Repositório RCAAP

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Adverse drug reactions constitute a major health problem in clinical practice. Drug allergy is defined as an immunologically mediated hypersensitivity reaction and represents 6-10% of all adverse drug reactions. Cli- nically, drug-induced allergic reactions can be classified as immediate (type I) and non-immediate (heterogeneous clinical manifestations, mostly related to type IV reactions). Several issues are considered in this revision, particularly immunopathologic mechanisms, cross-reactivity and the most relevant cutaneous reactions (maculopapular exanthe- ma, fixed drug eruption, acute generalized exanthematic pustulosis, drug hypersensitivity syndrome, also referred as drug rash with eosinophilia and systemic symptoms – DRESS, Stevens-Johnson syndrome and toxic epidermal necrolysis). The role of skin tests (epicutaneous or intradermal with late reading) in the diagnostic approach of non- -immediate reactions is also analysed. The most important causes of hypersensitivity reactions are antibiotics, parti- cularly beta-lactams. This group poses significant diagnostic and management difficulties and deserves, therefore, a more thorough attention, with particular attention to cross-reactivity patterns. Induction of drug tolerance should be considered in selected cases, especially when no safe or effective drug alternatives are available.KEYWORDS – Drug hypersensitivity; Beta-Lactams; Cross reactions; Skin Tests.

Introduction: Acne has a significant impact on patient’s self-esteem and quality of life. Several studies have shown psychological changes including anxiety, social inhibition, depression and suicidal ideation in acne patients. Since the approval of isotretinoin for the treatment of refractory or severe acne, there have been reports of cases and with interest sparked by the media for an association between isotretinoin and depression/suicidal ideation. Material and Methods: We reviewed the literature in order to assess the impact of acne on the daily lives of patients and the relationship of isotretinoin with depression or suicidal ideation. Results: The patient perception of the severity of acne differs from the medical evaluation, which is reflected in psychological and social repercussions, sometimes difficult to predict. Of the review carried we did not find causal relationship between isotretinoin therapy and depressive states or suicidal behavior. In many cases, the treatment improves the symptoms. Conclusions: The impact of acne, far beyond the impact of skin, requires the recognition of relevant psychological signs in a routine consultation, to establish appro- priate treatment strategies, individualized for each case.KEYWORDS – Acne vulgaris/psychology; Depression; Isotretinoin; Quality of life.

Psoriasis is a chronic systemic T-cell-mediated inflammatory disease with high morbidity. Psoriasis’s investigation has been intense, improving knowledge on physiopathology and leading to new biologic therapies for moderate and severe psoriasis’s treatment. This review will focus the present and the future of anti-cytokine therapies, beside the class of tumor necrosis factor-α (TNF-α) blockers.KEYWORDS – Antibodies, Monoclonal; Biological agents; Dermatologic agents; Psoriasis.

Introduction: Organ transplanted recipients have higher risk of skin cancer, and cumulative exposure to ultraviolet radiation is the most important risk factor. The objectives of this study were to assess photoprotection beha- vior and skin cancer awareness. Methods: A questionnaire-based study of kidney transplant recipients who were obser- ved for the first time between July of 2010 and December of 2011. A 5% significance level was used. Results: A total of 127 patients was enrolled in the study, with a mean age of 53 (s=12.98) and 66% being males. The mean number of schooling years was 8 (s= 4.7). 70% of the patients knew the higher risk for skin cancer in organ transplanted recipients and regular sunscreen use was referred by 22%. Only 8% of the patients were referred to the dermatologists in their first year after the transplant. In statistical analysis, knowing the higher risk for skin cancer was significantly associated with being observed by a dermatologist after transplantation and more schooling years. Sunscreen use was significantly associated with the female sex and a previous history of skin cancer. Conclusions: Organ transplanted recipients have insufficient knowledge about skin cancer and inadequate photoprotective measures since they are only rarely observed by a dermatologist after transplantation. Early observation in a specialist dermatology clinic is therefore important to improve compliance with photoprotection.KEYWORDS – Kidney transplantation; Neoplasms, radiation-induced; Skin neoplasms; Sunscreening agents; Ultra- violet rays.

The clinical diagnosis of cutaneous sarcomas is not an easy task, mainly due to their complex and hetero- geneous nature. Differential diagnosis may be difficult because there is substantial overlap of clinical features between a sarcoma that develop in superficial tissues (skin and subcutaneous tissue) and benign neoplasm and inflammatory dermatoses. Although not frequent, some types of cutaneous sarcomas have great importance, as they can be associa- ted with recurrence, aggressive local growth or metastasis, and can present high morbi-mortality rates. The authors report five clinical-pathological cases of cutaneous sarcomas – Kaposi’s sarcoma, dermatofibrosarcoma protuberans, atypical fibroxanthoma, leiomyosarcoma and angiosarcoma. A review of the relevant literature about cutaneous sarcomas with particular interest to dermatologists is presented, and we highlight some important clinical, laboratorial, histological and therapeutic findings.KEYWORDS – Skin neoplasms; Sarcoma; Sarcoma, Kaposi; Dermatofibrosarcoma; Histiocytoma, benign fibrous; Leio- myosarcoma; Hemangiosarcomal liposarcoma; Nerve sheath neoplasms.

91- year-old, Caucasian male patient, with a 35x40mm tumor, located in the right parietal region. Due to de dimension of the defects, primary closure was not able to accomplish, parallel relaxing incisions to the surgical defect was an option for reconstruction. Relaxing incisions to correct large defects of the scalp was proposed as an alternative and effective technique that avoids the execution of complex flaps and skin grafts procedures and has an acceptable cosmetic result.KEYWORDS – Reconstructive surgical procedures; Scalp; Surgical flaps.

Case report: A 75-year-old female patient underwent wide excision of morpheaform basal cell carcinoma located on the alar and supra-alar right regions and lateral area of the tip of the nose. The surgical defect was closed with a perforator dorso-nasal flap. There was no partial or total flap necrosis. The aesthetic result was quite acceptable. Comments: The perforator dorso-nasal flap is a simple and safe procedure for alar defects, with good aesthetic and functional outcomes.KEYWORDS – Carcinoma, Basal cell; Nose deformities, Acquired; Nose neoplasms; Rhinoplasty; Surgical flaps.

Reconstruction of large nasal defects, represents a challenge for Dermatologic Surgeon. We present a 87-year-old patient, with a large dimension squamous cell carcinoma, 3x2cm in the dorsum and the root of the nose. The surgical defect had a triangular shape. The realization of a flap conditioned a great movement of tissue and time- -consuming surgery. Due to the patient co-morbidities, was performed a total skin graft, with the skin of the glabella. The glabella is a good resource to perform grafts in this area, with good cosmetic quality, minimizing technical difficulties and complications of more invasive procedures.KEYWORDS – Nose; Reconstructive surgical procedures; Skin transplantation; Surgical flaps.

Introduction: The V-Y advancement flap is widely used in the reconstruction of surgical defects of the face, particularly on the periocular or eyelid areas. Its use in other locations has been taking new indications with high reconstructive quality. Case report: An 86-year-old female patient underwent wide excision of squamous cell carcinoma of the back of the right hand. Proximal pedicled V-Y advancement flap emerging from the radial edge of the hand was used to close the surgical defect. There was no partial or total flap necrosis. The aesthetic result was quite acceptable. Conclusion: The V-Y advancement flap is a viable surgical alternative for reconstruction of surgical defects of the back of the hand.KEYWORDS – Hand; Squamous cell carcinoma; Reconstructive surgical procedures; Skin transplantation; Surgical flaps.

Subungual squamous cell carcinoma is rare. Its atypical presentation can mimic several diseases and therefore the diagnosis can be easily missed or delayed. It is more frequently observed on the fingernails which may be explained by a much higher sunlight exposure and a possible role of human papilloma virus infection. We report a case of a 58-year-old man that was referred to our Department with a subungual tumour on his left fourth finger. Skin biopsy showed a Subungual squamous cell carcinoma and therefore whole nail unit was excised. Closure was performed with a full-thickness skin graft. The nail apparatus should be fully excised for two main reasons: malignant tumour and severe posttraumatic nail dys- trophy. Amputation remains necessary in case of invasive melanoma or in any Subungual squamous cell carcinoma with bone involvement.KEYWORDS – Carcinoma, squamous cell; Nails.

We describe a 44-year-old woman with recurrent episodes of red eye, myalgias, hypercholesterolemia, hypocomplementemia, monoclonal gammopathy and giant cell hepatitis that was observed due to erythematoviola- ceous plaque on the right arm. Skin biopsy revealed necrobiotic xanthogranuloma. This case illustrates the importance of accurate characterization of skin lesions in the setting of a systemic disease with difficult approach and highlights the second reported case of necrobiotic xanthogranuloma associated with giant cell hepatitis.KEYWORDS – Necrobiotic xanthogranuloma; Giant cells; Hepatitis; Paraproteinemias.

Papular urticaria (PU), also known as prurigo strophulus, is a relatively common skin disorder of chil- dhood caused by hypersensitivity to a variety of bites, including those of mosquitoes, fleas, bedbugs and others insects. It is characterized by a chronic or recurrent, papular or vesicobullous eruption, that is often pruritic and uncomfortable. The resultant scratching may lead to erosions and secondary pyoderma. Patients affected by these eruptions are frequently misdiagnosed and often subject to unnecessary, expensive and/or invasive evaluations. In order to avoid that, clinicians should be aware of the characteristic skin lesions of PU, possible exposures, and natural history of the disease. The most challenging aspects of PU is convincing parents/patients that the lesions are related to a bite reaction, demystify the common belief of the relationship with the ingestion of certain foods, and identifying and eradicating the source of the offending insect. We herein describe a 25-year-old female patient with bullous PU, and present a brief review of the literature, including the clinical features, utility of mnemonic “SCRATCH” to aid clini- cians in making an early and accurate diagnosis, differential diagnoses, and 3 “P’s” of therapy (Prevention, Pruritus control, and Patience).KEYWORDS – Skin diseases, vesiculobullous; Urticaria; Prurigo; Criança; Insects.

Ashy dermatosis, or erythema dyschromicum perstans, is a rare dermatosis of unknown etiology. The au- thors report the case of a 46-year-old healthy man that presented with a 1-year history of asymptomatic gray macules on the trunk. The constellation of clinical features, laboratory studies and histopathology allowed the diagnosis of Ashy dermatosis. Treatment with oral clofazimine was started, with complete resolution of the cutaneous lesions and without relapses after 6 months of follow-up. Therapeutic options for Ashy dermatosis are numerous, but none with consistent efficacy. Treatment with clofazimine has been attempted not only for its cosmetic effect, producing a uniform colouring of the skin that masks the pigmented areas, but also because its beneficial effect may be mediated by anti-inflammatory and immunomodulatory actions. This report supports the therapeutic efficacy of clofazimine in a patient with Ashy der- matosis.KEYWORDS – Clofazimine; Erythema; Pigmentation disorders; Skin diseases.

The Circumscriptum Neviform-like Lymphangioma(CNL) is a lymphatic malformation clinically characteri- zed by the presence of multiple vesicules of a clear or a serum/hematic content, grouped in a typical “herpetiform-like pattern”. Ocasionally, the CNL may affect the hypoderm, muscle and/or other organs, which may turn particularly difficult its therapeutics. We present a clinical case of a 17 year old patient with CNL referred to the Dermatology De- partment in order to be done a clinical evaluation, namely if the medication was the appropiate one. In this article we describe the dermatoscopic pattern of the CNL as well as the main differential diagnosis.KEYWORDS – Skin neoplasms; Lymphangioma, dermatoscopy; Nevus.

Bowen's disease consists of a squamous cell carcinoma in situ and the pigmented form of the disease is an unusual presentation. The authors describe a case of pigmented Bowen's disease in a male patient, 56 years, with an asymptomatic hyperpigmented plaque on the anterior surface of the right thigh for 10 years. Histopathological examination showed atypical keratinocytes on the entire epidermis with loss of polarity, melanin pigmentation in the basal layer and lichenoid lymphocytic infiltrate. A complete excision of the lesion with wide margins was made with no recurrence. Although relatively rare, pigmented Bowen's disease should always be remembered and included in the differential diagnosis of melanoma and other pigmented lesions.KEYWORDS – Bowen’s Disease; Skin pigmentation; Sunlight.

Mucinous carcinoma of the skin, also called mucinous adenocystic carcinoma or colloid carcinoma, is a rare malignancy. It was first described by Lennox et al. in 1952. It is derived from the sweat glands or their germinal structures but it’s appocrine or eccrine origin is still controversial. Histologically it can be confused with a metastatic lesion from the more common colloid carcinoma of the breast and mucinous adenocarcinoma of the intestine, lung, ovary or prostate. A 60-year-old woman presented to our department with a a 2-year history of a erythematous-blue nodule of the scalp, measuring 2 cm in diameter, and initially interpreted as a nodular basal cell carcinoma. After skin biopsy it was esta- blished the diagnosis of primary mucinous carcinoma or mucinous metastatic lesion. The entire lesion was then excised. Physical examination and careful systemic workup were negative. The diagnosis of a (primary) skin mucinous carcinoma was confirmed.KEYWORDS – Adenocarcinoma, mucinous.