Botulinum Toxin Type A to Improve Facial Symmetry in Facial Palsy: A Practical Guideline and Clinical Experience.

Unilateral peripheral facial nerve palsy jeopardizes quality of life, rendering psychological consequences such as low self-esteem, social isolation, anxiety, and depression. Among therapeutical approaches, use of Botulinum toxin type A (BoNT-A) on the nonparalyzed side has shown promising results and improvement of quality of life. Nevertheless, the correct technique is paramount, since over-injection of the muscles can result in lack of function, leading to a "paralyzed" appearance, and even worse, functional incompetence, which may cause greater distress to patients. Therefore, the objective of this article is to provide a practical guideline for botulinum toxin use in facial palsy. To this aim, adequate patient assessment, BoNT-A choice, injection plan and dosage, and injection techniques are covered.

Education is an important factor in end-of-life care: results from a survey of Brazilian physicians' attitudes and knowledge in end-of-life medicine.

BACKGROUND: According to the Latin America Association for palliative care, Brazil offers only 0.48 palliative care services per 1 million inhabitants. In 2012, no accredited physicians were working in palliative care, while only 1.1% of medical schools included palliative care education in their undergraduate curricula. As a reflection of the current scenario, little research about end-of-life care has been published so that studies addressing this subject in the Brazilian setting are crucial. METHODS: A cross-sectional study study conducted with students applying for the medical residency of the Federal University of São Paulo were invited to voluntarily participate in an anonymous and self-administered questionnaire survey. The latter included demographic information, attitudes, prior training in end-of-life care, prior end-of-life care experience, the 20-item Palliative Care Knowledge Test (PCKT) and a consent term. RESULTS: Of the 3086 subjects applying for residency, 2349 (76%) answered the survey, 2225 were eligible for analysis while 124 were excluded due to incomplete data. Although the majority (99,2%) thought it was important to have palliative care education in the medical curriculum, less than half of them (46,2%) reported having received no education on palliative care. The overall performance in the PCKT was poor, with a mean score of 10,79 (± 3). While philosophical questions were correctly answered (81,8% of correct answers), most participants lacked knowledge in symptom control (50,7% for pain, 57,3% for dyspnea, 52,2% for psychiatric problems and 43,4% for gastrointestinal problems). Doctors that had already concluded a prior residency program and the ones that had prior experience with terminal patients performed better in the PCKT (p < 0,001). The high-performance group (more than 50% of correct answers) had received more training in end-of-life care, showed more interest in learning more about the subject, had a better sense of preparedness, as well as a higher percentage of experience in caring for terminal patients (p < 0,001). CONCLUSIONS: Our study showed that Brazilian physicians lack not only the knowledge, but also training in end-of-life medicine. Important factors to better knowledge in end-of-life care were prior training, previous contact with dying patients and prior medical residency. Corroborating the literature, for this group, training showed to be a key factor in overall in this area of knowledge. Therefore, Brazilian medical schools and residency programs should focus on improving palliative training, especially those involving contact with dying patients.

Managing the Aesthetic Patient

wide variety of therapeutic options, some challenges have arisen: designing an adequate treatment plan, electing the most suitable procedures for the patient, taking into consideration the rheological characteristics of the products, considering the amount needed to achieve a natural look, but also defining the safest way to deliver the treatment. Aging of the facial structural tissue layers occurs at a different pace and the requirements for the aesthetic approach of a 30-year-old patient are different from a 60-year-old patient. A group of twelve experts in minimally invasive injectable procedures sought to identify common changes observed in different age groups in order to help in establishing a plan of treatment for patients of different ages. The individualized aesthetic plan should consider the main pillars of the aesthetic treatment -- aging process, facial assessment, and facial anatomy, to identify and systematize common changes observed in different age groups, as well as the safest and most reproducible techniques, especially for new injectors. J Drugs Dermatol. 2019;18(1):92-102.

Dynamic Changes of Facial Supporting Cornerstones (Pillars): Considerations in Aesthetic Approach.

The bony structures of the face provide the framework upon which the soft-tissue envelope rests, such that facial symmetry and proportionality usually depend upon the morphological patterns and anthropometrical measurements of a symmetrical skull. Facial bony pillars are dynamic and variable according to the demands placed upon them, as well as gender and aging differences. Thus, a more profound knowledge of facial supporting pillars and their dynamic behavior by physicians who practice minimally cosmetic procedures would allow for a more natural approach to facial beautification. It would help them to rebalance age-related and asymmetric congenital imperfections, and minimize any harmful stigma associated with bad cosmetic practice.

J Drugs Dermatol. 2018;17(4):466-470.

Reflectance confocal microscopy features of BRAF V600E mutated thin melanomas detected by immunohistochemistry.

The classification of melanoma into four histological subtypes has been questioned regarding its clinical validity in providing relevant information for treatment for metastatic tumors. Specific genetic alterations are associated with particular clinical and histopathological features, suggesting that these could be helpful in refining existing melanoma classification schemes. We analyzed BRAF V600E mutated melanomas to explore the Reflectance confocal microscopy (RCM) utility as a screening aid in the evaluation of the most appropriate patients for genetic testing. Thus, 32 melanomas were assessed regarding their BRAF V600E mutational status. Experts blinded to dermoscopic images and V600E immunohistochemistry results evaluated RCM images regarding previously described melanoma features. BRAF positive melanomas were related to younger age (p = 0.035), invasive melanomas (p = 0.03) and to the presence of hiporreflective cells (p = 0.02), epidermal nests (p = 0.02), dermal-epidermal junction nests (p = 0.05), edged papillae (p = 0.05), and bright dots (p = 0.05), and to absence of junctional thickening due to isolated cells (p = 0.01) and meshwork (p = 0.02). This study can not characterize other mutations in the BRAF, because the immunohistochemistry is specific to the type V600E. The findings should encourage the genetic evaluation of BRAF mutation. This study highlights the potential of RCM as a supplementary tool in the screening of BRAF-mutated melanomas.

Composto nutracêutico aumenta a síntese de colágeno, elastina e ácido hialurônico / Nutraceutical compound increases collagen, elastin and hyaluronic acid synthesis

Introdução: O uso de produtos nutracêuticos com a finalidade de atenuar os sinais do envelhecimento da pele tem sido proposto na literatura. O estímulo à síntese de elementos de sustentação da derme é um dos mecanismos relacionados a esse efeito. Objetivo: Avaliar a eficácia de um nutracêutico contendo luteína, licopeno, vitamina C e mangânes na síntese de colágeno, elastina e ácido hialurônico. Métodos: Estudo realizado in vitro, através de cultura de fibroblastos humanos tratadas com o produto investigado em diferentes concentrações não citotóxicas. A quantificação de elastina e colágeno foi determinada através de medidas espectrofotométricas enquanto que a de ácido hialurônico foi determinada por método imunoenzimático. Resultados: As culturas celulares tratadas com as diferentes concentrações do produto apresentaram quantidade sintetizada de colágeno, elastina e ácido hialurônico significativamente maior quando comparadas com a cultura não tratada (p<0,05). Conclusões: O uso de nutracêutico contendo licopeno, vitamina C, luteína e manganês demonstrou eficácia in vitro no estímulo à síntese de colágeno, elastina e ácido hialurônico, elementos essenciais na estrutura de sustentação da derme e responsáveis pelas características de firmeza e elasticidade da pele.

Introduction: The use of nutraceutical products in order to attenuate signs of skin aging has been proposed in the literature. The stimulus to the synthesis of substances that support the dermis is one of the mechanisms linked to this effect. Objective: To evaluate the effectiveness of a nutraceutical compound containing lutein, lycopene, vitamin C and manganese for the synthesis of collagen, elastin and hyaluronic acid. Methods: An in vitro study was carried out based on the culture of human fibroblasts treated with the investigated product in different non-cytotoxic concentrations. The quantification of the elastin and collagen was performed with the assistance of spectrophotometric measurements. Hyaluronic acid was measure using a immunoenzymatic method. Results: Cell cultures treated with the different concentrations of the product showed a significantly higher amount of synthesized collagen, elastin and hyaluronic acid as compared to the untreated culture (p <0.05). Conclusions: The use of the nutraceutical compound containing lycopene, vitamin C, lutein and manganese has shown in vitro efficacy for stimulating the synthesis of collagen, elastin and hyaluronic acid, components that are crucial for providing the dermis' supporting structure, being responsible for the skin's firmness and elasticity.

Dermoscopy of Naevus-associated Melanomas.

In order to determine dermoscopic parameters, a case-control test set of naevus-associated melanomas vs de novo melanomas paired by Breslow thickness and histopathological subtype was analysed by 2 blinded experienced dermoscopists, according to presence of naevus, pattern analysis and ABCD dermoscopy score. The ability to identify naevus-associated melanomas by pattern analysis was low for both blinded dermoscopists (κ < 0.2). Dermoscopy features associated with naevus-associated melanomas were: presence of negative pigment network (OR 9.915, CI 95% 2.182-45.049), globules (OR 2.383, CI 95% 1.15-4.95) and streaks (OR 2.439, CI 95% 1.271-4.680). In contrast, the presence of blue-white veil was related to absence of associated naevus (OR 0.520, CI 95% 0.273-0.991). With the results obtained, 2 different algorithms were proposed. The use of the proposed algorithms could help raise awareness of naevus-associated melanomas and avoid the possibility of incorrectly diagnosing a naevus-associated melanoma if partial biopsies are performed.

Nevus-associated melanomas: clinicopathologic features.

OBJECTIVES: The clinical significance of nevus-associated melanoma compared with de novo melanomas remains controversial. It has been suggested that nevus-associated melanomas have a higher Breslow thickness and therefore worse prognosis. Over a 10-year period, this study evaluated the incidence of nevus-associated melanoma and its prognostic significance related to clinicopathologic features. METHODS: Cross-sectional study from 1995 through 2004 in a dermatopathology referral center. With available data, we evaluated sex, primary location, histologic subtype, Breslow thickness, Clark level, presence of ulceration, associated lesion, and histologic subtype of the associated lesion. RESULTS: Of 135,653 pathologic records from skin biopsy specimens over a 10-year period, 1,190 melanoma records were selected. Nevus-associated melanomas corresponded to 390 (32.8%) melanomas, with thin melanomas having a nevus 1.52 times the association observed with thick melanomas (>1.01 mm; 95% confidence interval, 1.16-1.99; P < .001). Superficial spreading melanoma was the most frequent, while no lentigo maligna melanoma was associated with nevi. The median Breslow thickness of nevus-associated melanomas was lower than that of de novo melanomas. CONCLUSIONS: Nevus-associated melanomas, which represent one-third of the melanomas in southeast Brazil, are associated with intermittent sun exposure, superficial spreading melanomas, and lower Breslow thickness. This is one of the largest series describing nevus-associated melanomas in Latin America.

Inner gray halo, a novel dermoscopic feature for the diagnosis of pigmented actinic keratosis: clues for the differential diagnosis with lentigo maligna.

BACKGROUND: Pigmented actinic keratosis (PAK) is a frequent simulator of lentigo maligna (LM) on the face upon clinical and dermoscopic examination, leading to misdiagnosis and unnecessary excisions. LM and PAK share dermoscopic features, making it difficult to have a confident diagnosis of PAK only with current dermoscopic knowledge. OBJECTIVE: We sought to evaluate sensitivity, specificity, and interobserver reproducibility of a novel dermoscopic feature, inner gray halo (IGH), and establish its histopathological and confocal correlations. METHODS: Dermoscopists blinded to histopathological diagnosis evaluated 58 PAK and 21 LM for the presence of IGH and dermoscopy parameters. Areas exhibiting IGH were marked and imaged with reflectance confocal microscopy before sampling for histopathologic correlation. Reflectance confocal microscopy and transverse histologic sectioning were performed in 14 of 79 cases. RESULTS: IGH was present in 53 of 58 (94.1%) PAK and in 5 of 21 (23.8%) LM in our series (sensitivity 91.4%; specificity 71.4%; positive predictive value 89.8%). Interobserver agreement was excellent (Kappa 0.846). Through transverse and perpendicular histologic sections, a dermoscopic-histologic-confocal correlation of IGH was established. LIMITATIONS: A larger test set is needed to further validate the use of IGH in the differential diagnosis of PAK and facial pigmented lesions. CONCLUSION: IGH is a novel dermoscopic parameter useful for the differentiation of PAK from LM on the face.

Shiny white streaks: a sign of malignancy at dermoscopy of pigmented skin lesions.

The aim of this study was to evaluate the practical importance of the presence of shiny white streaks (SWS) (chrysalis or crystalline structures in polarized dermoscopy) for suspicion of malignancy, diagnosis of melanoma, and pre-operative estimation of Breslow thickness and its correlation with total dermoscopy score (TDS). SWS were present in 13.6% of 800 consecutive excised lesions. The presence of SWS was associated with malignancy (odds ratio (OR) 10.534, 95% confidence interval (95% CI) 6.357-17.455, p < 0.0005) in the context of melanocytic lesions with invasive melanoma (OR 10.333, 95% CI 3.812-28.014) and melanomas with high TDS (OR 6.286, 95% CI 1.673-23.619), but was also a factor in the diagnosis of featureless and some thin melanomas. These results corroborate the clinical applicability of SWS in aiding the diagnosis of malignancy and helping to raise the general dermatologist's awareness in cases of doubt and featureless lesions.

Dermatoscopia das lesões pigmentadas na face: um desafio diagnóstico / Dermoscopy of pigmented lesions of the face: a diagnostic challenge

A dermatoscopia do lentigo maligno na face tem parâmetros confiáveis e bem testados para sua diagnose. Algumas lesões benignas, como as queratoses actínicas pigmentadas, apresentam, contudo, aspectos dermatoscópicos comuns aos lentigos malignos, dificultando a correta diagnose. Isso muitas vezes leva a excisões desnecessárias de lesões benignas. Este artigo discute esses parâmetros morfológicos no escopo de analisar os pontos em comum entre lentigo maligno e queratose actínica pigmentada com a dermatoscopia, assim como coteja os aspectos já descritos para a diagnose das queratoses actínicas pigmentadas.

Dermoscopy of lentigo maligna on the face has reliable and well-tested parameters for its diagnosis. However, some benign lesions such as pigmented actinic keratoses have dermoscopic aspects that are common in malignant lentigo, making the correct diagnosis difficult. This fact often leads to unnecessary excisions of benign lesions. The present article discusses these morphological parameters in light of the dermoscopic analysis of the commonalities between lentigo maligna and pigmented actinic keratosis, also touching upon the aspects already described for the diagnosis of pigmented actinic keratoses.