Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology.

BACKGROUND: Urticarias are frequent diseases, with 15% to 20% of the population presenting at least one acute episode in their lifetime. Urticaria are classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may be induced or spontaneous. OBJECTIVES: To verify the diagnostic and therapeutic recommendations in chronic spontaneous urticaria (CSU), according to the experience of Brazilian experts, regarding the available guidelines (international and US). METHODS: A questionnaire was sent to Brazilian experts, with questions concerning diagnostic and therapeutic recommendations for CSU in adults. RESULTS: Sixteen Brazilian experts answered the questionnaire related to diagnosis and therapy of CSU in adults and data were analyzed. Final text was written, considering the available guidelines (International and US), adapted to the medical practices in Brazil. Diagnostic work up in CSU is rarely necessary. Biopsy of skin lesion and histopathology may be indicated to rule out other diseases, such as, urticarial vasculitis. Other laboratory tests, such as complete blood count, CRP, ESR and thyroid screening. Treatment of CSU includes second-generation anti-histamines (sgAH) at licensed doses, sgAH two, three to fourfold doses (non-licensed) and omalizumab. Other drugs, such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be indicated (non-licensed and with limited scientific evidence). CONCLUSIONS: Most of the Brazilian experts in this study partially agreed with the diagnostic and therapeutic recommendations of the International and US guidelines. They agreed with the use of sgAH at licensed doses. Increase in the dose to fourfold of sgAH may be suggested with restrictions, due to its non-licensed dose. Sedating anti-histamines, as suggested by the US guideline, are indicated by some of the Brazilian experts, due to its availability. Adaptations are mandatory in the treatment of CSU, due to scarce or lack of other therapeutic resources in the public health system in Brazil, such as omalizumab or cyclosporine.

Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology

Abstract: Background: Urticarias are frequent diseases, with 15% to 20% of the population presenting at least one acute episode in their lifetime. Urticaria are classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may be induced or spontaneous. Objectives: To verify the diagnostic and therapeutic recommendations in chronic spontaneous urticaria (CSU), according to the experience of Brazilian experts, regarding the available guidelines (international and US). Methods: A questionnaire was sent to Brazilian experts, with questions concerning diagnostic and therapeutic recommendations for CSU in adults. Results: Sixteen Brazilian experts answered the questionnaire related to diagnosis and therapy of CSU in adults and data were analyzed. Final text was written, considering the available guidelines (International and US), adapted to the medical practices in Brazil. Diagnostic work up in CSU is rarely necessary. Biopsy of skin lesion and histopathology may be indicated to rule out other diseases, such as, urticarial vasculitis. Other laboratory tests, such as complete blood count, CRP, ESR and thyroid screening. Treatment of CSU includes second-generation anti-histamines (sgAH) at licensed doses, sgAH two, three to fourfold doses (non-licensed) and omalizumab. Other drugs, such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be indicated (non-licensed and with limited scientific evidence). Conclusions: Most of the Brazilian experts in this study partially agreed with the diagnostic and therapeutic recommendations of the International and US guidelines. They agreed with the use of sgAH at licensed doses. Increase in the dose to fourfold of sgAH may be suggested with restrictions, due to its non-licensed dose. Sedating anti-histamines, as suggested by the US guideline, are indicated by some of the Brazilian experts, due to its availability. Adaptations are mandatory in the treatment of CSU, due to scarce or lack of other therapeutic resources in the public health system in Brazil, such as omalizumab or cyclosporine.

Serum levels of 25-hydroxy vitamin D in psoriatic patients.

Studies have shown a relationship between vitamin D and psoriasis. We compared serum levels of vitamin D of 20 psoriasis patients and 20 controls. The median vitamin D level was 22.80 ± 4.60 ng/ml; the median in the cases was 23.55 ± 7.6 ng/ml, and in controls 22.35 ± 3.10 ng/ml (p = 0.73). Only 2 cases and 4 controls had sufficient levels of vitamin D, although without statistical significance between the groups (p = 0.608). Levels were lower in women with psoriasis compared with those in male patients (20.85 ± 6.70 x 25.35 ± 2.90 ng/ml, p = 0.03), a finding that was not observed among controls.

Manifestações dermatológicas em pacientes infectados pelo HIV: um estudo de prevalência / Dermatological manifestations in HIV-infected patients: a prevalence study

Na infecção pelo HIV, a pele pode ser tanto um indicador precoce de doença quanto de gravidade. Este estudo analisou a frequência e a apresentação clínica de manifestações dermatológicas em pacientes portadores de HIV, destacando as lesões mais encontradas, e correlacionou suas características com o estado imunológico. Foram encontradas 129 lesões mucocutâneas dentre os 57 pacientes portadores de HIV examinados, havendo em média 2,25 lesões por paciente. As dermatoses mais comuns, em ordem decrescente de frequência, foram candidíase oral, onicomicose e dermatite seborreica. As lesões oportunistas mostraram relação significativa com deficiência imunológica, e as afecções de pele mais encontradas mostraram-se bons indicadores do estado imunológico do paciente e da progressão da doença.

In the HIV infection the skin can be either an early indicator of disease and severity. This study examined the frequency and clinical presentation of skin manifestations in patients with HIV, highlighting the most frequent injuries, and correlated their characteristics with the immune status. We found 129 mucocutaneous lesions among 57 patients with HIV, with an average of 2.25 lesions per patient. The most common skin diseases in descending order of frequency were oral candidiasis, onychomycosis and seborrheic dermatitis. Opportunistic lesions showed significant relationship with immune deficiency and the most frequent skin diseases proved to be good indicators of the immune status of the patient and disease progression.

Cytokine detection for the diagnosis of chromium allergy.

BACKGROUND: Patch testing remains the gold standard method for the identification of the etiologic agent of allergic contact dermatitis. However, it is a subjective, time-consuming exam whose technique demands special care and which presents some contraindications, which hamper its use. In a recent study, we showed that the proliferation assay can suitably replace patch testing for the diagnosis of chromium allergy, which had been previously demonstrated only for nickel allergy. In this study, we try to refine the method by reducing the incubation period of cultures for lymphocyte proliferation assays in response to chromium. OBJECTIVE: Develop an alternative or complementary diagnostic test for chromium allergic contact dermatitis. METHODS: We compared the production of 9 cytokines (IFN-γ, IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 and RANTES) between 18 chromium-allergic patients and 19 controls. RESULTS: Chromium increased the production of IFN-y, IL-5, IL-2 and IL-13 in allergic patients, but only IL-2 and especially IL-13 helped discriminate allergic patients from controls. The sensitivity, specificity and accuracy found with IL-13 were about 80%. CONCLUSIONS: IL-13 and IL-2 detection may be used to diagnose chromium allergy in 2-day cultures. However, in general, the 6-day cultures seem to be superior for this purpose.

Cytokine detection for the diagnosis of chromium allergy / Deteccao de citocinas no diagnostico de pacientes alergicos ao cromo

BACKGROUND: Patch testing remains the gold standard method for the identification of the etiologic agent of allergic contact dermatitis. However, it is a subjective, time-consuming exam whose technique demands special care and which presents some contraindications, which hamper its use. In a recent study, we showed that the proliferation assay can suitably replace patch testing for the diagnosis of chromium allergy, which had been previously demonstrated only for nickel allergy. In this study, we try to refine the method by reducing the incubation period of cultures for lymphocyte proliferation assays in response to chromium. OBJECTIVE: Develop an alternative or complementary diagnostic test for chromium allergic contact dermatitis. METHODS: We compared the production of 9 cytokines (IFN-γ, IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 and RANTES) between 18 chromium-allergic patients and 19 controls. RESULTS: Chromium increased the production of IFN-y, IL-5, IL-2 and IL-13 in allergic patients, but only IL-2 and especially IL-13 helped discriminate allergic patients from controls. The sensitivity, specificity and accuracy found with IL-13 were about 80%. CONCLUSIONS: IL-13 and IL-2 detection may be used to diagnose chromium allergy in 2-day cultures. However, in general, the 6-day cultures seem to be superior for this purpose. .

FUNDAMENTOS: O teste de contato permanece como padrão ouro para a identificação do agente causal da dermatite de contato alérgica, mas é um exame subjetivo, que demanda considerável tempo do paciente e do medico, exige cuidados na sua técnica e apresenta algumas contra-indicações que dificultam o seu uso. Em um estudo recente demonstramos que o teste de proliferação pode adequadamente substituir o teste de contato no diagnóstico de alergia ao cromo, algo previamente demonstrado apenas para o níquel. Neste estudo tentamos refinar o método reduzindo o período de incubação das culturas do teste de proliferação para o cromo. OBJETIVO: Desenvolver um método alternativo ao teste de contato para o diagnóstico dermatite de contato alérgica ao cromo. MÉTODOS: Comparamos o estímulo provocado pelo cromo na produção de nove citocinas (IFN-γ, IL2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 e RANTES) no sobrenadante das culturas de células do sangue periférico de 18 pacientes alérgicos ao cromo e 19 controles. RESULTADOS: O cromo aumentou a produção de IFN-y, IL-5, IL-2 e IL-13, mas apenas as citocinas IL-2 e principalmente IL-13 foram capazes de discriminar pacientes de controles. A sensibilidade, especificidade e acurácia encontradas com a IL-13 foram de aproximadamente de 80%. CONCLUSÕES: Concluímos que a detecção de IL-2 e IL-13 podem ser útil para o diagnóstico de alergia a cromo na cultura de 2 dias. Todavia, as culturas de 6 dias parecem, de um modo geral, superiores as de 2 dias para esse fim. .

Immunopathology of allergic contact dermatitis.

Allergic contact dermatitis is the consequence of an immune reaction mediated by T cells against low molecular weight chemicals known as haptens. It is a common condition that occurs in all races and age groups and affects the quality of life of those who present it. The immunological mechanism of this disease has been reviewed in recent decades with significant advance in its understanding. The metabolism and pathway of the haptens as well as the activation and mechanism of action of the cells responsible for both the immune reaction and its completion are discussed in this article.

Imunopatologia da dermatite de contato alérgica / Immunopathology of allergic contact dermatitis

A dermatite de contato alérgica é consequência de uma reação imune mediada por células T contra químicos de baixo peso molecular, denominados haptenos. É uma condição frequente que ocorre em todas as raças e faixas etárias e afeta a qualidade de vida de seus portadores. O mecanismo imunológico desta doença vem sendo revisto nas últimas décadas com significativo avanço no seu entendimento. A metabolização e o caminho dos haptenos, bem como a formação e o mecanismo de ação das células responsáveis tanto pela reação quanto pelo seu término, são discutidos neste artigo.

Allergic contact dermatitis is the consequence of an immune reaction mediated by T cells against low molecular weight chemicals known as haptens. It is a common condition that occurs in all races and age groups and affects the quality of life of those who present it. The immunological mechanism of this disease has been reviewed in recent decades with significant advance in its understanding. The metabolism and pathway of the haptens as well as the activation and mechanism of action of the cells responsible for both the immune reaction and its completion are discussed in this article.

Milia em placa / Milia en plaque

Milia em placa é uma forma rara e primária de milia. Questões referentes à cosmética e aos seus diagnósticos diferenciais perturbam os pacientes e desafiam os médicos. Relatamos um caso de milia em placa e discutimos a literatura pertinente.

Milia en plaque is a rare type of primary milia. Issues related to esthetics and differential diagnoses represent a concern to patients and a challenge for physicians. In this paper, a case of milia en plaque is reported and a review of the literature is described.

Milia en plaque.

Milia en plaque is a rare type of primary milia. Issues related to esthetics and differential diagnoses represent a concern to patients and a challenge for physicians. In this paper, a case of milia en plaque is reported and a review of the literature is described.

Detecção de citocinas em culturas de linfócitos em pacientes alérgicos ao cromo / Cytokine detection in lymphocyte cultures of chromium allergic patients

A dermatite de contato alérgica decorre de uma reação imunológica, mediada por células T, contra um contactante em pessoas previamente sensibilizadas. O exame padrão ouro para o diagnóstico da DCA é o teste de contato (TC). Infelizmente, o TC demanda tempo, não é inócuo e tem algumas limitações. O teste de proliferação linfocitária (TPL) convencional, uma alternativa ao TC, apresenta baixa sensibilidade no diagnóstico de alergia ao cromo. A fim de aprimorar a sensibilidade o resultado do teste foi obtido pela detecção de citocinas no sobrenadante das culturas e não por timidina radiomarcada. Dezoito pacientes alérgicos ao cromo e 19 controles foram testados com o teste convencional e com as citocinas IFN-?, IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 e rantes. Houve correlação entre alergia ao cromo e detecção das citocinas IFN-gama, IL-2, IL-5, IL-12 e IL-13. Dessas, os melhores resultados foram encontrados com a IL-13. O TPL pode ser utilizado como exame adicional ou alternativo no diagnóstico da DCA pelo cromo.

Allergic contact dermatitis (ACD) elapses from an specific T cell immunologic reaction against an allergen in a sensitized individual. The gold standard exam to confirm ACD is the patch test (PT). However, PT demands time, has potential side efects and some limitations. The standard lymphocyte proliferation assay (LPA) has sensitivity in the diagnosis of chromium allergy. To optimize this test the results were obtained by detection of cytokines instead radiolabeled thymidine. Eighteen patients allergic to chromium and 19 controls were tested with the conventional LPA and for the following cytokines: IFN-?, IL-2, IL-4, IL-5, IL-10, IL-12, IL-13, IL-17 and rantes. Correlation between allergy to chromium and detection of IFN-gama, IL-2, IL-5, IL-12 e IL-13 was found. The best results were found with IL-13. LPA can be used as an alternative or additional test in the diagnosis of ACD by chromium.