Treatment of actinic keratoses and cancerization field of the face and scalp with 0.015% ingenol mebutate gel in Brazilian individuals: safety, tolerability and patients' perspectives.

BACKGROUND: Actinic keratosis (AK) represents a risk of progression to squamous cell carcinoma. Ingenol mebutate gel is a novel therapeutic option for field-directed treatment. OBJECTIVES: To evaluate the safety, tolerability and patients' perspectives, related to the therapeutic success of managing AKs on the face and scalp with ingenol mebutate gel in Brazilian individuals. METHODS: This was an observational, retrospective and descriptive study of 68 areas of actinic keratosis on the face and scalp treated with Ingenol mebutate gel involving a total of 37 patients. The drug was applied for three consecutive days on an area of of 25 cm2 and documentation was performed on baseline and days 4, 8, 15, 60 and 180. On day 4, the composite local skin reaction score was calculated. At the end, a questionnaire was applied to evaluate patients' perspectives about the treatment. RESULTS: Adherence was 100%, no serious adverse events were recorded and the mean composite local skin reaction score (standard deviation) was 8.61±4.22. The treatment was considered optimum by 75.68% of the patients. STUDY LIMITATIONS: Calculation of composite local skin reaction score performed only on the fourth day. CONCLUSIONS: Treatment with ingenol mebutate gel was considered safe and tolerable in Brazilian subjects. Patients had a maximum adherence rate and a great improvement in self-esteem. The results of this research reproduce the findings of the literature.

Treatment of actinic keratoses and cancerization field of the face and scalp with 0 015% ingenol mebutate gel in Brazilian individuals: safety, tolerability and patients' perspectives

Abstract: Background: Actinic keratosis (AK) represents a risk of progression to squamous cell carcinoma. Ingenol mebutate gel is a novel therapeutic option for field-directed treatment. Objectives: To evaluate the safety, tolerability and patients' perspectives, related to the therapeutic success of managing AKs on the face and scalp with ingenol mebutate gel in Brazilian individuals. Methods: This was an observational, retrospective and descriptive study of 68 areas of actinic keratosis on the face and scalp treated with Ingenol mebutate gel involving a total of 37 patients. The drug was applied for three consecutive days on an area of of 25 cm2 and documentation was performed on baseline and days 4, 8, 15, 60 and 180. On day 4, the composite local skin reaction score was calculated. At the end, a questionnaire was applied to evaluate patients' perspectives about the treatment. Results: Adherence was 100%, no serious adverse events were recorded and the mean composite local skin reaction score (standard deviation) was 8.61±4.22. The treatment was considered optimum by 75.68% of the patients. Study limitations: Calculation of composite local skin reaction score performed only on the fourth day. Conclusions: Treatment with ingenol mebutate gel was considered safe and tolerable in Brazilian subjects. Patients had a maximum adherence rate and a great improvement in self-esteem. The results of this research reproduce the findings of the literature.

Profile of dermatological consultations in Brazil (2018)

Abstract: Background: Dermatological diseases are among the primary causes of the demand for basic health care. Studies on the frequency of dermatoses are important for the proper management of health planning. Objectives: To evaluate the nosological and behavioral profiles of dermatological consultations in Brazil. Methods: The Brazilian Society of Dermatology invited all of its members to complete an online form on patients who sought consultations from March 21-26, 2018. The form contained questions about patient demographics, consultation type according to the patient's funding, the municipality of the consultation, diagnosis, treatments and procedures. Diagnostic and therapeutic decisions were compared between subgroups. Results: Data from 9629 visits were recorded. The most frequent causes for consultation were acne (8.0%), photoaging (7.7%), nonmelanoma skin cancer (5.4%), and actinic keratosis (4.7%). The identified diseases had distinct patterns with regard to gender, skin color, geographic region, type of funding for the consultation, and age group. Concerning the medical conducts, photoprotection was indicated in 44% of consultations, surgical diagnostic procedures were performed in 7.3%, surgical therapeutic procedures were conducted in 19.2%, and cosmetic procedures were performed in 7.1%. Study limitations: Nonrandomized survey, with a sample period of one week. Conclusion: This research allowed us to identify the epidemiological profiles of the demands of outpatients for dermatologists in various contexts. The results also highlight the importance of aesthetic demands in privately funded consultations and the significance of diseases such as acne, nonmelanoma skin cancer, leprosy, and psoriasis to public health.

Profile of dermatological consultations in Brazil (2018).

BACKGROUND: Dermatological diseases are among the primary causes of the demand for basic health care. Studies on the frequency of dermatoses are important for the proper management of health planning. OBJECTIVES: To evaluate the nosological and behavioral profiles of dermatological consultations in Brazil. METHODS: The Brazilian Society of Dermatology invited all of its members to complete an online form on patients who sought consultations from March 21-26, 2018. The form contained questions about patient demographics, consultation type according to the patient's funding, the municipality of the consultation, diagnosis, treatments and procedures. Diagnostic and therapeutic decisions were compared between subgroups. RESULTS: Data from 9629 visits were recorded. The most frequent causes for consultation were acne (8.0%), photoaging (7.7%), nonmelanoma skin cancer (5.4%), and actinic keratosis (4.7%). The identified diseases had distinct patterns with regard to gender, skin color, geographic region, type of funding for the consultation, and age group. Concerning the medical conducts, photoprotection was indicated in 44% of consultations, surgical diagnostic procedures were performed in 7.3%, surgical therapeutic procedures were conducted in 19.2%, and cosmetic procedures were performed in 7.1%. STUDY LIMITATIONS: Nonrandomized survey, with a sample period of one week. CONCLUSION: This research allowed us to identify the epidemiological profiles of the demands of outpatients for dermatologists in various contexts. The results also highlight the importance of aesthetic demands in privately funded consultations and the significance of diseases such as acne, nonmelanoma skin cancer, leprosy, and psoriasis to public health.

Demographics and spatial distribution of the Brazilian dermatologists.

The medical-dermatological demographics favors health planning and guides expansion of the specialty. We conducted an ecological study of dermatologists members of the Brazilian Society of Dermatology (SBD). We evaluated: gender, age, address; which were compared with population and human development index indicators of municipalities. We evaluated 8384 members, distributed in 527 (9.5%) municipalities throughout Brazil. The female sex represented 78.4% of the members and the median age was 43 (36-54) years. The median density of dermatologists was 0.35 (0.21-0.37) per 10,000 inhabitants. The correlation (Spearman's rho) between density of dermatologists and human development index was 0.39 (p <0.01). The Brazilian dermatologist is characterized as: female, age <50 years and presenting an heterogeneous distribution throught the country.

Demographics and spatial distribution of the Brazilian dermatologists

Abstract: The medical-dermatological demographics favors health planning and guides expansion of the specialty. We conducted an ecological study of dermatologists members of the Brazilian Society of Dermatology (SBD). We evaluated: gender, age, address; which were compared with population and human development index indicators of municipalities. We evaluated 8384 members, distributed in 527 (9.5%) municipalities throughout Brazil. The female sex represented 78.4% of the members and the median age was 43 (36-54) years. The median density of dermatologists was 0.35 (0.21-0.37) per 10,000 inhabitants. The correlation (Spearman's rho) between density of dermatologists and human development index was 0.39 (p <0.01). The Brazilian dermatologist is characterized as: female, age <50 years and presenting an heterogeneous distribution throught the country.

Pain in photodynamic therapy: mechanism of action and management strategies.

Photodynamic therapy involves administration of a photosensitizing drug and its subsequent activation by irradiation with a light source at wavelengths matching the absorption spectrum of the photosensitizer. In many countries around the world, topical photodynamic therapy has been approved for treatment of cutaneous oncologic conditions such as actinic keratosis, Bowen's disease, and superficial basal cell carcinoma. Multicenter, randomized, controlled studies have confirmed its efficacy and superior cosmetic outcomes compared to conventional therapies. Nevertheless, this therapeutic method presents some adverse effects, such as erythema, edema, pigmentation, pustules, and pain. There is no doubt that pain is the most severe of the adverse effects, being sometimes responsible for definitive treatment interruption. The pain mechanism has not yet been fully understood, which makes complete pain control a challenge to be conquered. In spite of that, this literature review presents some useful pain management strategies as well as the most important pain-related factors in photodynamic therapy.

Pain in photodynamic therapy: mechanism of action and management strategies / Dor na terapia fotodinâmica: mecanismo de ação e estratégias de manejo

Photodynamic therapy involves administration of a photosensitizing drug and its subsequent activation by irradiation with a light source at wavelengths matching the absorption spectrum of the photosensitizer. In many countries around the world, topical photodynamic therapy has been approved for treatment of cutaneous oncologic conditions such as actinic keratosis, Bowen's disease, and superficial basal cell carcinoma. Multicenter, randomized, controlled studies have confirmed its efficacy and superior cosmetic outcomes compared to conventional therapies. Nevertheless, this therapeutic method presents some adverse effects, such as erythema, edema, pigmentation, pustules, and pain. There is no doubt that pain is the most severe of the adverse effects, being sometimes responsible for definitive treatment interruption. The pain mechanism has not yet been fully understood, which makes complete pain control a challenge to be conquered. In spite of that, this literature review presents some useful pain management strategies as well as the most important pain-related factors in photodynamic therapy.

A terapia fotodinâmica consiste na administração de uma droga fotossensibilizante e sua subseqüente irradiação com uma fonte de luz de espectro correspondente ao do seu fotossensibilizador. Em diversos países do mundo, a terapia fotodinâmica tópica é aprovada para o tratamento de condições oncológicas cutâneas como queratoses actínicas, doença de Bowen e carcinoma basocelular superficial. Estudos multicêntricos controlados e randomizados confirmam sua eficácia e seus resultados cosméticos superiores em relação às terapias convencionais. No entanto, existem alguns efeitos adversos inerentes a esse método terapêutico, como eritema, edema, pigmentação, pústulas e dor. Essa última é, sem dúvida, a mais importante deles, chegando a ser responsável pela interrupção definitiva do tratamento em alguns casos. O mecanismo dessa dor permanece ainda não completamente entendido. Tal fato faz do controle total da dor durante a terapia fotodinâmica um desafio ainda a ser conquistado. Apesar disso, esta revisão apresenta algumas estratégias que podem ajudar os pacientes a tolerar melhor a terapia fotodinâmica, além de relacionar os principais fatores ligados à dor descritos na literatura.

Adverse mucocutaneous reactions related to chemotherapeutic agents: part II.

Events and reactions involving chemotherapy are common in clinical oncology. Chemotherapeutic agents are widely used in therapy. Side effects range from the common to the rare and may be confused with other mucocutaneous manifestations resulting from the oncological treatment. The objective of this paper was to present data on skin reactions to chemotherapy, particularly those cases in which the dermatologist is requested to issue a report and asked to comment on the safety and viability of readministration of a specific drug. The authors describe aspects associated with these events, presenting a detailed analysis of each one of them.

Adverse mucocutaneous reactions to chemotherapeutic agents: part I.

The local and systemic treatment of tumors can cause changes in the skin, mucous membranes, hair and nails. Accurate diagnosis and appropriate treatment of side effects require knowledge about the patterns of the most common adverse reactions to drugs the patient may be using. The dermatologist must be familiar with the manifestations of certain soft tissue neoplasms, as well as with the adverse mucocutaneous forms of cancer treatment.

Reações tegumentares adversas relacionadas aos agentes antineoplásicos: parte II / Adverse mucocutaneous reactions related to chemotherapeutic agents: part II

Os eventos e reações envolvendo quimioterapia são frequentes na prática oncológica. Agentes quimioterápicos são uma modalidade de tratamento amplamente utilizada. Efeitos colaterais podem variar de frequência e também ser confundidos com outras manifestações tegumentares do tratamento oncológico. Este artigo objetiva expor as informações sobre reações cutâneas à quimioterapia, em especial, aqueles para os quais o dermatologista é requisitado a emitir parecer e a comentar sobre a segurança e a viabilidade da readministração de uma droga específica. Os autores descrevem os aspectos associados a esses eventos, fazendo uma análise detalhada de cada um deles.

Events and reactions involving chemotherapy are common in clinical oncology. Chemotherapeutic agents are widely used in therapy. Side effects range from the common to the rare and may be confused with other mucocutaneous manifestations resulting from the oncological treatment. The objective of this paper was to present data on skin reactions to chemotherapy, particularly those cases in which the dermatologist is requested to issue a report and asked to comment on the safety and viability of readministration of a specific drug. The authors describe aspects associated with these events, presenting a detailed analysis of each one of them.

Reações tegumentares adversas relacionadas aos agentes antineoplásicos: parte I / Adverse mucocutaneous reactions to chemotherapeutic agents: part I

O tratamento local e sistêmico das neoplasias pode causar alterações na pele, membranas mucosas, cabelos e unhas. O diagnóstico preciso e o tratamento adequado destes efeitos colaterais requerem conhecimento dos padrões das reações adversas mais comuns para as medicações que o paciente está utilizando. O dermatologista deve estar familiarizado com as manifestações tegumentares das neoplasias, bem como com os efeitos adversos mucocutâneos dos tratamentos antineoplásicos.

The local and systemic treatment of tumors can cause changes in the skin, mucous membranes, hair and nails. Accurate diagnosis and appropriate treatment of side effects require knowledge about the patterns of the most common adverse reactions to drugs the patient may be using. The dermatologist must be familiar with the manifestations of certain soft tissue neoplasms, as well as with the adverse mucocutaneous forms of cancer treatment.

Cutaneous melanoma: descriptive epidemiological study.

CONTEXT AND OBJECTIVE: Cutaneous melanoma represents around 3% of all skin tumors. About 20% of such patients will have advanced disease and will die before reaching five years of survival. The aim of this paper was to describe the clinical and histopathological variables and their correlations. DESIGN AND SETTING: Retrospective, descriptive, epidemiological study at the Melanoma Unit, Dermatological Clinic, Irmandade da Santa Casa de Misericórdia, São Paulo. METHODS: Records from 364 cases between May 1993 and January 2006 were analyzed. The frequencies of all study variables and their 95% confidence intervals were determined. The chi-squared test was used to evaluate associations among the variables, adopting a significant level of 0.05. RESULTS: Females predominated, with 1.4 women for each man. The patients mean age was 58.9 years. Nonwhite patients represented 13.7% of the sample. The prevalent anatomical sites for cutaneous melanoma were the trunk and feet, for both men and women. Acral lentiginous melanoma represented 22.3% of the cohort. In situ primary lesions were observed in few cases and a high percentage of thick cutaneous melanoma was detected. Ulceration was found in 13.4% of the thin tumors (< 1.0 mm). Thicker and ulcerated lesions predominated in male patients (p = 0.011 and p < 0.001 respectively) and in elderly patients (p = 0.021 and p = 0.015). CONCLUSIONS: The cohort mostly presented thick and ulcerated tumors, denoting late diagnosis and bad prognosis. Also, the sample was characterized by considerable prevalence of female patients, nonwhite patients, limb lesions and acral lentiginous melanoma.

Cutaneous melanoma: descriptive epidemiological study

CONTEXT AND OBJECTIVE: Cutaneous melanoma represents around 3 percent of all skin tumors. About 20 percent of such patients will have advanced disease and will die before reaching five years of survival. The aim of this paper was to describe the clinical and histopathological variables and their correlations. DESIGN AND SETTING: Retrospective, descriptive, epidemiological study at the Melanoma Unit, Dermatological Clinic, Irmandade da Santa Casa de Misericórdia, São Paulo. METHODS: Records from 364 cases between May 1993 and January 2006 were analyzed. The frequencies of all study variables and their 95 percent confidence intervals were determined. The chi-squared test was used to evaluate associations among the variables, adopting a significant level of 0.05. RESULTS: Females predominated, with 1.4 women for each man. The patients’ mean age was 58.9 years. Nonwhite patients represented 13.7 percent of the sample. The prevalent anatomical sites for cutaneous melanoma were the trunk and feet, for both men and women. Acral lentiginous melanoma represented 22.3 percent of the cohort. In situ primary lesions were observed in few cases and a high percentage of thick cutaneous melanoma was detected. Ulceration was found in 13.4 percent of the thin tumors (< 1.0 mm). Thicker and ulcerated lesions predominated in male patients (p = 0.011 and p < 0.001 respectively) and in elderly patients (p = 0.021 and p = 0.015). CONCLUSIONS: The cohort mostly presented thick and ulcerated tumors, denoting late diagnosis and bad prognosis. Also, the sample was characterized by considerable prevalence of female patients, nonwhite patients, limb lesions and acral lentiginous melanoma.

CONTEXTO E OBJETIVO: O melanoma cutâneo representa cerca de 3 por cento de todos os tumores da pele. Em torno de 20 por cento dos pacientes terão doença avançada e morrerão antes de completar cinco anos de sobrevida. O objetivo deste artigo é descrever as variáveis clínicas e histopatológicas, e suas correlações. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo, epidemiológico, descritivo realizado na Unidade de Melanoma, Clínica de Dermatologia, Irmandade da Santa Casa de Misericórdia de São Paulo, Brasil. MÉTODOS: 364 casos foram estudados de maio de 1993 a janeiro de 2006. Utilizou-se o intervalo de confiança de 95 por cento para as análises e para as associações o teste do qui-quadrado bicaudal. Estabeleceu-se nível de significância de 0,05. RESULTADOS: Predominou o sexo feminino resultando em uma proporção de 1,4 mulheres para cada homem. A média das idades dos pacientes foi de 58,9 anos. Para homens e mulheres, o melanoma cutâneo localizou-se, predominantemente no tronco e pés. O melanoma acrolentiginoso representou 22,3 por cento de toda amostra. Observou-se minoria de casos com lesão primária in situ e alto percentual de melanoma cutâneo espesso. Ulceração foi observada em 13,4 por cento para tumores finos (< 1,0 mm). Homens apresentaram lesões mais espessas (p = 0,011) e ulceradas (p < 0,001) e também idosos (p = 0,021 para a espessura e p = 0,015 para ulceração). CONCLUSÕES: Esta casuística constitui-se, na sua maioria, de tumores espessos e ulcerados, o que significa diagnóstico tardio e pior prognóstico. Também se caracterizou por presença marcante de sexo feminino, pacientes não-brancos, tumores em extremidades e melanoma acrolentiginoso.

Caso para diagnóstico / Case for diagnosis

É relatado caso de elastólise da derme média em paciente do sexo feminino, de 37 anos, que apresentava áreas de enrugamento fino da pele, principalmente nas flexuras e pápulas perifoliculares com aspecto em peau d´orange na região paravertebral, conferindolhe aspecto precocemente envelhecido. A histologia mostrava fragmentação e rarefação das fibras elásticas restritas à porção média da derme.

A case of mid-dermal elastolysis is reported in a 37-year-old female patient, who presented skin areas with fine wrinkles, mainly in fold areas and also perifollicular papules similar to peau d'orange in the paravertebral area, lending her a prematurely elderly appearance. Histological examination revealed fragmentation and rarefaction of elastic fibers, restricted to the mid-dermis portion.

Sarcomas cutâneos primários / Primary cutaneous sarcomas

Os sarcomas com apresentação cutânea primária são tumores raros e de grande heterogeneidade histológica. Com a evolução da oncologia cutânea e da cirurgia dermatológica, os dermatologistas têm sido cada vez mais requisitados para o diagnóstico e orientação terapêutica de tumores menos freqüentes. Este artigo de revisão analisa os sarcomas cutâneos primários observando suas características clínicas, etiopatogênicas e histológicas, bem como aspectos do tratamento e evolução. Enfatiza os sarcomas de maior relevância para o dermatologista, como angiossarcoma, dermatofibrossarcoma protuberans, fibroxantoma atípico, leiomiossarcoma, lipossarcoma, tumor maligno de bainha de nervo periférico e sarcoma epitelióide. O sarcoma de Kaposi não é abordado devido a suas características individuais específicas.

Processos linfoproliferativos da pele: parte 2 - linfomas cutâneos de células T e de células NK / Processos linfoproliferativos da pele: part 2 - cutaneous T-cell and NK-cell lymphomas

Os linfomas cutâneos de células T/NK constituem um grupo de doenças linfoproliferativas extranodais atualmente classificadas e subdivididas de acordo com o comportamento clínico segundo consenso da Organização Mundial de Saúde e da Organização Européia para Pesquisa e Tratamento do Câncer. Os linfomas cutâneos de células T/NK de comportamento clínico indolente compreendem a micose fungóide clássica, a micose fungóide foliculotrópica, a reticulose pagetóide, a cútis laxa granulomatosa, o linfoma cutâneo primário de grande célula anaplásica, a papulose linfomatóide, o linfoma subcutâneo de célula T paniculite-símile e o linfoma cutâneo primário de pequena e média célula T CD4+ pleomórfica. Os linfomas cutâneos de células T/NK de comportamento agressivo incluem a síndrome de Sézary, o linfoma extranodal de célula T/NK, tipo nasal, o linfoma cutâneo primário agressivo de célula T CD8+ epidermotrópica, o linfoma cutâneo de célula T gd e o linfoma cutâneo primário de célula T periférica, não especificado. O linfoma-leucemia de células T do adulto e a neoplasia hematodémica CD4+CD56+, embora considerados linfomas sistêmicos, são aqui abordados por apresentarem-se inicialmente na pele em significativo número de pacientes. O diagnóstico desses processos é realizado pelo exame histopatológico complementado pela análise do fenótipo das células neoplásicas, imprescindível no processo classificatório. O estadiamento para a avaliação da extensão anatômica da doença considera além do envolvimento cutâneo, o estado clínico e histológico dos linfonodos e das vísceras. Avaliação hematológica é fundamental na caracterização da síndrome de Sézary. Os tratamentos preconizados incluem terapêuticas dirigidas exclusivamente à pele, modificadores da resposta biológica e quimioterapia sistêmica.

Processos linfoproliferativos da pele: Parte 1 - Linfomas cutâneos de células B / Lymphoproliferative processes of the skin: Part 1 - Primary cutaneous B-cell lymphomas

Os linfomas cutâneos primários de células B pertencem ao grupo das neoplasias malignas originadas de linfócitos B, do tipo não-Hodgkin. A rotina diagnóstica nos processos linfoproliferativos de células B é realizada pela biópsia da pele lesada para a análise histopatológica, imuno-histoquímica e pesquisa do rearranjo gênico. A classificação dos linfomas cutâneos primários vem sendo discutida nos últimos anos; as usualmente utilizadas são as propostas pela World Health Organization - WHO e pela European Organization for Research and Treatment of Cancer - EORTC. A recente classificação consensual proposta por WHO-EORTC deverá substituí-las. Entretanto, apesar dos recentes progressos, ainda existem controvérsias e dificuldades quanto à classificação, ao diagnóstico e ao tratamento dos linfomas cutâneos primários de células B.