Repositório RCAAP

Introduction: The skin and mucosa are common targets of the drug reactions, with a broad range of clinical patterns and drugs involved. Objective: Our aim was to characterize the drug eruptions requiring hospitalization. Methods: Clinical and laboratory data of the inpatients with cutaneous drug reactions in our Department during a pe- riod of 11 years (2000-2010) were analyzed. Results: The study included 168 patients (110 female and 58 male). The clinical patterns were: maculopapular eruption (n=85, 50.6%), Stevens-Johnson Syndrome (SJS: n=14, 8.3%), toxic epidermal necrolysis (TEN: n=10, 5.9 %), SJS/TEN overlap (n=3), drug reaction with eosinophilia and systemic symptoms (DRESS: n=12), photosensivity reaction (n=10 cases), erythroderma (n=9), acute generalized exantematous pustulosis (n=6), fixed drug eruptions (n=6), vasculitis (n=5), erythema multiforme (n=3), urticaria/angioedema (n=2), Sweet syndrome (n=1), symmetrical drug-related intertriginous flexural exanthema (SDRIFE: n=1) and lichenoid eruption (n=1). The drugs most often involved were: antibiotics (39.8%, mostly amoxicillin with clavulanic acid or cotrimoxazole), anticonvulsants (15.5%), nonsteroidal anti-inflammatory drugs (13.1%) and allopurinol (12.5%). Concomitant virus infection was found in 4 patients (Epstein Barr virus, cytomegalovirus, human herpesvirus-6 and parvovirus B19). The median period between drug intake and skin lesion onset was of 8 days (range 6 hours - 90 days). Nineteen patients continued the drug for more than 10 days after the eruption onset; 6 of them developed erythroderma, but none developed SJS/TEN. Most of the patients were treated with systemic corticotherapy and 15 patients received intravenous immunoglobulin. The overall mortality was 5.3%, being 26% for SJS/TEN.Besides a high SCORTEN, infection and low albumin were related with the mortality in SJS/TEN.KEYWORDS – Hospitalization; Epidermal Necrolysis, Toxic; Drug Eruptions; Drug Hypersensitivity.

Introduction: Nowadays, the diagnosis of basal cell carcinoma (BCC) is one of the most frequent applica- tions of dermatoscopy in the daily practice. About 7 to 10% of BCC have pigmentation. Considering the several growth patterns of BCC and their asymmetrical distribution of pigment, the inclusion of pigmented BCC within the differential diagnoses of malignant melanoma is required. Methods: Eighty histologically confirmed pigmented BCC were recruited from 2008 to 2010 and analysed by digital dermatoscopy (FotofinderTM). To establish the dermatoscopic diagnosis of BCC was used a method described more than 10 years ago, based on the absence of pigment network (negative criteria) and the presence of at least one positive criteria (ovoid nests, blue-grayish globules, leaf-like areas, spoke-wheel areas, ulceration and arborizing vessels). Results and Conclusions: The frequency of positive parameters and the presence of other dermatoscopic structures (milia, pigment network, erythema, hypopigmentation and several types of vessels) were evaluated and compared with other validated studies.KEYWORDS – Carcinoma, Basal Cell; Dermoscopy; Skin Neoplasms; Telangiectasias.

Introduction: The sweat gland tumours (SGT) are rare and form a heterogeneous group of epithelial neoplasms which are often misdiagnosed. Material and methods: The authors performed an epidemiologic characterization concerning all the patients diagnosed with both benign and malignant SGT, according to the histopathologic analysis of all incisional and excisional skin biopsies performed between 1999 and 2008 in a Department of Dermatology. Biopsies showing persistence and/ or recurrence of previously diagnosed neoplasms were excluded. All patients were characterized by age, sex, clinical diagnosis and type and location of the neoplasm. Results: During that period 153 SGT were diagnosed; of those, 92,2% were benign tumours. Hidrocystoma was clearly the most common benign SGT (31.3%), while porocarcinoma was the most frequent malignant neoplasm (50%). Most SGT were localized in the head and nearly 25% in the lower limbs, the latter being for the most part poromas. Most of the patients were female (58,8%). Concordance between clinical and histological diagnosis was observed in only 24,8% of all cases – basal cell carcinoma was the most frequent clinical diagnosis among discordant cases (19,6%). Conclusions: Clinical diagnosis of most SGT is often challenging; histological analysis is usually required for definitive diagnosis and may be troublesome. As rare tumours, a clear perception of their epidemiology is crucial for an adequate approach.KEYWORDS – Sweat Gland Neoplasms;Hidrocystoma; Eccrine Porocarcinoma; Poroma; Skin Neoplasms.

Surgery is the first-line treatment of skin cancer. Resections of large cutaneous tumours involving the nose are frequently challenging for the surgeon. We describe a malar advancement flap with usage of its redundant skin as a graft for a large nose defect involving two facial aesthetic units.KEYWORDS – Reconstructive Surgical Procedures; Surgical Flaps; Skin Neoplasms; Skin Transplantation.

Pincer nail is characterized by an exaggerated transverse curvature of the nail plate that increases distally along its longitudinal axis. It is more common in toenails. It can lead to narrowing of the nail bed, usually accompanied by pain and functional disability. Several treatment options are described for correction of pincer nail and there is no consensus on the best approach. Zook's technique differs from other surgical techniques, since it allows preserving the nail matrix and the size of the nail. In this case, using this technique (modified by the combination of a fusiform excision of the lateral nail fold) was a safe and effective approach.KEYWORDS – Nails; Onycomycosis; Reconstructive Surgical Procedures; Nails, Malformed.

Secondary intention healing is a valid option for surgical wound management, allowing for excellent results and providing a clear advantage over other techniques in selected patients. The authors report the case of a 66-year-old Caucasian man who had squamous cell carcinoma excised from the concha that healed by secondary intention. Some aspects of this technique are reviewed.KEYWORDS – Wound Healing; Surgical Procedures; Skin Neoplasms; Reoperation.

Linear IgA dermatosis, or chronic bullous disease of childhood, is an acquired subepidermic immunobullous disease. This case illustrates a peculiar form of presentation of an uncommon pathology of childhood and emphasizes the importance of dapsone in its treatment, especially in at a time when availability of this drug is limited.KEYWORDS – Immunoglobulin A; Autoimmune Diseases; Skin Diseases, Vesiculobullous; Child; Dapsone.

Tinea capitis is a superficial infection of the scalp caused by dermatophyte fungi, being nowadays the most common fungal infection in children. Griseofulvin remains as the gold standard treatment, however, in many coun- tries, the newer oral antifungal agents (terbinafine, itraconazole and fluconazole) appear to have efficacy and safety profiles similar to those of griseofulvin, allowing treatment courses of shorter duration. This fact associated with the discontinuation of griseofluvin in some European countries has made these drugs increasingly popular in the treatment of this condition. The authors report the case of a girl with tinea capitis caused by Microsporum canis, treated initially with terbinafine and then with itraconazol without any improvement. Just griseofulvin proved to be effective, leading to the cure after 7 weeks of treatment. With this case report, the authors intend to emphasize the importance of the reintroduction of griseofulvin in Portugal.KEYWORDS – Tinea Capitis; Pediatric Age; Dermatophytes; Systemic Antifungal.

Atopic eczema is a chronic inflammatory dermatosis that affects mostly children. In most cases it can be trea- ted with topical therapy, but in a significant number of patients it is necessary to use systemic agents. In some patients side effects associated with long-term systemic treatment and insufficient therapeutic results oblige searching for new therapies. The authors describe a clinical case of a child with severe atopic eczema without a satisfactory response to prescribed therapy. Mycophenolate mofetil was started at 6 years of life, with complete resolution of inflammatory lesions at 5 months of treatment. Therapeutic results presented in this article raise new questions about immunosuppression in atopic dermatitis and suggest a promising therapeutic alternative for cases refractory to classical treatments. To date there is only one published study reporting the treatment with this drug in a small series of pediatric patients.KEYWORDS – Dermatitis, Atopic; Child; Immunosuppressive Agents; Mycophenolic Acid.

The androgen secreting tumors are rare and frequently undetectable. One of the most common is Leydig cell tumor and it is usually benign. This case reports a 67-year-old female patient, complaining of hirsutism and androgenetic alopecia. Laboratory tests showed an elevated serum testosterone. The ultrasound revealed the presence of a nodule in the left ovary. The patient underwent bilateral oophorectomy. The histopathologic examination revealed the presence of Leydig cells. The clinical follow up showed a slight improvement of symptoms and normalization of serum levels of testosterone.KEYWORDS – Hyperandrogenism; Virilism; Leydig Cell Tumor; Ovarian Neoplasms.

Introduction: Melanoma of the oral mucosa is a rare and aggressive neoplasm, representing 0.2 to 8% of all melanomas and 0.5% of all cancers of the oral cavity. Case report: We describe the case of a female patient of 84 years of age, referred to the outpatient dermatology by hyperpigmented macula, black, irregular borders, with about 3 x 4 cm of diameter, on which watched three nodular elements, implemented in the transition of the hard palate and soft palate and development unknown. Histopathology was compatible with melanoma. Staging imaging revealed no metastasis or loco-regional distance. Due to the local extend, age and general condition of the patient, the option to perform non ablative therapy with cryo- therapy was taken, leading to complete clinical regression after two cycles of treatment carried out 6 weeks apart. The patient is disease-free after 36 months of follow-up. Discussion: Although not having been subjected to standard therapy, the treatment modality performed (cryotherapy) was effective in controlling local disease.KEYWORDS – Melanoma; Palatal Neoplasms; Cryotherapy.

.

Wound healing is a complex and coordinated process which involves the interaction between cells and many signaling systems. This process is basically divided into 3 phases: inflammation, proliferation and tissue remode- ling. The exact mechanism of chronic wounds remais unclear. Recent developments in molecular biology allowed the identification of many new molecules that provided new insights in chronic wound pathology and treatment. We discuss the mechanisms involved in wound healing, as well as recent developments in the field, providing a comprehensive overview on wound healing.KEYWORDS – Wound Healing; Fibroblast Growth Factors; Extracellular Matrix; Integrins; Chronic Disease.

Currently, digital photography is a crucial resource for Dermatology. Although auto exposure modes are included in all point-and-shoot cameras, photography technical knowledge is very useful. Why is this photo grainy? Why is this photo blurred? How can I shoot in low light conditions? These are just some questions that you should be able to answer after reading this article. We give some basic/intermediate technical knowledge that should help you to get better photos and be able to understand eventual photographic errors. The usefulness of photography in Dermatology is well-known and it has been extensively discussed. Photography knowledge is fundamental for the modern dermatologist allowing optimal results.KEYWORDS – Dermatology; Photography.

As with adults, the history and localization of the dermatitis are crucial for the diagnosis of allergic contact dermatitis, certain contactants and/or habits that are characteristic for the child/adolescent may be responsible for unu- sual clinical presentations. The most important allergens in children are metals, such as chromium (in shoes) and nickel (sometimes associated with cobalt or palladium, the latter also giving rise to contact granulomas), particularly in girls, due to the popularity of cheap jewellery. More recently, other sources, like cell phones, emerged among young adults. Other allergens identified are ingredients of topical pharmaceutical products, particularly antiseptic agents; mercury and its derivatives are still used in some countries, but allergic reactions, even in young children, are most often not cli- nically relevant. Cosmetics, particularly skin care products and wipes, may give rise to sensitization to fragrance compo- nents or preservative agents. Rubber derivatives, often responsible for shoe or diaper dermatitis, resins, and plants may also be among the sensitization sources involved. Moreover, certain occupational allergens (e.g., those associated with hairdressing, construction, and metalworking) are found in adolescents. Changing regulations concerning the presence of allergens in common products, the incidence of contact allergy in children might decrease in the future (e.g. nickel in jewellery and mobile phones and hair dyes in children below the age of 16 years). The use of p-phenylenediamine in temporary henna tattoos still remains a problem. Patch testing in children is safe; most authors consider that irritant reactions are not frequently observed (except in atopics, particularly with metals) and the same patch test concentra- tions as in adults can be used. However, the possibility of false-positive and false-negative reactions has to be consi- dered and, if there is doubt about irritancy, lower patch test concentrations should also be tested. Due to reduced test surface area, diminished environmental exposure to certain allergens and particularly hypermobility of young children, testing with an abbreviated standard series is recommended by some, although others warn that many reactions may thus be missed. Anyway, it is important to take into account the history and clinical picture and to always add possible other allergens and personal products used.KEYWORDS – Dermatitis; Allergic Contact; Child; Allergens; Hypersensitivity.

Chronic wounds of the lower limbs are a major public healthcare problem affecting 1% of the adult po- pulation and 3-5% of people older than 65 years. In the last years this numbers are rising in the western population as a result of increased life expectancy and increased risk factors for atherosclerotic occlusion such as smoking, obesity and diabetes mellitus. This is very debilitating condition, which reduces significantly the quality of life, causing social discomfort and generating considerable costs not only to the patient but also to the society. Treating chronic leg ulcers is always a challenge. Over the last years, the treatment of this condition has progressed due to the frequent ineffectiveness of the methods used, awareness of the psychological and social impact and the recognition of the risks of malignancy of these wounds, starting to be considered the etiology as an essential factor for directed and more effective wound care. Although 90% of ulcers are of vascular origin, the list of other possible causes responsible for the other 10% is extremely long. In this survey the authors focus on the differential diagnosis of chronic leg ulcers and the impact of a directed treatment in the prognosis of this condition.KEYWORDS – Leg Ulcer; Wounds and Injuries; Etiology; Diagnosis, Differential.

Human papillomavirus (HPV) infection is considered to be a public health problem. HPV ́s role on the pathogenesis of cancer and genital warts is well established. There are two highly efficacious prophylactic HPV vaccines that have the potential to substantially reduce HPV-related diseases. This review focuses on clinical and epidemiologic characteristics of HPV infection and the vaccines ́ role on the prevention of the diseases caused by this virus.KEYWORDS – Papillomavirus Vaccines; Condylomata Acuminata; Papillomavirus Infections; Papillomaviridae; Neo- plasms.

Stevens-Johnson syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are uncommon mucocutaneous der- matosis with a potentially fatal outcome, mostly secondary to drug administration. The aim of this retrospective study was to evaluate the clinical and evolutive characteristics of the patients with SJS and TEN admitted to the Dermatology Department of Coimbra University Hospital, between June/2000 and June/2010. 38 patients (27 women and 11 men) were included, with a mean age of 58.5 years (±21,63 years, 14-88 years), 26 with SSJ, 4 with SJS-TEN overlap and 8 with TEN. Involve- ment of oral, ocular and genitalia mucous membranes were present in 35, 30 and 13 patients respectively, with involvement of at least two in 31 patients. Drugs were the causative factors in 81.6% of patients: allopurinol in 36%, antibiotics in 23%, anticonvulsants in 19% and nonsteroidal anti-inflammatory drugs in 10%. The mortality rate was 8.3% for SJS and 37.5% for TEN. There was a significant correlation between the fatal outcome and a state of immunosuppression, presence of me- tabolic acidosis and involvement of the genital mucosa. The reasonable and rational use of drugs is of crucial importance, particularly allopurinol, the most likely causative factor, in 29% of total, and present in 40% of patients with a fatal outcome.KEYWORDS – Stevens-Johnson Syndrome; Epidermal Necrolysis, Toxic; Allopurinol; Drug Eruptions; Pharmaceutical Preparations/Adverse Effects.

Objectives: To determine clinical and histopathological differences between melanoma associated with nevus (MAN) and de novo melanoma (MN). Methods: Retrospective study of all cases of cutaneous melanoma diagnosed between 2001 and 2009 in Centro de Dermatologia Médico-Cirúrgica de Lisboa. Results: Of the 397 melanomas included, 52.6% were of feminine sex and 47.4% of the masculine. Of these melano- mas only 9.3% were histologically associated with nevus, with discrete predominance of cases in the feminine sex (54%, p=0,033). In the group of the MAN the average of ages was slightly inferior (56,5 vs 59,3 years, p=0,577). The trunk was the preferential localization of all the melanomas (42.1%, p=0,005). Histologically the superficial spreading sub- type was more frequently associated with MAN. The MAN were thinner than the MN (1,42 versus 2,13 mm, p=0,030), specially in the feminine sex (0,99mm, p=0,031). The Breslow tumor thickness and the presence of ulceration had a significant statistical correlation with the metastatic spread and the mortality by melanoma. Conclusions: The majority of the melanomas seem to arise de novo. In our study, factors that were significantly associated with MAN include feminine sex, trunk location, younger age, inferior Breslow thickness and superficial spreading subtype.KEYWORDS – Melanoma; Nevus; Pigmented.

Non-melanoma skin cancer (NMSC), common designation for both basal cell carcinomas (BCC) and squamous cell carcinomas (SCC), is the most frequent malignant skin neoplasm. The authors have performed a retros- pective analysis of all patients diagnosed with NMSC based on histopathologic analysis of all incisional or excisional skin biopsies performed between 2004 and 2008 in a Department of Dermatology. A total of 3075 NMSC were iden- tified, representing 88% of all malignant skin neoplasms (n=3493) diagnosed in the same period. Of those, 68,3% were BCC. Most NMSC patients were female and over 60 years old. Of all NMSC, 81,7% (n=1443) were located in sun-exposed skin, and represented 95,1% of malignant skin neoplasms in sun-exposed skin. NMSC was the most frequent malignant skin neoplasm in most topographic locations, except for abdomen and pelvis – over 95% of all malig- nant skin neoplasms in the face, neck and scalp were NSMC. BCC was clearly predominant in all locations, except in upper and lower limbs, lower lip and genitals, where SCC represented respectively 77,7%, 77,4%, 94,7% and 95,3% of NMSC. Being the most common skin cancer, NMSC should be under constant surveillance, in order to monitor its epidemiologic dynamics, the efficiency of preventive measures and the adaptation of the healthcare resources.KEYWORDS – Skin Neoplasms; Carcinoma, Basal Cell; Carcinoma, Squamous Cell.