Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology

Abstract: Background: Urticarias are frequent diseases, with 15% to 20% of the population presenting at least one acute episode in their lifetime. Urticaria are classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may be induced or spontaneous. Objectives: To verify the diagnostic and therapeutic recommendations in chronic spontaneous urticaria (CSU), according to the experience of Brazilian experts, regarding the available guidelines (international and US). Methods: A questionnaire was sent to Brazilian experts, with questions concerning diagnostic and therapeutic recommendations for CSU in adults. Results: Sixteen Brazilian experts answered the questionnaire related to diagnosis and therapy of CSU in adults and data were analyzed. Final text was written, considering the available guidelines (International and US), adapted to the medical practices in Brazil. Diagnostic work up in CSU is rarely necessary. Biopsy of skin lesion and histopathology may be indicated to rule out other diseases, such as, urticarial vasculitis. Other laboratory tests, such as complete blood count, CRP, ESR and thyroid screening. Treatment of CSU includes second-generation anti-histamines (sgAH) at licensed doses, sgAH two, three to fourfold doses (non-licensed) and omalizumab. Other drugs, such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be indicated (non-licensed and with limited scientific evidence). Conclusions: Most of the Brazilian experts in this study partially agreed with the diagnostic and therapeutic recommendations of the International and US guidelines. They agreed with the use of sgAH at licensed doses. Increase in the dose to fourfold of sgAH may be suggested with restrictions, due to its non-licensed dose. Sedating anti-histamines, as suggested by the US guideline, are indicated by some of the Brazilian experts, due to its availability. Adaptations are mandatory in the treatment of CSU, due to scarce or lack of other therapeutic resources in the public health system in Brazil, such as omalizumab or cyclosporine.

Association between tumor-infiltrating lymphocytes and sentinel lymph node positivity in thin melanoma

Abstract: Background: Sentinel lymph node biopsy in thin invasive primary cutaneous melanoma (up to 1mm thick) is a controversial subject. The presence of tumor-infiltrating lymphocytes could be a factor to be considered in the decision to perform this procedure. Objective: To evaluate the association between the presence of tumor-infiltrating lymphocytes and lymph node metastases caused by thin primary cutaneous melanoma. Methods: Cross-sectional study with 137 records of thin invasive primary cutaneous melanoma submitted to sentinel lymph node biopsy from 2003 to 2015. The clinical variables considered were age, sex and topography of the lesion. The histopathological variables assessed were: tumor-infiltrating lymphocytes, melanoma subtype, Breslow thickness, Clark levels, number of mitoses per mm2, ulceration, regression and satellitosis. Univariate analyzes and logistic regression tests were performed as well the odds ratio and statistical relevance was considered when p <0.05. Results: Among the 137 cases of thin primary cutaneous melanoma submitted to sentinel lymph node biopsy, 10 (7.3%) had metastatic involvement. Ulceration on histopathology was positively associated with the presence of metastatic lymph node, with odds ratio =12.8 (2.77-59.4 95% CI, p=0.001). The presence of moderate/marked tumor-infiltrating lymphocytes was shown to be a protective factor for the presence of metastatic lymph node, with OR=0.20 (0.05-0.72 95% CI, p=0.014). The other variables - clinical and histopathological - were not associated with the outcome. Study limitations: The relatively small number of positive sentinel lymph node biopsy may explain such an expressive association of ulceration with metastatization. Conclusions: In patients with thin invasive primary cutaneous melanoma, few or absent tumor-infiltrating lymphocytes, as well as ulceration, represent independent risk factors for lymph node metastasis.

Phenotypic, molecular and antimicrobial susceptibility assessment in isolates from chronic ulcers of cured leprosy patients: a case study in Southern Brazil

BACKGROUND: One of the most stigmatizing physical sequelaeof leprosy in cured patients is the development of chronic lower extremity ulcers. The bacterial diversity present in ulcers is considered one of the factors that can delay the healing process, as well as serve as a focus for severe secondary infections. OBJECTIVE: To identify the microbiota and antimicrobial resistance profile of bacteria isolated from skin ulcers in patients cured of leprosy. METHODS: After obtaining informed consent, material was collected from ulcers of 16 patients treated at the Outpatient Public Health Dermatology Clinic of Rio Grande do Sul and Hospital Colônia Itapuã. Sampleswere collected during dressing, and the material sent to the Microbiology Laboratory of the Federal University of Health Sciences of Porto Alegre for microbiological culture. Methicillin-resistant Staphylococcus aureus (MRSA) was characterized by two molecular methods, including detection of the mecA gene by PCR and SCCmecgene typing. RESULTS: Cultures revealed microorganisms in all ulcers: Gram-negative bacilli in 80%, Gram-positive cocci in 63%, and mixed microflora in 36%. Staphylococcus aureus and Pseudomonas aeruginosa were the most prevalent bacteria. Assessment of the antimicrobial resistance profile was notable for the presence of MRSA. Molecular analysis of this isolate revealed presence of the mecA gene contained in a type IV staphylococcal cassette chromosome mec (SCCmec). CONCLUSIONS: In patients with leprosy, laboratory culture of skin ulcers is essential for correct antibiotic selection and to control emerging pathogens, such as MRSA carrying SCCmec type IV. .

A melanoma risk score in a Brazilian population / Um escore de risco para melanoma em uma população brasileira

BACKGROUND: Important risk factors for cutaneous melanoma (CM) are recognized, but standardized scores for individual assessment must still be developed. OBJECTIVES: The objective of this study was to develop a risk score of CM for a Brazilian sample. METHODS: To verify the estimates of the main risk factors for melanoma, derived from a meta-analysis (Italian-based study), and externally validate them in a population in southern Brazil by means of a case-control study. A total of 117 individuals were evaluated. Different models were constructed combining the summary coefficients of different risk factors, derived from the meta-analysis, multiplied by the corresponding category of each variable for each participant according to a mathematical expression. RESULTS: the variable that best predicted the risk of CM in the studied population was hair color (AUC: 0.71; 95% CI: 0.62-0.79). Other important factors were freckles, sunburn episodes, and skin and eye color. Consideration of other variables such as common nevi, elastosis, family history, and premalignant lesions did not improve the predictive ability of the models. CONCLUSION: The discriminating capacity of the proposed model proved to be superior or comparable to that of previous risk models proposed for CM. .

FUNDAMENTOS: importantes fatores de risco para melanoma cutâneo são reconhecidos, mas escores padronizados para avaliação individual ainda precisam ser elaborados. OBJETIVOS: o objetivo deste estudo foi desenvolver um escore de risco de melanoma cutâneo para uma amostra brasileira. MÉTODOS: verificar as estimativas dos principais fatores de risco para melanoma, derivado de uma meta-análise (estudo de base italiano) e, externamente, validar em uma população do sul do Brasil por um estudo caso-controle. Um total de 117 indivíduos foram avaliados. RESULTADOS: a variável com maior poder preditivo para o risco de melanoma cutâneo na população estudada foi a cor do cabelo (AUC: 0,71, IC 95%: 0,62-0,79). Outros fatores importantes para o modelo foram: sardas, queimaduras solares, e cor de pele e cor dos olhos. Adicionando outras variáveis, como os nevos comuns, elastose, história familiar e lesões pré-malignas não houve melhora da capacidade preditiva. CONCLUSÃO: A capacidade discriminatória do modelo proposto mostrou-se superior ou comparável aos modelos de risco anteriores propostos para melanoma cutâneo. .

Bacterial skin colonization and infections in patients with atopic dermatitis / Colonização bacteriana e infecções da pele em pacientes com dermatite atópica

Atopic Dermatitis is a chronic inflammatory skin disease that affects a large number of children and adults. The disease results from an interaction between genetic predisposition, host environment, skin barrier defects, and immunological factors. A major aggravating factor associated with Atopic Dermatitis is the presence of microorganisms on the patient's skin surface. Staphylococcus aureus and Streptococcus pyogenes, for instance, can exacerbate chronic skin inflammation. As a result, antimicrobials have often been prescribed to control the acute phase of the disease. However, increased bacterial resistance to antimicrobial agents has made it difficult for dermatologists to prescribe appropriate medication. In the presence of disseminated dermatitis with secondary infection, systemic antibiotics need to be prescribed; however, treatment should be individualized, in an attempt to find the most effective antibiotic with fewer side effects. Also, the medication should be used for as short as possible in order to minimize bacterial resistance.

A dermatite atópica é uma doença inflamatória crônica da pele que afeta um grande número de crianças e adultos. A doença resulta da interação entre predisposição genética, fatores ambientais, defeitos da barreira cutânea e fatores imunológicos. Um dos grandes fatores agravantes associados à dermatite atópica é a presença de microorganismos na superfície cutânea desses pacientes. Staphylococcus aureus e Streptococcus pyogenes, por exemplo, podem exacerbar a inflamação crônica da pele. Como resultado, antimicrobianos são prescritos para controlar a fase aguda da doença. O constante crescimento da resistência bacteriana aos antimicrobianos tem tornado a escolha do mais adequado medicamento uma difícil decisão para os dermatologistas. Na presença de dermatite disseminada com infecção secundaria, antibióticos sistêmicos necessitam ser prescritos; no entanto, o tratamento deve ser individualizado, de forma a encontrar o antimicrobiano mais eficaz e com menores efeitos colaterais. Além disso, esse medicamento deve ser utilizado pelo menor tempo possível, a fim de minimizar a resistência bacteriana.

Tratamento da doença de Hailey-Hailey com toxina botulínica tipo A / Hailey-Hailey disease treatment with Botulinum toxin type A

Duas irmãs com doença de Hailey-Hailey, com lesões recorrentes - uma em axilas e outra em região inguinal -, e resposta limitada aos tratamentos clássicos. Elas foram tratadas com aplicação de toxina botulínica tipo A. Observamos que houve importante melhora na paciente tratada na região inguinal e remissão completa na paciente em cujas axilas sofreram tratamento. Além disso, foi possível poupar uso de antibióticos sistêmicos e corticoides tópicos. O alto custo é um fator restritivo para uso rotineiro e estudos maiores são necessários para definir eficácia e relação custo-benefício dessa intervenção.

Two sisters with recurrent lesions, one on axillae and other on the groin, and with limited response to classical treatments were treated with injections botulinum toxin type A. We observed marked improvement in the patient treated in the groin and complete remission in the patient treated in the axillae. It was possible to spare the use of systemic antibiotics and topical corticosteroids. The high cost is a restrictive factor to routine use and large studies are necessary to access efficacy and cost benefit profile.

Avaliação do aprendizado dos pacientes sobre a regra do ABCD: um estudo randomizado no sul do Brasil / Evaluation of patients' learning about the ABCD rule: a randomized study in southern Brazil

Fundamentos: A regra do ABCD é utilizada para orientar médicos, profissionais da saúde e pacientes quanto ao reconhecimento das principais características de lesões cutâneas suspeitas de melanoma. Não há, no Brasil,estudos que validem a utilização da regra do ABCD pelos pacientes após orientações realizadas por dermatologistas. Objetivos: Avaliar o aprendizado da regra do ABCD por pacientes atendidos em centro dermatológico de referência no sul do Brasil. Métodos: Estudo randomizado com 80 pacientes ambulatoriais de ambos os sexos, com 12 anos ou mais. Foram avaliados: grau de escolaridade, renda mensal e acesso aos meios de comunicação. O grupo de intervenção recebeu orientações sobre o emprego da regra do ABCD, ao passo que o grupo-controle não recebeu. Ambos os grupos foram avaliados quanto às suas respostas em três momentos (basal, fora do consultório e no consultório, 15 dias após) em painel de fotografias. O nível de significância utilizado foi o p < 0,05 e o poder de 0,80. Resultados: O grupo que recebeu as informações respondeu de forma correta, com mais frequência, quanto ao diagnóstico dos melanomas, quando comparado ao grupo-controle (p < 0,01). Excetuando-se o acesso ao rádio, que influenciou positivamente os resultados (p < 0,05), as outras variáveis avaliadas não os afetaram. Conclusões: A regra do ABCD pode ser usada para capacitar pacientes acima de 17 anos a identificar alterações sugestivas de melanoma. Esse aprendizado independe de sexo, nível de escolaridade, renda mensal e acesso aos meios de comunicação, exceto rádio.

Background: the ABCD rule is used to guide physicians, health care professionals and patients to recognize the main characteristics of suspicious skin lesions for melanoma. In Brazil there are no studies to validate the use of the ABCD rule by patients after instructions given by dermatologists. Objectives: to evaluate the learning of the ABCD rule by patients at a dermatology center of reference in the Southern region of Brazil. Methods: a randomized study, with 80 outpatients. The following were evaluated: sex, age, level of schooling, monthly income and access to means of communication. The intervention group received instructions regarding the use of the ABCD rule and the control group did not. Both groups were evaluated at three points in time (baseline; outside the office; and in the doctor's office, 15 days later) regarding their answers about a panel of photographs. The level of significance used was p < 0.05 and a power of 0.80. Results: the group that received information answered correctly regarding the diagnosis of melanomas more often compared to the control group (p < 0.01).Except access to radio broadcasting, which had a positive influence of the results (p < 0.05), the other variables evaluated did not influence the results. Conclusions: the ABCD rule can be used to train patients, above the age of 17 years, to identify changes that suggest melanoma. This learning is independent of sex, level of schooling, monthly income and access to means of communication, except the radio.