitos adversos observados. Resultados: Na opinião das pacientes, 85% apresentaram melhora no aspecto geral da pele e 71% na flacidez. Para o médico avaliador, 100% das pacientes apresentaram melhora no aspecto geral da pele e na flacidez, porém em graus variáveis e não proporcionais ao grau de gravidade inicial. Onze pacientes tiveram aumento da espessura dérmica acima de 20% dos pontos. Não houve efeitos colaterais importantes no período avaliado. Conclusões: Os resultados são promissores e devem ser confirmados com a realização de estudos com casuística maior.

Introduction: The treatment of sagging skin in body areas is still a big challenge, as there are few aesthetic procedures aiming to improve it. The poly-L-lactic acid (PLLA) is an injectable synthetic polymer of the alpha-hydroxy acids family, which injection into the deep dermis or superficial hypodermis induces a local and gradual reaction, with synthesis of new collagen by the fibroblasts and consequent increase of dermal thickness. Purpose: Evaluate the effects of poly-L-lactic acid on the sagging skin of the body. Methods: Fourteen patients with sagging in gluteal region underwent two applications of poly-L-lactic acid with a 45 days interval between them. We performed an initial clinical evaluation and after six months of the second application, photos before and after six months of treatment, questionnaires answered by the patient and by the evaluating physician and ultrasound examination of all patients to assess the increase of dermal thickness. The adverse effects observed were also evaluated. Results: In patient's opinion, 85% presented improvement of general appearance of the skin and 71% noticed improvement of sagging. For the evaluating physician, 100% of patients presented improvement of general appearance of the skin and improvement of sagging, but in different degrees and not proportional to the initial degree of severity. There was no significant side effects in the period evaluated. Conclusions: The results are promising and should be confirmed with studies with a larger sample size.

Urticária crônica e comorbidades mais frequentemente relacionadas / Chronic urticaria and more frequently related comorbidities

Objetivo: Avaliar a associação entre urticária crônica e doenças sistêmicas (síndrome metabólica, artropatias, doença vascular periférica e do trato gastrintestinal). Métodos: Estudo transversal, descritivo, de base clínica. Foi realizado um levantamento de dados por meio de prontuários de 95 pacientes, que estiveram em tratamento ambulatorial de rotina de abril de 2014 a abril de 2015, mediante assinatura de um Termo de Consentimento Livre e Esclarecido pelo paciente durante suas consultas de rotina no Ambulatório de Urticária. Para analisar a associação das doenças, foi utilizado o teste estatístico qui quadrado, considerando sexo feminino e masculino, e a doença. Consideraram- se relevância estatística as relações com p abaixo de 0,05 (p<0,05). O nível de significância adotado foi de 95%. O programa utilizado foi o Stata 11.0. Resultados: Artropatias foram positivas em aproximadamente 55% das mulheres do estudo e 17% dos homens (p=0,001 e p<0,05, respectivamente). Houve significância estatística na relação entre doença vascular e urticária crônica (p=0,022 e p<0,05, respectivamente). Conclusão: Não foi encontrada associação relevante estatisticamente para afirmar que houve confiança na associação entre diabetes e urticária crônica (p=0,801 e p>0,05, respectivamente). Não se obteve relevância na relação com doenças do trato gastrointestinal (p=0,437/p>0,05). relevância na relação com doenças do trato gastrointestinal (p=0,437/p>0,05).

Objective: To evaluate the association between Chronic urticaria and systemic diseases such as metabolic syndrome, arthropathies, peripheral vascular disease, and gastrointestinal diseases. Methods: a cross-sectional, descriptive study of clinical basis. A survey of data was performed through the medical records of 95 patients who underwent routine outpatient treatment from April 2014 to April 2015, and signed na Informed Consent during their routine appointments in the Urticaria Clinic. To analyze the diseases associations we used the statistical Chi-square test, considering male and female patients, and the disease. Relations with p lower than 0.05 (p<0.05) were considered statistically relevant. Significance level was 95%. The software used was Stata 11.0. Results: Arthropathies were positive in approximately 55% of women in the study, and 17% of men (p=0.001 and p<0.05, respectively).There was a statistically significant relationship between vascular disease and chronic urticaria (p=0.022 and p<0.05, respectively). Conclusion: No statistically significant association was found to state that there was confidence in the association between diabetes and Chronic urticaria (p=0.801 and p>0.05, respectively). No relevant relation was observed with gastrointestinal diseases (p=0.437/ p>0.05).

Expression of heparanase in basal cell carcinoma and squamous cell carcinoma

Abstract: Background: Heparanase is an enzyme that cleaves heparan sulfate chains. Oligosaccharides generated by heparanase induce tumor progression. Basal cell carcinoma and squamous cell carcinoma comprise types of nonmelanoma skin cancer. Objectives: Evaluate the glycosaminoglycans profile and expression of heparanase in two human cell lines established in culture, immortalized skin keratinocyte (HaCaT) and squamous cell carcinoma (A431) and also investigate the expression of heparanase in basal cell carcinoma, squamous cell carcinoma and eyelid skin of individuals not affected by the disease (control). Methods: Glycosaminoglycans were quantified by electrophoresis and indirect ELISA method. The heparanase expression was analyzed by quantitative RT-PCR (qRTPCR). Results: The A431 strain showed significant increase in the sulfated glycosaminoglycans, increased heparanase expression and decreased hyaluronic acid, comparing to the HaCaT lineage. The mRNA expression of heparanase was significantly higher in Basal cell carcinoma and squamous cell carcinoma compared with control skin samples. It was also observed increased heparanase expression in squamous cell carcinoma compared to the Basal cell carcinoma. Conclusion: The glycosaminoglycans profile, as well as heparanase expression are different between HaCaT and A431 cell lines. The increased expression of heparanase in Basal cell carcinoma and squamous cell carcinoma suggests that this enzyme could be a marker for the diagnosis of such types of non-melanoma cancers, and may be useful as a target molecule for future alternative treatment.

Correlation between the histopathology of chronic urticaria and its clinical picture

Abstract BACKGROUND: Chronic urticaria is characterized by transient, pruritic lesions of varying sizes, with central pallor and well-defined edges, with disease duration longer than six weeks. Its cellular infiltrate consists of neutrophils, lymphocytes and eosinophils. There is a subgroup of patients with eosinophilic or neutrophilic urticaria, resistant to the treatment with antihistamines, but that respond to a combination of antihistamine with other drugs. OBJECTIVE: To evaluate the present infiltration in chronic urticaria biopsies and correlate it with the clinical disease activity and response to treatment. METHODS: Forty-one patients with chronic urticaria were classified according to the score of severity of the disease, response to treatment and type of perivascular infiltrate. Inflammatory infiltrates were divided in eosinophilic (46.30%), neutrophilic and mixed. RESULTS: An association was found between the eosinophilic infiltrate and clinical scores of greater severity (p = 0.002). CONCLUSION: This association shows that the eosinophilic inflammatory infiltrates denote high clinical activity, which means more severe and exuberant clinical pictures of the disease.