Multiple-Digit Pigmented Bowen's Disease Induced by Human Papillomavirus in an Immunocompetent Child.

Introduction: Bowen's disease is a squamous cell carcinoma in situ, the most common malignancy of the nail unit. Presenting more frequently in the fingernails, common risk factors include ionizing radiation, oral exposure to arsenic or pesticides, dyskeratosis congenita, and quite commonly diverse subtypes of HPV. We report the first case of multiple periungual pigmented Bowen's disease in a pediatric patient. Case Presentation: A healthy 13-year-old boy presented with a 9-month history of a pigmented erythematous patch on the proximal nail fold of his 3rd right finger without associated symptoms. A punch biopsy was taken, and the diagnosis of Bowen's disease was made. The patient received photodynamic therapy and three cycles of imiquimod without response, and two new lesions appeared on the first and second right fingers. Surgical removal was performed on all lesions. A polymerase chain reaction detected an HPV type 16. Discussion/Conclusion: Multiple periungual Bowen's disease is rare, with the most frequent risk factors being HPV infection and chronic immunosuppression. Less than 10% of the cases present as longitudinal melanonychia. To date, there are no previous reports of multiple pigmented periungual Bowen's disease. HPV-induced Bowen's disease is usually present in adults aged between 22 and 89 years as persistent verrucae. In this case, koilocytosis and the fact that all lesions appeared on the right hand are suggestive of HPV infection.

Neurotecoma de pálpebra superior esquerda: raro relato de caso / Neurothekeoma of the left upper eyelid: rare case report

Neurotecomas são neoplasias raras, benignas, de presumida linhagem fibro-histiocítica. Ao exame dermatológico e ao anatomopatológico, apresentam múltiplos diagnósticos diferenciais, o que torna sua identificação desafiadora. Relatamos o caso de paciente do sexo masculino, de 28 anos de idade, que apresentou crescimento de pápula endurecida na pálpebra superior direita, com histopatológico e imuno-histoquímica sugestivos de neurotecoma

Neurothekeomas are rare, benign dermal tumors of presumed fibrohistiocytic lineage. They present multiple differential diagnoses, making their identification challenging at the dermatological and anatomopathological examination. We report the case of a 28-year-old man who presented a hardened papule growth on the left upper eyelid with histopathology and immunohistochemistry suggestive of neurothekeoma.

Clinical, histopathological and immunohistochemical evaluation of daylight photodynamic therapy in the treatment of field cancerization: a study of 30 cases.

BACKGROUND: Actinic keratosis (AK) are pre-malignant lesions, precursors of squamous cell carcinoma (SCC). Normal skin adjacent to AK, may present initial mutations with potential risk for new neoplasms, currently known today as field cancerization (FC). OBJECTIVES: To evaluate the effectiveness of daylight photodynamic therapy (PDT) with methyl amino levulinate (MAL) based on clinical evaluation, histological examination and immunohistochemical expression of p53 and Ki67. MATERIAL AND METHODS: Thirty patients, over 35 years old, phototypes between I and III, presenting non-hypertrophic AK on the face or scalp. Two biopsies with 2 mm punch of the lesion and adjacent skin before and 60 days after daylight PDT were performed. Results: Improvement was seen in lesion thickness and Ki67. 19 (63.33%) lesions had atypia improvement with a p-value <.05, showing efficacy in treatment. After daylight PDT, 22 (73.33%) patients showed satisfactory esthetic improvement. CONCLUSION: The study shows that PDT has cellular and molecular effects that support its indication in the control of carcinogenesis, as it decreases atypia and controls the expression of Ki67, reducing the proliferation of atypical cells. However, its indication following this study is still mainly aimed at clinical improvement of the skin, at this moment, probably due to the sample size.

Total body mapping in the follow-up of melanocytic lesions: recommendations of the Brazilian Society of Dermatology

Abstract Total body mapping comprises photographic documentation of the entire body surface followed by digital dermatoscopy of selected melanocytic lesions, aiming to compare their evolution over time and identify new lesions. As this is an exam based on comparative analysis of serial dermoscopic body images, standardization of the technique for performing total body mapping is essential. Prepared by specialists from the Brazilian Society of Dermatology, using the modified Delphi method, this article provides recommendations for carrying out total body mapping in Brazil, regarding its indications, technical aspects, and the issuing of the report.

Total body mapping in the follow-up of melanocytic lesions: recommendations of the Brazilian Society of Dermatology.

Total body mapping comprises photographic documentation of the entire body surface followed by digital dermatoscopy of selected melanocytic lesions, aiming to compare their evolution over time and identify new lesions. As this is an exam based on comparative analysis of serial dermoscopic body images, standardization of the technique for performing total body mapping is essential. Prepared by specialists from the Brazilian Society of Dermatology, using the modified Delphi method, this article provides recommendations for carrying out total body mapping in Brazil, regarding its indications, technical aspects, and the issuing of the report.

Keep it simple. A ten-year experience in reconstructions after Mohs micrographic surgery

Abstract Background: Mohs micrographic surgery is worldwide used for treating skin cancers. After obtaining tumor-free margins, choosing the most appropriate type of closure can be challenging. Objectives: Our aim was to associate type of surgical reconstructions after Mohs micrographic surgery with the characteristics of the tumors as histological subtype, anatomical localization and especially number of surgical stages to achieve complete excision of the tumour. Methods: Transversal, retrospective analyses of medical records. Compilation of data such as gender, age, tumor location, histological subtype, number of stages to achieve clear margins and type of repair used. Results: A total of 975 of facial and extra-facial cases were analyzed. Linear closure was the most common repair by far (39%) and was associated with the smallest number of Mohs micrographic surgery stages. This type of closure was also more common in most histological subtypes and anatomical locations studied. Using Poisson regression model, nose defects presented 39% higher frequency of other closure types than the frequency of primary repairs, when compared to defects in other anatomic sites (p< 0.05). Tumors with two or more stages had a 28.6% higher frequency of other closure types than those operated in a single stage (p< 0.05). Study limitations: Retrospective study with limitations in obtaining information from medical records. The choice of closure type can be a personal choice. Conclusions: Primary closure should not be forgotten especially in surgical defects with fewer stages and in non-aggressive histological subtypes in main anatomic sites where Mohs micrographic surgery is performed.

Keep it simple. A ten-year experience in reconstructions after Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery is worldwide used for treating skin cancers. After obtaining tumor-free margins, choosing the most appropriate type of closure can be challenging. OBJECTIVES: Our aim was to associate type of surgical reconstructions after Mohs micrographic surgery with the characteristics of the tumors as histological subtype, anatomical localization and especially number of surgical stages to achieve complete excision of the tumour. METHODS: Transversal, retrospective analyses of medical records. Compilation of data such as gender, age, tumor location, histological subtype, number of stages to achieve clear margins and type of repair used. RESULTS: A total of 975 of facial and extra-facial cases were analyzed. Linear closure was the most common repair by far (39%) and was associated with the smallest number of Mohs micrographic surgery stages. This type of closure was also more common in most histological subtypes and anatomical locations studied. Using Poisson regression model, nose defects presented 39% higher frequency of other closure types than the frequency of primary repairs, when compared to defects in other anatomic sites (p < 0.05). Tumors with two or more stages had a 28.6% higher frequency of other closure types than those operated in a single stage (p < 0.05). STUDY LIMITATIONS: Retrospective study with limitations in obtaining information from medical records. The choice of closure type can be a personal choice. CONCLUSIONS: Primary closure should not be forgotten especially in surgical defects with fewer stages and in non-aggressive histological subtypes in main anatomic sites where Mohs micrographic surgery is performed.

Horizontal histological sections in the preliminary evaluation of basal cell carcinoma submitted to Mohs micrographic surgery.

BACKGROUND: Mohs micrographic surgery is a surgical technique for the treatment of nonmelanoma skin cancer. Surgery begins by removing the visible tumor before excision of the tissue specimens for evaluation of the tumor margins. OBJECTIVES: To present a new way to evaluate the material obtained from debulking, by horizontal histological analysis of the fragment. METHODS: Descriptive retrospective cross-sectional study based on the medical records and histological lamellae of patients with primary basal cell carcinomas smaller than 1.5cm submitted to Mohs micrographic surgery and who had the visible tumor analyzed by horizontal histological sections. RESULTS: The sample evaluated included 16 patients with lesions located on the face. Comparing the histopathological examinations of incisional biopsy in vertical sections and debulking in horizontal sections, there was agreement in seven cases. The histological analysis performed in horizontal sections allowed identification of the tumor site in 13 cases, and the relation between tumor and margin showed that in 11 cases, the lateral margin was compromised. STUDY LIMITATIONS: The technique was better-applied in lesions smaller than 2cm. CONCLUSION: Horizontal histological analysis of debulking has advantages for Mohs surgery, since it allows visualization of almost all tumor extension in the same view plane of the dermatoscopy, allowing better definition of the histological subtype, tumor site, and tumor/margin of lesions less than 1.5cm.

Horizontal histological sections in the preliminary evaluation of basal cell carcinoma submitted to Mohs micrographic surgery

Abstract Background: Mohs micrographic surgery is a surgical technique for the treatment of nonmelanoma skin cancer. Surgery begins by removing the visible tumor before excision of the tissue specimens for evaluation of the tumor margins. Objectives: To present a new way to evaluate the material obtained from debulking, by horizontal histological analysis of the fragment. Methods: Descriptive retrospective cross-sectional study based on the medical records and histological lamellae of patients with primary basal cell carcinomas smaller than 1.5 cm submitted to Mohs micrographic surgery and who had the visible tumor analyzed by horizontal histological sections. Results: The sample evaluated included 16 patients with lesions located on the face. Comparing the histopathological examinations of incisional biopsy in vertical sections and debulking in horizontal sections, there was agreement in seven cases. The histological analysis performed in horizontal sections allowed identification of the tumor site in 13 cases, and the relation between tumor and margin showed that in 11 cases, the lateral margin was compromised.Study limitations: The technique was better-applied in lesions smaller than 2 cm. Conclusion: Horizontal histological analysis of debulking has advantages for Mohs surgery, since it allows visualization of almost all tumor extension in the same view plane of the dermatoscopy, allowing better definition of the histological subtype, tumor site, and tumor/margin of lesions less than 1.5 cm.

Microscopia confocal de reflectância como ferramenta para avaliar os efeitos causados pelo microagulhamento: uma série de cinco casos / Reflectance confocal microscopy as a tool for assessing the injury caused by microneedling: a serie of five cases

O microagulhamento é um procedimento cirúrgico ambulatorial que pode ser utilizado para diferentes indicações com o objetivo de estimular a produção de colágeno. Foram avaliados 5 casos no transcorrer das 72 horas após o procedimento, por meio da Microscopia Confocal de Reflectância, com o objetivo de avaliar a vida útil dos orifícios.

Microneedling is an ambulatory surgical procedure that can be used for different indications with the objective of stimulating the production of collagen. Five cases were evaluated in the first 72 hours after the procedure by reflectance confocal microscopy in order to evaluate the pores lifetime.

O uso da terapia fotodinâmica com aminolevulinato de metila e luz do dia para tratamento de queratoses actínicas / The use of photodynamic therapy with methyl aminolevulinate and daylight for the treatment of actinic keratoses

Introdução: A queratose actínica (QA) é lesão pré-maligna que pode progredir para carcinoma espinocelular. O diagnóstico é clínico, dermatoscópico e por microscopia confocal. Atualmente, aborda-se o tratamento do campo cancerizável, abrangendo QAs clinicamente visíveis e subclínicas, sendo a terapia fotodinâmica (PDT) uma opção terapêutica. Objetivo: Avaliar melhora das QAs e campo cancerizável em pacientes submetidos a PDT com luz do dia, com análise clínica, dermatoscópica e por microscopia confocal. Métodos: Foram selecionados dez pacientes, com múltiplas QAs na face. Realizada a PDT utilizando luz do dia com aminolevulinato de metila e feita documentação fotográfica clínica, dermatoscópica e por microscopia confocal antes do tratamento e 60 dias após seu início. Resultados: Dos nove pacientes que completaram o tratamento, oito (88,8%) apresentaram melhora clínica e regressão no grau da QA com uma sessão. Na dermatoscopia, quatro pacientes (44,4%) apresentaram melhora significativa, três pacientes (33,3%) apresentaram melhora parcial e dois pacientes (22,2%) tiveram suas lesões estáveis. Na microscopia confocal, seis (66,6%) pacientes tiveram regressão no grau da lesão. Conclusões: A PDT com luz do dia se mostrou eficaz para tratamento de QAs, apresentando alto grau de tolerabilidade e eficácia, além de bom perfil de segurança.

Introduction: Actinic keratosis (AK) is a pre-malignant lesion that can progress to squamous cell carcinoma. The diagnosis is through clinical, dermatoscopic and confocal microscopy assessment. Currently, the approach is the treatment of the field cancerization, comprising of clinically visible and subclinical AKs, for which photodynamic therapy (PDT) is a therapeutic option. Objective: To evaluate improvement of AKs and cancerization field in patients submitted to daylight PDT, with clinical, dermatoscopic and confocal microscopy assessment. Methods: Ten patients with multiple AKs on the face were selected. Daylight PDT was performed using methyl aminolevulinate and clinical, dermatoscopic and confocal microscopy photographic documentation was performed before and 60 days after the treatment. Results: Of the nine patients who completed the treatment, 8 (88.8%) showed clinical improvement and reduction in the severity of AK with one treatment. On dermatoscopy, 4 patients (44.4%) showed significant improvement, 3 patients (33.3%) showed partial improvement and 2 patients (22.2%) had no change. On confocal microscopy, 6 (66.6%) patients presented reduction in the severity of the lesion. Conclusions: Daylight PDT proved to be effective for the treatment of AKs, with high tolerability and efficacy, besides a good safety profile.

Descriptive dermoscopy terminology in Portuguese language in Brazil: a reproducibility analysis of the 3rd consensus of the International Dermoscopy Society

Abstract: Background: Dermoscopy is a noninvasive complementary diagnostic method largely used in dermatology. Feasibility, accuracy, and reproducibility are key elements for a diagnostic method to be useful, hence the importance of the terminology used to describe dermoscopic criteria. Objective: To evaluate the reproducibility of the English descriptive terminology proposed for dermoscopic criteria at the 3rd Consensus Meeting of the International Dermoscopy Society in Brazilian Portuguese. Methods: Nine Brazilian dermatologists independently analyzed the translation of sixty dermoscopic descriptive terms proposed at the 3rd Consensus Conference of the International Society of Dermoscopy. Interobserver agreement index was analyzed using the Fleiss' kappa test. Results: The interobserver agreement of the descriptive terminology in Brazilian Portuguese was considered weak (κ = 0.373; p < 0.05). The interobserver agreement of the descriptive terminology used to describe morphology and arrangement of vascular structures was considered moderate (κ = 0.43; p < 0.05). Study limitations: Our study limitations include the small number of participants and limited regional representation (only 2 out of 5 Brazilian regions were represented). Conclusions: The descriptive English terminology proposed at the 3rd Consensus Conference of the International Dermoscopy Society revealed weak reproducibility and the morphology and arrangement of vascular structures presented moderate reproducibility in Brazilian Portuguese. Despite small regional differences, metaphoric terminology in dermoscopy seems to be the most useful and reproducible system to be adopted in Brazilian Portuguese.

Descriptive dermoscopy terminology in Portuguese language in Brazil: a reproducibility analysis of the 3rd consensus of the International Dermoscopy Society.

BACKGROUND: Dermoscopy is a noninvasive complementary diagnostic method largely used in dermatology. Feasibility, accuracy, and reproducibility are key elements for a diagnostic method to be useful, hence the importance of the terminology used to describe dermoscopic criteria. OBJECTIVE: To evaluate the reproducibility of the English descriptive terminology proposed for dermoscopic criteria at the 3rd Consensus Meeting of the International Dermoscopy Society in Brazilian Portuguese. METHODS: Nine Brazilian dermatologists independently analyzed the translation of sixty dermoscopic descriptive terms proposed at the 3rd Consensus Conference of the International Society of Dermoscopy. Interobserver agreement index was analyzed using the Fleiss' kappa test. RESULTS: The interobserver agreement of the descriptive terminology in Brazilian Portuguese was considered weak (κ = 0.373;p < 0.05). The interobserver agreement of the descriptive terminology used to describe morphology and arrangement of vascular structures was considered moderate (κ = 0.43; p < 0.05). STUDY LIMITATIONS: Our study limitations include the small number of participants and limited regional representation (only 2 out of 5 Brazilian regions were represented). CONCLUSIONS: The descriptive English terminology proposed at the 3rd Consensus Conference of the International Dermoscopy Society revealed weak reproducibility and the morphology and arrangement of vascular structures presented moderate reproducibility in Brazilian Portuguese. Despite small regional differences, metaphoric terminology in dermoscopy seems to be the most useful and reproducible system to be adopted in Brazilian Portuguese.

Reflectance confocal microscopy as a tool for screening surgical margins of basal cell carcinoma.

Surgical excision of basal cell carcinoma with minimum margins requires serial assessment of layers by frozen histopathology in the case of Mohs micrographic surgery. Evaluation of presurgical tumor margins by in vivo reflectance confocal microscopy is a potential alternative. We selected 12 basal cell carcinoma lesions that were analyzed by confocal microscopy to define margins. The lesions were excised by Mohs surgery. Six tumors showed negative margins in the first phase of Mohs micrographic surgery. We concluded that reflectance confocal microscopy can be useful in the preoperative definition of basal cell carcinoma margins.

Reflectance confocal microscopy as a tool for screening surgical margins of basal cell carcinoma

Abstract: Surgical excision of basal cell carcinoma with minimum margins requires serial assessment of layers by frozen histopathology in the case of Mohs micrographic surgery. Evaluation of presurgical tumor margins by in vivo reflectance confocal microscopy is a potential alternative. We selected 12 basal cell carcinoma lesions that were analyzed by confocal microscopy to define margins. The lesions were excised by Mohs surgery. Six tumors showed negative margins in the first phase of Mohs micrographic surgery. We concluded that reflectance confocal microscopy can be useful in the preoperative definition of basal cell carcinoma margins.

A utilidade da microscopia confocal nas lesões de lentigo maligno / The utility of confocal microscopy in lentigo maligna lesions

O diagnóstico das lesões pigmentadas da face é considerado desafiador uma vez que lesões benignas e malignas podem compartilhar características clínicas e dermatoscópicas semelhantes, principalmente em lesões iniciais, sendo muitas vezes difícil de identificar as lesões de lentigo maligno da face. Assim, a microscopia confocal de reflectância pode se tornar uma ferramenta útil no diagnóstico dos lentigos malignos bem como para o seu planejamento cirúrgico.

The diagnosis of pigmented facial lesions is considered challenging since benign and malignant lesions might have similar clinical and dermoscopic features ­ especially in the early stages of the lesion ­ entailing that it is often difficult to identify lentigo maligna lesions in the face. In this way, confocal reflectance microscopy has the potential to become a useful tool both in the diagnosis and surgical planning of lentigo maligna.