Unveiling idiopathic guttate hypomelanosis: pathology, immunohistochemistry, and ultrastructural study.

BACKGROUND: Idiopathic guttate hypomelanosis (IGH) is a pigment disorder of unknown etiology. Despite its high prevalence and the unaesthetic appearance of the lesions, there are relatively few histological studies on this disorder. This is an important gap to understanding its pathogenesis. OBJECTIVES: To assess the microscopic structure of IGH lesions compared to normal adjacent skin areas and the possible interaction between melanocytes and the subjacent dermis. METHODS: In this cross-sectional study, we took biopsy specimens of hypochromic lesions and adjacent normal skin from 20 patients with IGH. We analyzed the fragments using routine stains, immunohistochemistry, and electron microscopy. RESULTS: We found superficial dermal fibrosis in 90% (18/20) of our IGH cases and unreported keratinocyte cytoplasmic changes on electron microscopy. CONCLUSION: Our results suggest an interaction between melanocytes and the subjacent dermis in IGH. These findings can help to understand melanocyte biology and the pathogenesis of other achromic lesions.

Lupus miliaris disseminatus faciei: when a rare skin disease involves the eyelid / Lupus miliaris disseminatus faciei: quando uma rara dermatose acomete a pálpebra

ABSTRACT The authors present a case of lupus miliaris disseminatus faciei , a rare skin disease of unknown etiology, which may cause unaesthetic scarring due to its difficult treatment. The histopathological examination of epithelioid granulomas with caseating necrosis, together with the clinical features, are important for diagnosis and early treatment with better results. Despite difficult and unsatisfactory treatment, there are ongoing studies on therapy to improve aesthetic and social impairment. This case report describes an initial misdiagnosis delaying appropriate treatment, and highlights the value of physical examination and clinical judgment for another pathological examination, whenever necessary, aiming at better treatment outcomes in daily practice.

RESUMO Os autores apresentam um caso de lupus miliaris disseminatus faciei , uma dermatose rara, de etiologia desconhecida, que pode deixar cicatrizes não estéticas, pela dificuldade de tratamento. O exame histopatológico de granulomas compostos por células epitelioides, com necrose caseosa, e as características clínicas, são importantes para o diagnóstico e tratamento precoce, com melhores resultados. Apesar do tratamento difícil e insatisfatório, há estudos em andamento sobre terapias para melhorar o comprometimento estético e social. Este relato de caso descreve um diagnóstico inicial errôneo, que atrasou o tratamento adequado, e destaca o valor do exame físico e raciocínio clínico para solicitar outro exame anatomopatológico, quando necessário, de forma a obter melhores desfechos com o tratamento, na prática diária.

How much medication is delivered in a novel drug delivery technique that uses a tattoo machine?

BACKGROUND: Even though dermatologists often perform drug delivery procedures, it is necessary to assess their safety. OBJECTIVE: Quantify the amount of medication delivered using the MMP drug delivery technique and outline other safety parameters. METHODS: Using a simple and novel technique, we attempted to quantify the amount of medication delivered by weighing human skin samples before and after delivery. RESULTS: In drug delivery done on human skin using a liquid with a density of 1,271,460 µg/ml (the values expressed in this manuscript are in µg), a needling density of 570 perforations/cm2 , and a needling depth of 300 microns, we estimate that 1,175 µg/cm2 were delivered (standard deviation 601 µg/cm2 , standard error 190 µg/cm2 ). LIMITATIONS: This result is only applicable to the protocol proposed in this study for the MMP drug delivery technique. CONCLUSION: The MMP drug delivery technique injects small amounts of medication (1,175 µg/cm2 ) homogeneously into the dermis.

Evaluation of C-reactive protein as an inflammatory marker of pemphigus foliaceus and superficial pyoderma in dogs.

BACKGROUND: C-reactive protein (CRP) is a major acute phase protein in dogs and may be an inflammatory marker of autoimmune diseases. HYPOTHESIS/OBJECTIVES: To measure pre- and post-treatment CRP levels in dogs with superficial pyoderma (SP) and pemphigus foliaceus (PF) compared to normal dogs; to evaluate possible correlation between CRP values, indirect immunofluorescence (IIF), and pemphigus foliaceus extent and severity index (PEFESI) scores. ANIMALS: Fifty nine dogs divided into three groups: Group I (control, n = 31), Group II (SP, n = 14) and Group III (PF, n = 14). METHODS: CRP levels were measured in Group I dogs. Skin biopsies of Groups II and III dogs were obtained for histopathological examination. In Group II dogs, CRP levels were measured at days 0, 15, 30 and 60. In Group III dogs were evaluated by PEFESI, IIF and CRP levels at days 0, 15, 30, 60 and 90. RESULTS: Group III showed a higher median CRP (37.4 mg/mL) compared to the other groups (Group I, CRP 2.9 mg/mL, P < 0.0001; Group II CRP 3.8 mg/mL, P = 0.008). There was no significant difference in CRP levels between groups I and II. IIF titres and CRP levels decreased in most cases of PF with clinical improvement. Dogs with CRP >10.6 µg/mL were 5.5 times more likely to have PF than SP. There was a strong positive correlation between CRP values and PEFESI and a weak positive correlation between CRP values and IIF titres. CONCLUSION AND CLINICAL IMPORTANCE: CRP levels are increased in dogs with PF and exceed levels found in most dogs with SP.

Neuroma encapsulado em paliçada - simulando carcinoma basocelular: relato de caso / Case report: Palisaded encapsulated neuroma simulating a Basal Cell Carcinoma

Os neuromas encapsulados em paliçada são tumores neurais solitários da pele caracterizados pela presença de feixes compactos e paralelos de fascículos de células de Schwann. Apresenta-se um caso desse tumor, confirmado por exame anatomopatológico, em paciente do sexo feminino, de 55 anos, que relatou mácula hipocrômica de crescimento que evoluiu para pápula de superfície lisa e em domo, com telangiectasias, simulando carcinoma basocelular. Ter conhecimento dessa entidade é importante para a realização de diagnósticos diferenciais com outras lesões, em especial com o CBC, tumores de apêndice cutâneo, nevos e cistos epidérmicos.

Palisaded encapsulated neuromas are solitary neural skin tumors characterized by the presence of compact and parallel bundles of Schwann cell fascicles. The present article reports a case of this type of tumor, which was confirmed by anatomic pathological examination of a 55-year-old female patient who reported hypochromic macula growth, which had evolved into a smooth domed superficial papule with telangiectasias, simulating a basal cell carcinoma. Having knowledge of this entity is crucial in order to carry out differential diagnoses-comparing it to other lesions-especially basal cell carcinomas, skin appendage tumors, nevi, and epidermal cysts.

Dermatologists' accuracy in early diagnosis of melanoma of the nail matrix.

OBJECTIVE: To measure and compare the accuracy of 4 different clinical methods in the diagnosis of melanoma in situ of the nail matrix among dermatologists with different levels of clinical experience. DESIGN: Twelve cases of melanonychias (5 melanomas and 7 nonmelanomas) were presented following 4 successive steps: (1) clinical evaluation, (2) evaluation according to the ABCDEF rule, (3) dermoscopy of the nail plate, and (4) intraoperative dermoscopy. At each step, the dermatologists were asked to decide if the lesion was a melanoma. SETTING: The test was administered at 2 dermatological meetings in 2008. PARTICIPANTS: A total of 152 dermatologists, including 11 nail experts, 53 senior dermatologists, and 88 junior dermatologists. MAIN OUTCOME MEASURES: The answers were evaluated as percentage of right answers for each diagnostic step according to the different grade of expertise. Differences among the percentage of right answers in the different steps were evaluated with the z test at a 5% level of significance. The agreement was investigated using Cohen kappa statistic. RESULTS: The only method that statistically influenced the correct diagnosis for each category (experts, seniors, and juniors) was intraoperative dermoscopy (z test; P < .05). Cohen kappa statistic showed a moderate interobserver agreement. CONCLUSIONS: Overall accuracy of dermatologists in the diagnosis of nail matrix melanoma in situ is low because the percentages of physicians who indicated the correct diagnosis during each of the first 3 clinical steps of the test ranged from 46% to 55%. The level of expertise did not statistically influence the correct diagnosis.

Tratamento do líquen plano pigmentoso com luz intensa pulsada / Treatment of lichen planus pigmentosum with intense pulsed light

Trata-se do relato de um caso de líquen plano pigmentoso,associado ao líquen plano clássico, tratado com luz intensa pulsada. A tecnologia da luz intensa pulsada tem sido utilizada com êxito na remoção de várias lesões cutâneas pigmentadas benignas e, no caso raro aqui abordado, provou sua efetividade.

This a case report of lichen planus pigmentosus associated with classical lichen planus treated with intense pulsed light. Intense pulsed light technology has been used successfully for removal of various benign pigmented skin lesions and, in this rare case, it has proved its effectiveness.

5-Fluorouracil superficial peel for multiple actinic keratoses.

BACKGROUND: Chronically photodamaged skin usually presents with multiple, widespread, actinic keratoses (AKs), and treatment of the entire affected area is recommended. METHODS: We report our experience with a combination of Jessner's solution or 70% glycolic acid (GA) with 5% 5-fluorouracil (5-FU) solution for superficial pulse peeling used in the treatment of widespread AKs in 31 patients. Pulse peelings were performed at biweekly intervals. The endpoint for treatment was complete or maximum clearance of the lesions at clinical evaluation. Pre- and post-skin biopsy and histopathologic examination were performed in three patients for the purpose of demonstrating the pulse peel effects. RESULTS: All patients achieved a satisfactory result, including the complete regression, or at least 80% clearing, of AK lesions and an overall improvement of photodamaged skin. CONCLUSION: We consider this superficial 5-FU pulse peel to be a safe, well-tolerated, very effective, and highly inexpensive therapeutic option for the treatment of multiple, diffuse AKs. Its benefit/cost ratio will be of interest to public health services, mainly in developing countries.

A comparative study of teledermatoscopy and face-to-face examination of pigmented skin lesions.

We examined the agreement between diagnoses of pigmented skin lesions based on an in-person (face-to-face) dermatological examination and diagnoses based on the study of medical records and images transferred through the web (teledermatoscopy). Two experienced dermatologists examined and diagnosed 64 pigmented skin lesions, which had been surgically excised and undergone histopathology examination. Two years later, the same cases were studied and diagnosed once again by the same dermatologists via the web. There was 72% agreement between the in-person diagnoses and the biopsy results (the gold standard), and 66% agreement between the telediagnoses and the biopsy results. Telemedicine had high sensitivity (87%) and specificity (73%), although there were 4 false-negative diagnoses. A web-based dermatoscopic diagnostic service appears to be feasible and would meet the needs for access to specialized services in rural areas. However, further work is required to decrease the number of false negative cases.

Pênfigo foliáceo canino: estudo retrospectivo de 43 casos clínicos e terapia (2000-2005) / Canine Pemphigus foliaceus: a retrospective study of 43 clinical cases and therapy (2000-2005)

No período de agosto de 2000 a julho de 2005 foram atendidos 43 casos de Pênfigo Foliáceo (PF) canino no Serviço de Dermatologia do Hospital Veterinária, Universidade de São Paulo. Com este estudo retrospectivo visou-se atualizar dados referentes à caracterização sexual, definição racial e raça, idade, tipo e topografia lesional, quadro sintomático e resposta aos tratamentos isolados com prednisona e com a associação desta à azatioprina, além de demonstrar o aumento na ocorrência do PF relativamente à série histórica pretérita (1986-2000) do mesmo Serviço.

From August 2000 to July 2005 were attended 43 cases of canine Pemphigus foliaceous (PF) by the Dermatology Service of the Veterinary Teaching Hospital, University of São Paulo. The aim of the present study was to update the records referred to sex, breed, age, type and location of the lesions, clinical signs, and response to treatments with prednisone or combination with prednisone and azathioprine, and also to demonstrate the increase of occurrence of PF compared with the former series (1986-2000) observed in the same Service.

Xantogranuloma necrobiótico solitário sem paraproteinemia / Necrobiotic xanthogranuloma without paraproteinemia

O xantogranuloma necrobiótico é doença crônica granulomatosa e xantomatosa, caracterizada por pápulas e placas infiltradas, eritematosas e amareladas, preferencialmente localizadas na região periorbital. É comum associar-se com paraproteinemia e risco aumentado para malignidades hematológicas e linfoproliferativas. Sua patogênese permanece desconhecida. Agentes alquilantes, como clorambucil e melfalan, podem ser utilizados no tratamento com sucesso variável. Relata-se um exemplo dessa rara doença em paciente com lesão única e sem paraproteinemia.

Necrobiotic xanthogranuloma is a chronic granulomatous and xantomathous disease, characterized by indurated, nontender, yellowish and erythematous nodules and plaques especially located on the periorbital region. It is commonly associated with paraproteinemia and an increased risk for hematological and lymphoproliferative malignancies. Its pathogenesis remains unclear. Alkylating agents, such as chlorambucil and melphalan may be used to treat the disease with variable success. We report a case of this rare disease in a patient with a solitary tumor and without paraproteinemia.

Urticaria unresponsive to antihistaminic treatment: an open study of therapeutic options based on histopathologic features.

BACKGROUND: The non- or low-sedating H1 receptor antagonists represent the basic therapy for urticaria. OBJECTIVE: To test an alternative approach to patients unresponsive to conventional treatment. MATERIALS AND METHODS: A total of 22 patients with chronic urticaria unresponsive to conventional antihistamine treatment were enrolled for this study. They had uncontrolled urticaria even using multiple combinations of antihistamines on maximum doses and corticosteroids in short cycles (prednisone 20-40 mg, per os once a day, 3-7 days per month). Cutaneous biopsies of the urticaria lesions were taken. These findings were classified as: (I) a mixture of perivascular dermal inflammatory infiltrate composed of lymphocytes, monocytes and neutrophils and/or eosinophils; (II) inflammatory infiltrate composed chiefly of neutrophils; and (III) inflammatory infiltrate composed mainly of eosinophils. According to histology, the patients were submitted to one of the following therapeutic schemes: class A - antihistamine treatment plus dapsone; class B - colchicine or dapsone; class C - montelukast. RESULTS: Four patients in class A, 08 in class B and seven in class C displayed complete control of urticaria after 12 weeks of treatment; one patient in class B and two in class C did not respond to treatment. Two years after discontinuation, 16 patients are still free of urticaria. CONCLUSIONS: This study suggests an alternative approach for treating unresponsive chronic urticaria.

Urticaria as a cutaneous sign of adult-onset Still's disease.

BACKGROUND: The cardinal signs and symptoms of adult-onset Still's disease (AOSD) include periodic fever, arthralgia and arthritis, lymphadenopathy, hepatosplenomegaly, an evanescent rash accompanied by neutrophilic granulocytosis, and a negative rheumatoid factor and antinuclear antibody test. OBJECTIVE: To alert clinicians and dermatologists to internal diseases such as AOSD when assisting patients with urticarial eruptions and systemic symptoms. METHODS: A case report of a 52-year-old white woman who received conventional therapy for urticaria for 3 years, with no improvement. Following this period, a diagnosis of AOSD was performed based on the presence of systemic symptoms. RESULTS: The inflammatory activity markers decreased by the second month of methotrexate therapy; however, the cutaneous lesions failed to disappear. Thalidomide was initiated, and total improvement of the cutaneous lesions was observed after 2 weeks. CONCLUSION: Urticarial rash is an uncommon presentation of AOSD, and clinicians must be alert to the possibility of a misdiagnosis in these cases.

A histologic study of adverse effects of different cosmetic skin fillers.

OBJECTIVE: This study was designed to describe the histologic aspects of the cutaneous and mucosal adverse reactions to fillers used for cosmetic purposes. METHODS AND MATERIALS: Eleven specimens of adverse reactions caused by Restylane, Artecoll, Metacril, New-Fill, Aquamid, and liquid silicone were processed and stained by hematoxylin-eosin and Alcian blue and submitted to polarized light. RESULTS: Most of the reactions were foreign-body granulomas. CONCLUSIONS: The type of granuloma and the characteristics of the agent were determined, contributing to the histologic identification of the material used. In the cases involving Restylane and Aquamid, it was possible to identify the material using Alcian blue stain and by the presence of necrosis. This stain was strongly positive in Restylane and faintly positive in Aquamid, and intense necrosis was observed in Aquamid cases. In the other cases the filler material itself was recognized and identified.

Dermoscopy of the nail bed and matrix to assess melanonychia striata.

Melanonychia striata represents a diagnostic dilemma for dermatologists. The use of dermoscopy to assess the nail has advantages over clinical examination. However, when compared to skin lesions, it gives fewer details. We describe two cases of melanonychia striata submitted to dermoscopic examination of the nail bed and matrix. This is a new procedure that enables observing dermoscopic characteristics that are not visualized in the nail plate, thus, providing additional information.

Carcinoma espinocelular do lábio: avaliação de fatores prognósticos / Espinocelular carcinoma of the lip: assesment of prognostic factors

Dentre os cânceres do lábio de 90 por cento a 95 por cento dos casos afetam o lábio inferior, sendo o carcinoma espinocelular o mais freqüente. A classificação TNM sintetiza as características clínicas do tumor, permitindo realizar um prognóstico e possibilitando comparações dos resultados. Relaciona três parâmetros: tamanho do tumor (T), propagação aos gânglios linfáticos regionais (N) e metástases à distância (M), mas estabelece padrões a partir de 2cm. Para o carcinoma espinocelular do lábio lesões com 2cm são extremamente grandes. OBJETIVO: O objetivo deste estudo é verificar a relação entre as características epidemiológicas, clínicas, evolutivas e histopatológicas do carcinoma espinocelular do lábio tendo como parâmetro lesões de tamanhos a partir de 0,5cm. CASUíSTICA E MÉTODO: Foi elaborado um estudo retrospectivo transversal em pacientes com carcinoma espinocelular do lábio, no período 1993-2000, em São Paulo, Brasil. Estudou-se prontuários, laudos originais dos exames histopatológicos e lâminas de tumores de pacientes com carcinoma espinocelular do lábio. Os tumores foram classificados de 0.5 em 0.5cm, sendo verificado o tipo, o grau de diferenciação histológica, a presença de desmoplasia, as invasões muscular, neural e vascular, e o tipo de infiltrado inflamatório. RESULTADOS: A análise estatística mostrou que metástases e recidivas não dependem da cor de pele ou do sexo dos pacientes e que há independência entre a localização do tumor, no lábio superior ou inferior, e a incidência de metástases e recidiva. Houve correlação entre o tamanho da lesão a partir de 0,5cm e a ocorrência de metástases e recidiva. Verificou-se que o tamanho da lesão determina a invasão em outros tecidos. O infiltrado inflamatório verificado em todas as lesões era linfoplasmocitário e, em algumas, associado com eosinófilos sem relação com o tamanho do tumor. CONCLUSÃO: Tumores menores que 2cm podem apresentar comportamentos evolutivos distintos, sob o ponto de vista clínico e histopatológico. O tipo mais prevalente de lesão é o ulcerativo e o que mais metastatiza e recidiva é o úlcero-vegetante. Os tipos úlcero-vegetante e vegetante estão ligados a lesões de maior tamanho. O tamanho do tumor se relaciona, de forma semelhante, com os graus II e III, nos quais ocorrem os maiores índices de metástases e recidivas. O tumor invade em ordem decrescente de freqüência músculos, nervos e vasos sanguíneos...