Manifestação clínica de sarcoidose sistêmica após preenchimento cutâneo / Clinical manifestation of systemic sarcoidosis after cutaneous filling

A sarcoidose é doença granulomatosa não infecciosa de etiologia desconhecida, em que fatores ambientais, infecciosos, imunológicos e genéticos parecem estar relacionados. Manifestações clínicas podem ocorrer em qualquer órgão, mas há predomínio em pulmão e linfonodos intratorácicos. O envolvimento cutâneo da doença ocorre em cerca de 25% dos casos, sendo o procedimento de preenchimento cutâneo um potencial desencadeante. Relata-se caso de uma paciente que apresentou lesões granulomatosas na face após preenchimento cutâneo com ácido hialurônico. Na investigação das lesões cutâneas, a paciente apresentou critérios diagnósticos de sarcoidose com extenso acometimento pulmonar.

Sarcoidosis is a non-infectious granulomatous disease of unknown etiology in which environmental, infectious, immunological, and genetic factors appear to be correlated. Clinical manifestations can occur in any organ, however there is predominance in the lungs and in intrathoracic lymph nodes. The cutaneous involvement of the disease occurs in roughly 25% of cases, with cutaneous filling procedures figuring as a potential trigger. The authors of the present article report a case of a patient who had granulomatous lesions on the face following cutaneous filling with hyaluronic acid. In the investigation of cutaneous lesions, the patient presented diagnostic criteria for sarcoidosis, with extensive pulmonary involvement.

Clinical and histological study of permanent alopecia after bone marrow transplantation

Abstract: BACKGROUND: Permanent alopecia after bone marrow transplantation is rare, but more and more cases have been described, typically involving high doses of chemotherapeutic agents used in the conditioning regimen for the transplant. Busulfan, classically described in cases of irreversible alopecia, remains associated in recent cases. The pathogenesis involved in hair loss is not clear and there are few studies available. In addition to chemotherapeutic agents, another factor that has been implicated as a cause is chronic graft-versus-host disease. However, there are no histopathological criteria for defining this diagnosis yet. OBJECTIVE: the study aims to evaluate clinical and histological aspects in cases of permanent alopecia after bone marrow transplantation, identifying features of permanent alopecia induced by myeloablative chemotherapy and alopecia as a manifestation of chronic graft-versus-host disease. METHODS: data were collected from medical records of 7 patients, with description of the clinical features and review of slides and paraffin blocks of biopsies. RESULTS: Two distinct histological patterns were found: one similar to androgenetic alopecia, non-scarring pattern, and other similar to lichen planopilaris, scarring alopecia. CONCLUSION: The first pattern corroborates the literature cases of permanent alopecia induced by chemotherapeutic agents, and the second is compatible with manifestation of chronic graft-versus-host disease on scalp, that has never been described yet. The results contribute to the elucidation of the factors involved in these cases, including the development of therapeutic methods.

Clinical and histological study of permanent alopecia after bone marrow transplantation.

BACKGROUND: Permanent alopecia after bone marrow transplantation is rare, but more and more cases have been described, typically involving high doses of chemotherapeutic agents used in the conditioning regimen for the transplant. Busulfan, classically described in cases of irreversible alopecia, remains associated in recent cases. The pathogenesis involved in hair loss is not clear and there are few studies available. In addition to chemotherapeutic agents, another factor that has been implicated as a cause is chronic graft-versus-host disease. However, there are no histopathological criteria for defining this diagnosis yet. OBJECTIVE: the study aims to evaluate clinical and histological aspects in cases of permanent alopecia after bone marrow transplantation, identifying features of permanent alopecia induced by myeloablative chemotherapy and alopecia as a manifestation of chronic graft-versus-host disease. METHODS: data were collected from medical records of 7 patients, with description of the clinical features and review of slides and paraffin blocks of biopsies. RESULTS: Two distinct histological patterns were found: one similar to androgenetic alopecia, non-scarring pattern, and other similar to lichen planopilaris, scarring alopecia. CONCLUSION: The first pattern corroborates the literature cases of permanent alopecia induced by chemotherapeutic agents, and the second is compatible with manifestation of chronic graft-versus-host disease on scalp, that has never been described yet. The results contribute to the elucidation of the factors involved in these cases, including the development of therapeutic methods.

Lower facial remodeling with botulinum toxin type A for the treatment of masseter hypertrophy

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. .

Lower facial remodeling with botulinum toxin type A for the treatment of masseter hypertrophy.

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.

Increased photosensitivity? Case report of porphyria cutanea tarda associated with systemic lupus erythematosus.

The association of porphyria cutanea tarda (PCT) and systemic lupus erythematosus (SLE) is rare. Systemic lupus erythematosus, of complex pathophysiology and pleomorphic clinical manifestations, is similar to PCT regarding photosensitivity. One finding that can differentiate both diseases is the presence of cutaneous blisters, which are rare in SLE, but characteristic of PCT. We report one case of the association of PCT and SLE and revise the literature, emphasizing pathophysiological, clinical and therapeutic aspects. One relevant information for clinical practice relates to the treatment of SLE with antimalarials, which is a risk for PCT.

Avaliação comparativa do laser de CO2 fracionado e da dermoabrasão no tratamento de cicatriz de acne / Comparative assessment of CO2 fractional laser and dermabrasion in the treatment of acne scars

Introdução: Cicatrizes de acne são frequentes e de tratamento desafiador. Diversas técnicas têm sido utilizadas para remover, reposicionar e aplainar cicatrizes de acne, melhorando o aspecto da superfície da pele. Recentemente a utilização do Laser de CO2 fracionado foi incluída entre as opções para a correção dessas cicatrizes com bons resultados e menor tempo de recuperação. Objetivo: Avaliar e comparar a resposta do tratamento de cicatrizes de acne com Laser de CO2 fracionado e dermoabrasão em pacientes com cicatrizes de acne. Métodos: Foram analisados nove pacientes, seis submetidos a Laser de CO2 fracionado, e três a dermoabrasão. Avaliaram-se parâmetros subjetivos e objetivos dos dois tratamentos. Resultados: Os dois grupos de pacientes mostraram melhora objetiva e subjetiva. Conclusões: Foi demonstrada eficácia semelhante dos tratamentos para cicatrizes de acne moderadas a graves com as duas técnicas.

Introduction: Acne scars are common, and their treatment is challenging. Several techniques have been used to remove, reposition, and flatten acne scars to improve the appearance of the skin's surface. More recently, fractional CO2 laser has been used to correct such scars due its good results and shorter recovery time. Objective: To evaluate and compare fractional CO2 laser vs. dermabrasion-based treatment of acne scars. Methods: Nine patients were assessed ­ six received fractional CO2 laser and three were treated with dermabrasion.Subjective and objective parameters were evaluated for both treatment modalities. Results: Both patient groups showed objective and subjective improvement. Conclusions: This study has demonstrated that fractional CO2 laser and dermabrasion-based treatments have similar efficacy in moderate to severe acne scars.

Fotossensibilidade amplificada? Relato de porfiria cutânea tarda associada a lúpus eritematoso sistêmico / Increased photosensitivity? Case report of porphyria cutanea tarda associated with systemic lupus erythematosus

A associação de porfiria cutânea tarda (PCT) e lúpus eritematoso sistêmico (LES) é rara. O LES, de fisiopatologia complexa e manifestações clínicas pleomórficas, assemelha-se à PCT pela fotossensibilidade. Um achado que pode diferenciar as duas doenças são as lesões cutâneas bolhosas, raras no LES, mas características da PCT. Descrevemos um caso de associação de PCT e LES e revisamos a literatura, enfatizando questões fisiopatológicas, clínicas e terapêuticas. Um dado relevante para a prática clínica concerne ao tratamento do lúpus com antimaláricos, o que pode oferecer riscos para a PCT.

The association of porphyria cutanea tarda (PCT) and systemic lupus erythematosus (SLE) is rare. Systemic lupus erythematosus, of complex pathophysiology and pleomorphic clinical manifestations, is similar to PCT regarding photosensitivity. One finding that can differentiate both diseases is the presence of cutaneous blisters, which are rare in SLE, but characteristic of PCT. We report one case of the association of PCT and SLE and revise the literature, emphasizing pathophysiological, clinical and therapeutic aspects. One relevant information for clinical practice relates to the treatment of SLE with antimalarials, which is a risk for PCT.

NAPSI utilization as an evaluation method of nail psoriasis in patients using acitretin.

BACKGROUND: assessment instruments of nail psoriasis have been published in literature as means to standardize the previous subjective assessments of authors. OBJECTIVES: Using Nail Psoriasis Severity Index for evaluation in patients with plaque psoriasis during treatment with acitretin. METHODS: Thirty volunteers with plaque psoriasis were selected for the study. Twenty patients (8 women and 12 men) completed the study. The initial dose of acitretin was 0.3 mg/kg/day for 30 days and was later raised to 0.5 mg/kg/day. Nail Psoriasis Severity Index was collected in the first evaluation, after 2 and 4 months. Nails of both hands were evaluated. RESULTS: nail lesions were present in all patients at first evaluation. The initial Nail Psoriasis Severity Index median was 20 and the final score 20.5 (2.5% of worsening at the end of the study). No statistically significant difference between the three evaluations was found (X2 = 0.8084, GL = 2, p = 0.6657). Seven patients worsened in the final score. Three patients improved 50% of the initial Nail Psoriasis Severity Index and only one had an improvement of 75%. Linear correlation showed a weak association between the improvement percentage in PASI and Nail Psoriasis Severity Index (r = 0.105, F = 2.12, p = 0.162). CONCLUSION: The method was easy and of rapid execution while potentially bringing information about changes in nail plate and matrix during treatment. The Nail Psoriasis Severity Index does not quantify the existing lesions and might not have the sensitivity to detect small changes.

NAPSI utilization as an evaluation method of nail psoriasis in patients using acitretin / Utilização do NAPSI como instrumento de avaliação na psoríase ungueal em pacientes com uso da acitretina

BACKGROUND: assessment instruments of nail psoriasis have been published in literature as means to standardize the previous subjective assessments of authors. OBJECTIVES: Using Nail Psoriasis Severity Index for evaluation in patients with plaque psoriasis during treatment with acitretin. METHODS: Thirty volunteers with plaque psoriasis were selected for the study. Twenty patients (8 women and 12 men) completed the study. The initial dose of acitretin was 0.3 mg/kg/day for 30 days and was later raised to 0.5 mg/kg/day. Nail Psoriasis Severity Index was collected in the first evaluation, after 2 and 4 months. Nails of both hands were evaluated. RESULTS: nail lesions were present in all patients at first evaluation. The initial Nail Psoriasis Severity Index median was 20 and the final score 20.5 (2.5% of worsening at the end of the study). No statistically significant difference between the three evaluations was found (X2 = 0.8084, GL = 2, p = 0.6657). Seven patients worsened in the final score. Three patients improved 50% of the initial Nail Psoriasis Severity Index and only one had an improvement of 75%. Linear correlation showed a weak association between the improvement percentage in PASI and Nail Psoriasis Severity Index (r = 0.105, F = 2.12, p = 0.162). CONCLUSION: The method was easy and of rapid execution while potentially bringing information about changes in nail plate and matrix during treatment. The Nail Psoriasis Severity Index does not quantify the existing lesions and might not have the sensitivity to detect small changes.

FUNDAMENTOS: instrumentos de avaliação da psoríase ungueal têm sido publicados na literatura como meio de padronizar as avaliações antigamente subjetivas dos autores. OBJETIVOS: utilizar índice de Gravidade da Psoríase Ungueal ou Nail Psoriasis Severity Index para avaliação em pacientes portadores de psoríase em placas durante o tratamento com acitretina. MÉTODOS: trinta voluntários portadores de psoríase em placas foram selecionados para o estudo. Vinte deles ( 8 mulheres e 12 homens) completaram o estudo. A dose inicial da acitretina foi de 0,3mg/kg/dia por 30 dias sendo elevado posteriormente para 0,5mg/kg/dia. Utilizou-se a avaliação do Nail Psoriasis Severity Index na primeira avaliação, após 2 e 4 meses avaliando-se as unhas de ambas as mãos. RESULTADOS: lesões de unhas estavam presentes em todos os pacientes na primeira avaliação. A mediana inicial do Nail Psoriasis Severity Index foi de 20 e o escore final 20,5 (2,5% de piora ao final do estudo), sem diferença estatística significativa entre as três (X2=08084, GL=2, p=0,6657). Sete pacientes pioraram no escore final. Três pacientes obtiveram melhora de 50% do Nail Psoriasis Severity Index inicial em relação ao final e apenas 1 obteve melhora de 75 . A correlação linear simples mostrou fraca associação entre a porcentagem de melhora do PASI e do Nail Psoriasis Severity Index (r=0,105, F=2,12, p=0,l62). CONCLUSÕES: o método se mostrou de fácil e de rápida execução, podendo trazer informações sobre as alterações de lâmina e matriz de um modo global. O Nail Psoriasis Severity Index não quantifica as lesões existentes isoladamente, podendo não ter a sensibilidade de detectar pequenas alterações.

Avaliação histológica comparativa da eficácia de ácido tricloroacético e subcisão, isolados e combinados, no tratamento de estrias abdominais / Comparative histological evaluation of the effectiveness of trichloroacetic acid and subcision (isolated or combined) in the treatment of abdominal striae

Introdução: estrias são consideradas cicatrizes, não sendo conhecidos tratamentos resolutivos para essa condição. Objetivo: comparar a resposta de três modalidades terapêuticas: subcisão , subcisão + ATA 20% e ATA 20% no tratamento de estrias. Métodos: 11 pacientes portadoras de estrias em abdômen inferior, dividido em quadrantes: uma estria de cada quadrante foi submetida a: subcisão, subcisão + ATA 20% e ATA 20%, respectivamente. O quarto quadrante foi utilizado como controle. Cada estria selecionada foi biopsiada antes e após 12 semanas. Para avaliar a eficácia, utilizou-se o teste de Wilcoxon. Para ava-liar comparativamente as diferenças entre os tratamentos foi aplicado o teste de Kruskal-Wallis. Resultados: Em todos os tratamentos realizados houve redução da média pré e pós-tratamento; no entanto, o tratamento com ATA 20% mostrou-se estatisticamente significativo no parâmetro epidérmico e na coloração de fibras colágenas. A subcisão associada ao ATA 20% teve resultado estatisticamente significativo no parâmetro derme superficial enquanto a subcisão isolada mostrou-se significativa apenas na derme superficial. Realizou-se uma sessão de tratamento, sendo necessários estudos subsequentes para avaliação clinico-histológica após número maior de sessões. Conclusões: Os tratamentos propostos são seguros e de baixo custo operacional, sendo ótima opção para estrias abdominais.

Introduction: Abdominal striae(i.e. stretch marks) are considered scars, for which there are no known treatments. Objective: To compare the effectiveness of three treatments: subcision, 20% trichloroacetic acid, and subcision + 20% trichloroacetic acid in the treatment of stretch marks. Methods: The lower abdomens of 11 patients with stretch marks were divided into four quadrants. Each patient had one stria selected for a single treatment session; the three treatments (subcision, 20% trichloroacetic acid, and subcision + 20% trichloroacetic acid) were administered in 3 quadrants, and the 4th quadrant served as a control. Each selected stria was biopsied before and after 12 weeks. The Wilcoxon test was used to evaluate the efficacy of the treatment. The Kruskal-Wallis test was used to evaluate the differences between the treatments. Results: In all treatments there was a reduction in the mean value after treatment, however the 20% trichloroacetic acid treatment was statistically significant for the epidermalparameter and the collagen fiber staining. The subcision associated with 20% trichloroacetic acid presented a statistically significant result in the superficial dermis parameter, while the isolated subcision was significant in the superficial dermis parameter only. Conclusions: These treatments are safe and present low operating costs, which make them a great alternative for treating abdominal striae. Future studies should conduct a clinical-histological evaluation after a greater number of sessions.

Nailfold capillaroscopy as a diagnostic and prognostic method in rosacea.

BACKGROUND: There is no appropriate and reliable method of evaluating and monitoring severity in rosacea. OBJECTIVE: To determine the importance of nailfold capillaroscopy as a diagnostic and prognostic method for patients with rosacea. METHODS: A cross-sectional study where eight patients with rosacea and 8 control subjects were submitted to nailfold capillaroscopy from May to July 2009. We collected clinical data related to gender, age, skin phototype, and rosacea stage according to Plewig and Kligman classification and the classification of the National Rosacea Society. Additionally, we evaluated the progression of the disease and treatment therapies previously used. RESULTS: The majority of the patients evaluated (6 out of 8 patients) had rosacea subtype I (vascular) or erythematotelangiectatic rosacea. The mean duration of the disorder was 5.96 years, and 87.5% of the patients were under treatment with topical metronidazole. Nailfold cappilaroscopy showed that evidence of devascularization was absent in both groups. CONCLUSION: Nailfold capillaroscopy presents a nonspecific pattern and does not seem to help in the diagnosis or prognosis of rosacea.

Uso da capilaroscopia ungueal como método diagnóstico e prognóstico de rosácea / Nailfold capillaroscopy as a diagnostic and prognostic method in rosacea

FUNDAMENTOS: Não há um método adequado e fidedigno de avaliação e seguimento da severidade na rosácea. OBJETIVO: Determinar a importância da capilaroscopia periungueal como método diagnóstico e prognóstico em pacientes portadores de rosácea. MÉTODOS: Estudo transversal onde foram submetidos ao exame da capilaroscopia periungueal 8 pacientes com rosácea e 8 controles no período entre maio e julho de 2009. Foram coletados dados clínicos relacionados ao sexo, idade, fototipo, classificação da rosácea de acordo com a classificação de Plewig e Kligman e a classificação da National Rosacea Society. Adicionalmente, avaliamos o tempo de evolução da doença e tratamentos previamente utilizados. RESULTADOS: A grande maioria das pacientes avaliadas (6 das 8 pacientes) apresentavam rosácea grau I (vascular) ou eritêmato-teleangiectásica. A idade média de duração da rosácea foi de 5,96 anos, sendo que 87,5 por cento faziam tratamento com metronidazol tópico. Nenhum paciente tanto do grupo rosácea como controle demonstrou evidência de desvascularização ao exame capilaroscópico. CONCLUSÃO: A capilaroscopia periungueal apresenta um padrão inespecífico e não parece auxiliar no diagnóstico ou prognóstico da rosácea.

BACKGROUND: There is no appropriate and reliable method of evaluating and monitoring severity in rosacea. OBJECTIVE: To determine the importance of nailfold capillaroscopy as a diagnostic and prognostic method for patients with rosacea. METHODS: A cross-sectional study where eight patients with rosacea and 8 control subjects were submitted to nailfold capillaroscopy from May to July 2009. We collected clinical data related to gender, age, skin phototype, and rosacea stage according to Plewig and Kligman classification and the classification of the National Rosacea Society. Additionally, we evaluated the progression of the disease and treatment therapies previously used. RESULTS: The majority of the patients evaluated (6 out of 8 patients) had rosacea subtype I (vascular) or erythematotelangiectatic rosacea. The mean duration of the disorder was 5.96 years, and 87.5 percent of the patients were under treatment with topical metronidazole. Nailfold cappilaroscopy showed that evidence of devascularization was absent in both groups. CONCLUSION: Nailfold capillaroscopy presents a nonspecific pattern and does not seem to help in the diagnosis or prognosis of rosacea.

Alopecia: manifestação cutânea rara de sarcoidose / Alopecia: an uncommon cutaneous manifestation of sarcoidosis

A sarcoidose é doença granulomatosa multissistêmica que geralmente compromete o trato respiratório e os linfonodos hilares. A pele é comumente afetada, mas raramente o couro cabeludo. Dois casos de sarcoidose com lesões no couro cabeludo são relatados: o primeiro, em paciente negra apresentando áreas de alopecia no couro cabeludo associada a outras lesões cutâneas; e o segundo, em paciente branca, portadora de sarcoidose pulmonar, com alopecia como manifestação cutânea isolada. A sarcoidose de couro cabeludo merece especial atenção, pois nos pacientes com essa forma de lesão cutânea existe alta incidência de acometimento sistêmico.

Sarcoidosis is a multi-system granulomatous disease that generally affects the respiratory tract and hilar lymph nodes. The skin is also commonly involved, although cutaneous sarcoidosis on the scalp is rare. Two cases of scalp sarcoidosis are reported: the first presented with patchy alopecia, cutaneous sarcoidosis and also systemic disease in a black patient; the second case is related to an uncommon presentation with alopecia as the single cutaneous manifestation in a Caucasian patient with pulmonary sarcoidosis. Scalp sarcoidosis deserves special attention because there is a high incidence of other systemic lesions with this cutaneous manifestation, thus a careful investigation should be performed in these patients.