Síndrome de arlequim idiopática: sucesso terapêutico com toxina botulínica / Idiopathic harlequin syndrome: successful therapy with botulium toxin

A síndrome de arlequim é uma rara desordem autonômica que se caracteriza por anidrose e falta de rubor unilateral da face, podendo acometer as regiões cervical e torácica. De forma paradoxal, há rubor e sudorese compensatórios no lado contralateral à alteração. É idiopática na maioria dos casos, mas pode ser congênita, secundária a lesões estruturais e à iatrogenia pós-cirúrgica. O tratamento é direcionado ao fator causal. Descreve-se caso de paciente com diagnóstico de síndrome de arlequim idiopática, sendo realizada aplicação de toxina botulínica na hemiface acometida pelos sintomas compensatórios com boa resposta terapêutica

Harlequin syndrome is a rare autonomic disorder characterized by anhidrosis and lack of unilateral flushing of the face, which may affect the cervical and thoracic regions. Paradoxically, there is compensatory flushing and sweating on the contralateral side to the alteration. It is idiopathic in most cases, but it can be congenital or secondary to structural or post-surgical iatrogenic lesions. Treatment is directed at the causative factor. We describe the case of a patient with a diagnosis of idiopathic Harlequin Syndrome with botulinum toxin application in the hemiface affected by compensatory symptoms with good therapeutic response.

Atualizações do uso cosmiátrico e terapêutico da toxina botulínica / Updates on the cosmiatric and therapeutic use of botulinum toxin

A toxina botulínica tem como mecanismo de ação a paralisia neuromuscular flácida transitória. Estudos recentes estão identificando novas formas de uso da toxina botulínica para diversos fins, tanto no campo estético quanto no terapêutico. Este trabalho teve como objetivo realizar uma revisão bibliográfica sobre essas aplicações. No âmbito estético, a toxina botulínica demonstrou benefício em tratamento de cicatrizes hipertróficas, rejuvenescimento da região escrotal, definição do músculo gastrocnêmio e sendo usada em microdoses. Já no tratamento de patologias, a revisão demonstrou que a toxina botulínica pode ser útil para tratamento da neuralgia pós-herpética e de outras síndromes álgicas, da hiperidrose craniofacial, da rosácea e da doença de Hailey-Hailey.

Botulinum toxin has transient flaccid neuromuscular paralysis as its mechanism of action. Recent studies are identifying new ways to use botulinum toxin for a variety of purposes, both in the aesthetic and in the therapeutic field. This work aimed to conduct a literature review on these applications. In the aesthetic field, botulinum toxin has shown benefit in the treatment of hypertrophic scars, rejuvenation of the scrotal region, definition of the gastrocnemius muscle, and microdoses use. In the treatment of pathologies, the review has shown that botulinum toxin may be useful for the treatment of post-herpetic neuralgia and other pain syndromes, craniofacial hyperhidrosis, rosacea, and Hailey-Hailey disease.

Sutura com cones absorvíveis para rejuvenescimento facial: descrição da técnica e análise de 21 pacientes / Suture with absorbable cones for facial rejuvenation: technique description and analysis of 21 patients

Introdução: O uso injetável do ácido poli-L-láctico (PLLA), polímero biocompatível reabsorvível com alto poder de estímulo ao colágeno, já é consagrado na Dermatologia Cosmiátrica. Os fios de sustentação do PLLA, cravejados por cones de poli-L-lactídeo-co- -glicolídeo (PLGA), além de desencadearem a neocolagênese por meio da resposta inflamatória subclínica, proporcionam um efeito lifting devido à tração proporcionada por estes cones. O interesse pelo lifting com fios está em evidência e necessita de estudos detalhados para avaliação de indicações, complicações e eficácia do tratamento. Objetivos: Este estudo buscou avaliar a segurança, eficácia e satisfação do paciente em relação ao rejuvenescimento após lifting facial por meio da sutura absorvível. Métodos: Foram selecionados e submetidos ao tratamento com fios de sustentação 21 pacientes que apresentavam flacidez no terço médio e inferior da face. Questionário de satisfação foi aplicado. Resultados: No presente estudo, 71,4% dos pacientes relataram ótimo resultado estético após três meses da realização do procedimento. Efeitos colaterais, como equimose, dor e irregularidade da superfície facial, foram descritos principalmente na primeira semana após o procedimento. Conclusões: A sutura de PLLA com cones de PLGA foi eficaz no tratamento da flacidez facial leve a moderada de pacientes bem indicados, e seus efeitos colaterais foram mínimos quando comparados aos de técnicas invasivas. Estes resultados devem ser confirmados por estudos com casuística maior.

Introduction: Injectable use of poly-L-lactic acid (PLLA), biocompatible absorbable polymer with a high capacity to stimulate collagen, is already well-established in Cosmetic Dermatology. PLLA lifting threads, studded with poly-L-lactic-co-glycolic (PLGA) cones, besides triggering neocollagenesis through subclinical inflammatory response, provide a lifting effect due to the traction caused by these cones. The interest in thread lifting is in evidence and needs detailed studies for the evaluation of treatment indications, complications, and efficacy. Objectives: This study aimed at evaluating safety, efficacy and patient satisfaction in regards to rejuvenation after facial lifting using the absorbable suture. Methods: Twenty-one patients with laxity of the middle and lower third of the face were selected and submitted to the treatment with lifting threads. A satisfaction questionnaire was applied. Results: In this study, 71.4% of the patients reported great aesthetic result three months after the procedure. Side effects such as bruising, pain and uneven facial skin surface were described mainly on the first week after the procedure. Conclusions: PLLA sutures with PLGA cones was effective for the treatment of mild to moderate facial laxity in well-indicated patients, and the side effects were minimal when compared to invasive techniques. These results should be confirmed by studies with a larger number of individuals.

Mycobacterium chelonae cutaneous infection in a patient with mixed connective tissue disease.

Around 50 mycobacteria species cause human disease. Immunosuppressive states predispose to non-tuberculous mycobaterium infection, such as Mycobacterium chelonae: AFB, non-tuberculous, fast growth of low virulence and uncommon as a human pathogen. It may compromise the skin and soft tissues, lungs, lymph nodes and there is also a disseminated presentation. The diagnosis involves AFB identification and culture on Agar and Lowenstein-Jensen medium base. A 41-year-old female with MCTD (LES predominance) is reported, presenting painless nodules in the right forearm. She denied local trauma. Immunosuppressed with prednisone and cyclophosphamide for 24 months. Lesion biopsy has demonstrated positive bacilloscopy (Ziehl-Neelsen stain) and M.chelonae in culture (Lowenstein-Jensen medium base), therefore clarithromycin treatment has been started (best therapy choice in the literature).

Mycobacterium chelonae cutaneous infection in a patient with mixed connective tissue disease

Around 50 mycobacteria species cause human disease. Immunosuppressive states predispose to non-tuberculous mycobaterium infection, such as Mycobacterium chelonae: AFB, non-tuberculous, fast growth of low virulence and uncommon as a human pathogen. It may compromise the skin and soft tissues, lungs, lymph nodes and there is also a disseminated presentation. The diagnosis involves AFB identification and culture on Agar and Lowenstein-Jensen medium base. A 41-year-old female with MCTD (LES predominance) is reported, presenting painless nodules in the right forearm. She denied local trauma. Immunosuppressed with prednisone and cyclophosphamide for 24 months. Lesion biopsy has demonstrated positive bacilloscopy (Ziehl-Neelsen stain) and M.chelonae in culture (Lowenstein-Jensen medium base), therefore clarithromycin treatment has been started (best therapy choice in the literature).

Linear chronic discoid lupus erythematosus following the lines of Blaschko.

Linear chronic discoid lupus erythematosus is a rare manifestation of cutaneous lupus in which erythematous, atrophic, dyschromic lesions are located along the lines of Blaschko. This report describes the case of a 15-year old boy with a 2-year history of discoid, erythematous, hyper and hypopigmented lesions with central atrophy, situated along the lines of Blaschko on his right arm. Histopathology showed epidermal atrophy, hyperkeratosis, follicular plugging, thickening of the basement membrane zone, and superficial and deep chronic perivascular and periadnexal inflammatory infiltrate, with dermal mucin deposit, thus confirming diagnosis. A total of 14 cases have been described of this variant, the onset of which is often in childhood. There is no difference in incidence between genders. Lesions most commonly develop on the face. There have been no reports of any association with systemic disease.

Lúpus eritematoso crônico discoide nas linhas de Blaschko / Linear chronic discoid lupus erythematosus following the lines of Blaschko

O lúpus eritematoso crônico discoide linear é manifestação rara da doença lúpica cutânea, em que lesões eritêmato-atrófico-discrômicas dispõem-se nas linhas de Blaschko. Descrevemos o caso de um menino de 15 anos, com dois anos de história de lesões discoides eritêmato-atróficas, hipo e hiperpigmentadas, dispostas nas linhas de Blaschko do membro superior direito. O exame histopatológico revelou atrofia da epiderme, hiperqueratose, rolhas córneas, espessamento da zona da membrana basal, infiltrado inflamatório crônico perianexial e perivascular superficial e profundo, depósito de mucina na derme, confirmando o diagnóstico. Há, no total, 14 casos descritos dessa variante que se inicia frequentemente na infância e que não apresenta predomínio quanto ao sexo. As lesões ocorrem preferencialmente na face. Não há relatos de associação com doença sistêmica.

Linear chronic discoid lupus erythematosus is a rare manifestation of cutaneous lupus in which erythematous, atrophic, dyschromic lesions are located along the lines of Blaschko. This report describes the case of a 15-year old boy with a 2-year history of discoid, erythematous, hyper and hypopigmented lesions with central atrophy, situated along the lines of Blaschko on his right arm. Histopathology showed epidermal atrophy, hyperkeratosis, follicular plugging, thickening of the basement membrane zone, and superficial and deep chronic perivascular and periadnexal inflammatory infiltrate, with dermal mucin deposit, thus confirming diagnosis. A total of 14 cases have been described of this variant, the onset of which is often in childhood. There is no difference in incidence between genders. Lesions most commonly develop on the face. There have been no reports of any association with systemic disease.

Análise do uso racional de medicamentos anti-hipertensivos utilizados em hospital-escola / Analysis of the rational use of antihypertensive drugs in a school hospital

Objetivo Verificar quais são os anti-hipertensivos mais prescritos para pacientes em seguimento ambulatorial, avaliando a racionalidade das prescrições e interações farmacológicas. Determinar, na amostra, a prevalência de comorbidades e complicações associadas à hipertensão arterial sistêmica. Métodos Foi realizada análise retrospectiva em 543 prontuários de pacientes com diagnóstico de hipertensão arterial sistêmica, em seguimento ambulatorial no período compreendido entre 2000 e 2007. Para o levantamento dos dados, utilizou-se um questionário composto de idade, tempo de diagnóstico, medicamentos utilizados, adesão terapêutica, presença de comorbidades e reações adversas. Resultados A idade variou entre 20 e 95 anos, sendo 49,0% homens e 51,0% mulheres. A monoterapia foi verificada em 23,4% dos pacientes, 42,2% estavam utilizando dois medicamentos, 25,4% utilizavam três e 9,0% quatro ou mais. O medicamento prevalente foi o captopril (65,0%), seguido de hidroclorotiazida (44,4%) e propranolol (28,4%). As associações mais comuns foram captopril com hidroclorotiazida (32,7%) e captopril com propranolol (22,1%). Dislipidemia foi a comorbidade mais frequente (44,2%). Quanto às lesões de órgãos-alvo (retino, nefro ou cardiopatia), houve prevalência de apenas uma destas complicações (31,0%). A margem de erro para a estimativa de proporção realizada é de 4,0%, com um intervalo de confiança de 95,0%. Conclusão A utilização de dois medicamentos para o controle da pressão arterial mostrou-se prevalente, sendo os medicamentos mais utilizados os inibidores da enzima conversora de angiotensina e sua associação com diuréticos ou betabloqueadores. A disponibilidade dos medicamentos na rede pública parece ser o principal fator determinante na prescrição.

Objective The aim of this study is to determine the antihypertensive drugs most commonly prescribed to outpatients, assessing the rationality of prescriptions and drug interactions. It is also to determine the prevalence of comorbidities and complications associated with hypertension in the sample. Methods A retrospective analysis was done of 543 medical records of patients diagnosed with hypertension who were being followed from 2000 to 2007. A questionnaire containing age, time of diagnosis, medications used, adherence to treatment, comorbidities and adverse reactions was used to collect data. Results The patients aged from 20 to 95 years; 49.0% were males and 51.0% were females. Monotherapy was observed in 23.4% of the patients, 42.2% were using two drugs, 25.4% used three and 9% used four or more drugs. The most common drug was captopril (65.0%), followed by hydrochlorothiazide (44.4%) and propranolol (28.4%). The most common associations were captopril with hydrochlorothiazide (32.7%) and captopril with propranolol (22.1%). Dyslipidemia was the most common comorbidity (44.2%). Regarding lesions of target organs (retinopathy, nephropathy or cardiopathy), only one of these complications prevailed (31.0%). The error margin for the estimated proportion was 4.0%, with a confidence interval of 95.0%. Conclusion The use of two drugs to control blood pressure prevailed. The most commonly used drugs were angiotensin-converting enzyme inhibitors and their association with diuretics or beta blockers. The availability of these drugs in the public services seems to be the main determinant for their prescription.