Osteomielite crônica como uma armadilha ao diagnóstico na prática do dermatologista / Chronic osteomyelitis as a diagnostic pitfall in the practice of the dermatologist: a case report

Na prática clínica da dermatologia não é incomum nos depararmos com situações desafiadoras, de difícil caracterização e que podem nos induzir ao erro diagnóstico. Quadros cutâneos com apresentações semelhantes entre si estão aqui inclusas e, neste caso, é de suma importância a atuação do médico dermatologista de forma a unir as informações da anamnese, exame físico e exames complementares, a fim de excluir condições de pior prognóstico e que requerem atuação mais agressiva de outras condições benignas e/ou com menor impacto negativo. Apresentamos abaixo uma dessas situações de desafio diagnóstico em que uma lesão cutânea secundária à osteomielite crônica foi inicialmente atribuída à causa inflamatória ou neoplásica (AU)

In the clinical practice of Dermatology, it is not uncommon to encounter challenging situations that are difficult to characterize and may lead to misdiagnosis. Skin conditions with similar presentations are included here and, in this case, it is of utmost importance that the dermatologist combines information from the medical history, physical examination and complementary tests in order to exclude conditions with worse prognosis and that require more aggressive action than other benign conditions and/or with less negative impac (AU)

Assessment of psoriasis severity in Brazilian patients with chronic plaque psoriasis attending outpatient clinics: a multicenter, population-based cross-sectional study (APPISOT).

PURPOSE: Data on chronic plaque psoriasis severity and its potential clinical and lifestyle implications in the Brazilian population are limited. The primary aim of this study was to assess the clinical severity of plaque psoriasis in Brazil. Further objectives included evaluating potential associations between disease severity and demographic, lifestyle, and clinical characteristics, health-related quality of life (HRQOL), and work productivity. MATERIALS AND METHODS: This observational (non-interventional) cross-sectional study was conducted in 26 dermatologic clinics across 11 Brazilian states. Psoriasis severity was assessed using investigator judgment and Finlay's Rule of Tens: a Psoriasis Area and Severity Index (PASI) score >10, a Body Surface Area (BSA) > 10%, or a Dermatology Life Quality Index (DLQI) score >10. RESULTS: Among 1125 patients, 205 (18.2%) had moderate-to-severe disease. On multiple regression analyses, psoriasis severity was significantly (directly) associated with the presence of physical inactivity and comorbid pain, anxiety, and depression; and significantly (inversely) associated with HRQOL and work productivity. LIMITATIONS: Cross-sectional studies cannot assess temporal trends, and observational studies cannot conclusively determine causality or exclude biases and confounding due to unmeasured variables. CONCLUSIONS: Among Brazilian patients with moderate-to-severe psoriasis, disease severity had far-reaching adverse impacts on lifestyle, comorbidities, HRQOL, and work productivity.

Transplante de melanócitos - Variação da técnica de microenxertia / Melanocyte transplantation ­ a variation of the micrografting technique

Vitiligo é desordem adquirida da pigmentação, caracterizada pelo desenvolvimento de máculas acrômicas bem definidas na pele. É considerado estável quando nenhuma lesão nova aparece ou quando lesões preexistentes não sofrem alterações ao longo de pelo menos um ano. Nesses casos o tratamento cirúrgico é importante opção terapêutica. A microenxertia por punch é a técnica de transplante de melanócitos mais comumente realizada, com ótima repigmentação. Descreve-se uma variação dessa técnica utilizando enxertos ainda menores e mais finos (que consistem de epiderme e derme fina), para buscar resultados esteticamente melhores do que os da técnica tradicional, principalmente ao tratar áreas com significativo acometimento estético.

Vitiligo is an acquired pigmentation disorder characterized by the development of well-defined achromic macules in the skin. It is deemed stable when no new lesion emerges or when pre-existing lesions do not undergo changes for at least one year. In these cases, surgical treatment is an important therapeutic option. Punch micrografting is the most commonly performed melanocyte transplantation technique, resulting in excellent repigmentation. The authors describe a variation of this technique using even smaller and finer grafts (consisting of epidermis and thin dermis), in order to achieve aesthetical outcomes that are better than those obtained with the traditional technique, especially when treating areas with significant aesthetic impairment.

Eletrocirurgia de alta frequência em cicatrizes do tipo ice-picks: estudo comparativo prévio e posterior ao tratamento / High-frequency electrosurgery in ice-pick scars: pre and post treatment comparative study

Introdução: Cicatrizes de acne são causa frequente de consulta ao dermatologista, ocorrendo como resultado do processo inflamatório da acne vulgar. As cicatrizes atróficas são as mais comuns, podendo apresentar-se como superficiais, médias ou profundas. Existem várias opções de tratamento para cicatrizes atróficas profundas, porém, geralmente, apresentam eficácia limitada, efeitos colaterais indesejáveis e custo elevado. Objetivo: Avaliar o tratamento de cicatrizes atróficas profundas com eletrocirurgia de alta frequência. Métodos: Dez pacientes com cicatrizes de acne atróficas profundas receberam três sessões de tratamento com eletrocirurgia de alta frequência com intervalos de um mês entre elas. Um mês após a última sessão foram avaliados: aspectos histológicos de cicatrizes selecionadas, antes e um mês após a última sessão; opinião dos pacientes classificando os resultados em piora, ausência de melhora ou melhora das lesões; e avaliação de fotografias padronizadas antes e um mês após a última sessão, por médico não vinculado à pesquisa que também classificou os resultados em piora, ausência de melhora ou melhora das lesões. Resultados: Na análise histológica foi evidenciada redução de fibrose local; na opinião de todos os pacientes o resultado evidenciou melhora das lesões; todos também apresentaram melhora clínica das lesões avaliadas por dermatologista. Conclusão: A eletrocirurgia de alta frequência é método simples, de baixo custo e eficaz no tratamento de cicatrizes de acne atróficas e profundas.

Introduction: Acne scars result from inflammation of acne vulgaris and are a frequent cause of complaints in dermatology practices. Atrophic scars are the most common, and may be classified into superficial, medium, and deep. There are several treatment options for deep atrophic scars, however they have limited efficacy in general, undesirable side effects and are expensive. Objective: To evaluate the treatment of deep atrophic scars with high frequency electrosurgery. Methods: Ten patients with deep atrophic acne scars received 3 high frequency electrosurgery treatment sessions with intervals of 1 month. The following were used to evaluate the outcome 1 month after the last session: histological aspects of selected scars as compared to the baseline; ratings attributed to the results by the patients (worsened, unchanged or improved); and standardized photographs at baseline and 1 month after the last session performed by a physician not related to the study, who also rated the results (worsened, unchanged or improved). Results: Histological analysis evidenced a reduction in local fibrosis. All patients noticed improvement in the lesions. The evaluator dermatologist physician verified the presence of clinical improvement in all patients. Conclusion: High frequency electrosurgery is a straightforward, inexpensive and effective method for the treatment of atrophic deep acne scars.

Tratamento da alopecia androgenética: associação de laser Erbium Glass 1550nm e infiltração de ativos / Androgenetic alopecia treatment: associating 1550nm erbium-glass laser with drug injections of active principles

Introdução: A alopecia androgenética é a forma mais comum de perda de cabelos em homens e mulheres. As opções de tratamento com medicações são as mais utilizadas atualmente, embora tragam poucos resultados. Recentemente o uso do laser tem sido sugerido para tratar essa entidade. A infiltração de medicação no couro cabeludo também vem crescendo como opção terapêutica, apesar de existirem poucos trabalhos científicos sobre esse tratamento. Objetivo: Avaliar o resultado do uso do laser de Erbium Glass 1550nm associado à infiltração de ativos (minoxidil, finasterida, fatores de crescimento e complexo vitamínico) para tratamento da alopecia androgenética masculina e feminina. Métodos: Estudo retrospectivo de pacientes com esse diagnóstico, submetidos a sessões mensais da associação terapêutica proposta. Os resultados foram avaliados por meio de fotografias comparativas realizadas antes e após o período de tratamento e de pesquisa de opinião dos pacientes. Resultados: Foram tratados 62 pacientes, com sessões, cujo número variou de três a 14; 48,39% dos pacientes apresentaram melhora discreta, e 46,77% melhora importante. A maioria (96,77%) ficou satisfeita com o tratamento. Os pacientes muito satisfeitos realizaram maior número de sessões, em média mais de seis. Conclusões: A associação de laserterapia com Erbium Glass 1550nm e infiltração de ativos no couro cabeludo é opção eficaz e segura para o tratamento da alopecia androgenética.

Introduction: Introduction: Androgenetic alopecia is the most common type of hair loss in men and women. Nowadays, medication based treatments are the most frequently used nevertheless they yield poor results. More recently, the use of lasers has been proposed to treat this condition. At the same time, the infiltration of medications in the scalp has also been growing as a therapeutic option, although there are few scientific studies on this treatment modality. Objective: To evaluate the results of using 1,550nm Erbium-Glass laser associated with the injection of active principles (minoxidil, finasteride, growth factors and a vitamin complex) for the treatment of male and female androgenetic alopecia. Methods: A retrospective study was carried out with patients with androgenetic alopecia diagnosis, who underwent monthly sessions of the proposed combination therapy. The results were evaluated by means of comparative photographs taken before and after the treatment period and the assessment of the patients' opinion. Results: Sixty-two patients were treated with 3 to 14 sessions; 48.39% of patients had mild improvement, and 46.77% had significant improvement. The vast majority (96.77%) was satisfied with the treatment. The patients who were very satisfied with the outcomes underwent a greater number of sessions (more than six, on average). Conclusions: The association of 1,550nm Erbium-Glass laser therapy with the injection of active principles in the scalp is an effective and safe option for the treatment of androgenetic alopecia.

Erythroplasia of Queyrat treated with topical 5-fluorouracil

Abstract We report a 33-year-old male patient diagnosed with erythroplasia of Queyrat. The patient had an erythematous and eroded lesion affecting more than 50% of the glans associated with bleeding and local pain. Despite previous indication of penectomy, he was successfully treated with topical 5-fluorouracil.

Infliximab in patients with psoriasis and other inflammatory diseases: evaluation of adverse events in the treatment of 168 patients.

BACKGROUND: Psoriasis is immune-mediated chronic inflammatory disease with preference for skin and joints. The skin involvement occurs by hyperproliferation and abnormal differentiation of keratinocytes. It is associated with comorbidities, mainly related to the clinical manifestations of the metabolic syndrome. Increased TNF-alpha expression (TNF-α) is related to its pathophysiology. Infliximab is an intravenous drug that acts neutralizing the biological activity of TNF-α and prevents the binding of the molecule to the target cell receptor, inhibiting cell proliferation of psoriasis and other diseases mediated by TNF-α. A lot of infusion reactions have been described in the literature. OBJECTIVE: To evaluate the adverse effects of intravenous treatment with infliximab, analyzing patients with psoriasis compared to those with other chronic inflammatory diseases (rheumatoid arthritis, ankylosing spondylitis, Crohn's disease and ulcerative colitis). METHOD: Analysis of medical records and adverse events of 168 patients undergoing infliximab infusion for psoriasis and chronic inflammatory diseases treatment. RESULTS: 168 patients who have used infliximab were evaluated, 24 had psoriasis and 144 had chronic inflammatory diseases. Only 2 (8.3%) patients with psoriasis showed adverse events requiring treatment discontinuation, and just 6 (4.2%) female patients with chronic inflammatory diseases experienced adverse events. CONCLUSION: Infliximab is a safe drug, with a low percentage of adverse events and there were more adverse events in women with chronic inflammatory diseases and in patients who received more infliximab infusions.

Infliximab in patients with psoriasis and other inflammatory diseases: evaluation of adverse events in the treatment of 168 patients

Abstract: Background: Psoriasis is immune-mediated chronic inflammatory disease with preference for skin and joints. The skin involvement occurs by hyperproliferation and abnormal differentiation of keratinocytes. It is associated with comorbidities, mainly related to the clinical manifestations of the metabolic syndrome. Increased TNF-alpha expression (TNF-α) is related to its pathophysiology. Infliximab is an intravenous drug that acts neutralizing the biological activity of TNF-α and prevents the binding of the molecule to the target cell receptor, inhibiting cell proliferation of psoriasis and other diseases mediated by TNF-α. A lot of infusion reactions have been described in the literature. Objective: To evaluate the adverse effects of intravenous treatment with infliximab, analyzing patients with psoriasis compared to those with other chronic inflammatory diseases (rheumatoid arthritis, ankylosing spondylitis, Crohn's disease and ulcerative colitis). Method: Analysis of medical records and adverse events of 168 patients undergoing infliximab infusion for psoriasis and chronic inflammatory diseases treatment. Results: 168 patients who have used infliximab were evaluated, 24 had psoriasis and 144 had chronic inflammatory diseases. Only 2 (8.3%) patients with psoriasis showed adverse events requiring treatment discontinuation, and just 6 (4.2%) female patients with chronic inflammatory diseases experienced adverse events. Conclusion: Infliximab is a safe drug, with a low percentage of adverse events and there were more adverse events in women with chronic inflammatory diseases and in patients who received more infliximab infusions.

Erythroplasia of Queyrat treated with topical 5-fluorouracil.

We report a 33-year-old male patient diagnosed with erythroplasia of Queyrat. The patient had an erythematous and eroded lesion affecting more than 50% of the glans associated with bleeding and local pain. Despite previous indication of penectomy, he was successfully treated with topical 5-fluorouracil.

Clouston Syndrome: 25-year follow-up of a patient

Abstract: Clouston syndrome is a rare genodermatosis that affects skin and annexes. It is a form of ectodermal dysplasia characterized by generalized hypotrichosis, palmoplantar hyperkeratosis and nail dystrophy. This paper reports a 25-year follow-up of a patient with Clouston syndrome, from childhood to adulthood, monitoring diagnosis and clinical course of the disease.

Síndrome de Stevens-Johnson, necrólise epidérmica tóxica e eritema multiforme major são a mesma doença? / Syndrome Stevens-Johnson, toxic epidermal necrolysis and erythema multiforme major are the same disease?

O objetivo do presente estudo é descrever as diferentes classificações e expressões da síndrome de Stevens-Johnson (SSJ), necrólise epidérmica tóxica (NET) e eritema multiforme major (EMM). Fizemos uma revisão bibliográfica abordando os aspectos históricos sobre os conceitos referentes a essas patologias mucocutâneas. Artigos experimentais, descritivos, de revisão e relatos de caso, obtidos da plataforma de pesquisa Pubmed (US National Library of Medicine / National Institute of Health), foram selecionados com o intuito de elucidar as diferentes manifestações de doenças que já provocaram contradições em relação aos diagnósticos, tratamentos e prognósticos. Evidenciou-se a diferenciação entre as doenças SSJ e EMM, ao passo que a SSJ e a NET foram consideradas uma extensão da mesma patologia.

The association of fractional CO2 laser 10.600nm and photodynamic therapy in the treatment of onychomycosis.

BACKGROUND: Onychomycosis is a fungal infection of the nails caused in most cases by dermatophytes Trichophyton rubrum and Trichophyton mentagrophytes. Despite numerous available antifungal drugs for therapy of this infection, the cure rate is low, with high rates of relapse after treatment and side effects. OBJECTIVES: To present a new option for the treatment of onychomycosis, in search of a more effective and rapid method than conventional ones. METHODS: Patients underwent two sessions of CO2 fractional laser 10.600nm associated with photodynamic therapy. Mycological and digital photography were performed before and after the treatment. RESULTS: McNemar test with continuity correction and degrees of freedom = 1: for clinical cure rate, 13.06, with p=0.00005; for mycological cure, 17.05, with p=0.00005; 72% felt fully satisfied with the procedure. CONCLUSIONS: The use of fractional CO2 laser 10.600nm associated with photodynamic therapy can be effective in the treatment of onychomycosis, decreasing the risk of systemic lesions that may be triggered with prolonged use of oral antifungals.

The association of fractional CO2 laser 10.600nm and photodynamic therapy in the treatment of onychomycosis

AbstractBACKGROUND:Onychomycosis is a fungal infection of the nails caused in most cases by dermatophytes Trichophyton rubrum and Trichophyton mentagrophytes. Despite numerous available antifungal drugs for therapy of this infection, the cure rate is low, with high rates of relapse after treatment and side effects.OBJECTIVES:To present a new option for the treatment of onychomycosis, in search of a more effective and rapid method than conventional ones.METHODS:Patients underwent two sessions of CO2 fractional laser 10.600nm associated with photodynamic therapy. Mycological and digital photography were performed before and after the treatment.RESULTS:McNemar test with continuity correction and degrees of freedom = 1: for clinical cure rate, 13.06, with p=0.00005; for mycological cure, 17.05, with p=0.00005; 72% felt fully satisfied with the procedure.CONCLUSIONS:The use of fractional CO2 laser 10.600nm associated with photodynamic therapy can be effective in the treatment of onychomycosis, decreasing the risk of systemic lesions that may be triggered with prolonged use of oral antifungals.

Incontinência pigmentar: relato de dois casos / Incontinentia pigmenti: report of two cases

Introdução: Incontinência pigmentar é uma genodermatose incomum ligada ao X. É doença que afeta tecidos derivados do ectoderma e mesoderma com alterações sistêmicas múltiplas. As manifestações cutâneas são características da enfermidade e progridem de forma cronológica, assim como os achados histopatológicos. Objetivo: Essa é uma doença rara com manifestações cutâneas e extracutâneas, sendo as primeiras mais frequentes, cujo diagnóstico precoce e acompanhamento multidisciplinar são de suma importância. Descrição do caso: Relatamos dois casos de incontinência pigmentar em crianças do sexo feminino com manifestações clínicas diversas e diferentes critérios diagnósticos, de acordo com antecedentes familiares. Discussão: O acometimento cutâneo é uma característica marcante da incontinência pigmentar, o que torna a avaliação dermatológica o passo inicial na sua investigação. Cabe ao dermatologista se atentar para esse diagnóstico e encaminhar precocemente para avaliação multidisciplinar, a fim de minimizar possíveis complicações e promover qualidade de vida ao paciente.

Clouston Syndrome: 25-year follow-up of a patient.

Clouston syndrome is a rare genodermatosis that affects skin and annexes. It is a form of ectodermal dysplasia characterized by generalized hypotrichosis, palmoplantar hyperkeratosis and nail dystrophy. This paper reports a 25-year follow-up of a patient with Clouston syndrome, from childhood to adulthood, monitoring diagnosis and clinical course of the disease.

Case for diagnosis

Graham-Little-Piccardi-Lassueur Syndrome is a rare form of Lichen Planus, characterized by the presence of the triad: non-scarring hair loss in the inguinal and axillary regions and follicular spinous or disseminated acuminate papules; typical, cutaneous or mucous LP; and scarring alopecia of the scalp with or without atrophy. These features do not have to be present simultaneously.