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.

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.

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.

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.

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.

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.

Comparison between anti-PGL-I serology and Mitsuda reaction: clinical reading, microscopic findings and immunohistochemical analysis.

The lepromin test, serum IgM antibodies against Mycobacterium leprae and in situ observations of T cell subsets in biopsies of Mitsuda reaction using monoclonal antibodies were performed on 44 untreated leprosy patients belonging to various classifications of the disease. The Mitsuda reaction was accessed clinically and histologically after 28 days. Clinical reading and histological analysis of Mitsuda reaction showed good agreement. The high positivity in clinical reading correlated with compact granulomas in histology. There is a graduation of Mitsuda reaction that follows the immunological spectrum of the disease. The histological study of Mitsuda reaction is valuable to confirm the immunological condition in doubtful clinical reaction. Anti-PGL-I IgM levels correlated with disease classification, increasing from the tuberculoid towards the lepromatous pole of the disease spectrum. There was an inverse correlation between serum IgM antibody levels and clinical and histological reading of Mitsuda reaction. There were no statistical difference in quantities and distribution of CD4+ and CD8+ T cells in all Mitsuda reactions. The pattern of cellular content of Mitsuda reaction could not be related to the T cells.

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.

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.

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.

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.

False positive reaction of the immunohistochemistry technique using anti-BCG polyclonal antibodies to identify Mycobacterium leprae in wild nine-banded armadillos.

The authors studied 66 wild nine-banded armadillos from Brazil. The ear samples were collected and Ziehl-Neelsen or Fite-Faraco stains were performed, as well as immunostaining using polyclonal BCG antibody, to avaluate the presence of the Mycobacterium leprae. The AFB were not detected by the Ziehl-Neelsen or Fite-Faraco staining, neither immunoexpression of the BCG marker. However, many normal structures from the ears of the nine-banded armadillos, such as condrocytes, condroblasts, fibroblasts and endothelial cells, and Gram positive bacteria cocci, showed false positive reaction by the BCG marker. The authors discuss the use of the immunohistochemical studies with the polyclonal BCG antibody to identify M. leprae antigens in wild armadillos.

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.