Repositório RCAAP

The management of the large anogenital warts (LAW) is a challenge due to limited treatment options, high recurrence rates, association with immunosuppression and the risk of malignant transformation. We analyzed the clinical records of 53 patients with LAW (total wart area more than 5 cm2) attended in our Sexual Transmitted Infections Unit du- ring 10 years (2000-2009). The study included 50 men and 3 women, with a mean age of 39,9 years (range 21-74). The majority (n=47, 88,6%) was heterosexual . and 21 patients (39,6%) had the human immunodeficiency virus infection (HIV). Buschke-Lowenstein giant condyloma was seen in 33,3% of the HIV+ patients comparing with 6,2% of the HIV- patients. Different therapeutic methods, as monotherapy or in combination, were used: cryosurgery (n=44), electrosurgery (n=9), CO2 laser (n=2) and excision (n=3), with a mean number of 4,7 sessions in the HIV+ patients and 2,6 in the HIV- patients. Clinical clearance patients achieved in 31 patients (no lesions and no evidence of disease at 6 months follow-up) and 22 patients showed initial improvement but were lost at follow-up. Recurrence of the lesions, although of lesser extent, was seen after a mean interval of 2,7 years in 69% of the HIV+ patients and in 38% of the HIV- patients. The patient low compliance adds to the problems encountered in the treatment of LAW, as 41% of the patients abandoned the follow-up. Cryotherapy is effective in the lesion’s volume reduction, allowing further clearance with the same or another surgical method.KEYWORDS – Human Papillomavirus (HPV); Condyloma Acuminatum, Anogenital; Buschke-Lowenstein Tumor; Human Immunodeficiency Virus (HIV).

Surgical defects in the nose are often challenging due to difficulty to recruit local skin enough to cover complex or large defects, and skin grafts are not always suitable due to cosmetic impairment. Interpolated flaps are viable options in these cases, consisting in random pattern skin flaps harvested at some distance from the defect that remain connected with the donor site from 10 to 21 days. We report the case of a 71-year-old male diagnosed with a malignant melanoma on the free border of the right nasal ala. Radial excision with margins of approximately 1,5cm was performed, creating a complex full-thickness surgical defect involving not only the free wall and margin of the right nasal ala but also the right soft triangle, nasal lobe and columella, which was reconstructed using a melolabial interpolated flap, with very satisfactory esthetic results both for donor and reconstructed areas. Post-operatory complications were not reported.KEYWORDS – Surgical Flaps; Reconstructive Surgical Procedures; Nose Neoplasms; Melanoma; Skin Neoplasms.

The lips, as moving structures of the face, are cosmetically and functionally important areas. Closure of surgical defects involving the oral commissures is particularly challenging, due to the high risk of local anatomy disruption and functional or esthetical compromise. We describe the case of a 69-year old patient who was observed with a large basal cell carcinoma of the right perioral region, extending to the right oral commissure. This lesion was radically excised, and the resulting surgical defect was closed using a homolateral double opposing rhomboidal flap. Post-operatory complications were not reported and the final result was esthetically very satisfactory, with preservation of lip function. Double opposing rhomboidal flaps are viable options for reconstructing defects involving the oral com- missures – in these simple procedures, donor skin is obtained from the nearby cheek and mandibular areas, allowing the preservation of the lip structure and function under a low risk of surgical complications.KEYWORDS – Surgical Flaps; Reconstructive Surgical Procedures; Lip Neoplasms; Carcinoma, Basal Cell.

Scleredema adultorum of Buschke (SAB) is a rare connective tissue disease characterized by non-pitting induration of the skin. Histologically there is thickening of the dermis with large collagen fibers separated by deposits of mucopolysaccharids. A 51-year-old male patient, with poorly controlled diabetes mellitus, progressively developed in a 5-year period, a di- ffuse cutaneous infiltration with ill-defined limits on the posterior neck, upper half of the trunk and proximal limbs, with marked skin stiffness and a significantly reduced mobility of the shoulder girdles and neck. The diagnosis of SAB was confirmed by histological examination. Other complementary exams did not reveal significant changes, allowing the diagnosis of the third subtype of SAB - diabeticorum. The patient was treated with phototherapy, initially with UVA1 without any benefit, and later with an experimental therapeutic modality of PUVA1 with significant clinical improvement, allowing the patient to dress himself.KEYWORDS – Scleredema Adultorum; Diabetes Mellitus; Phototherapy; PUVA Therapy.

Erythroplasia of Queyrat is a rare in situ carcinoma of the uncircumcised man and its treatment depends on the extent and location of the lesion. We describe the case of a 68 years old patient, with clinical and histological diagnosis of Erythroplasia of Queyrat. Given the size and location of the lesion, preventing the surgical option, we performed the treatment with CO2 laser. The patient underwent a single session of laser therapy with complete resolution of the lesion. The authors aim with this paper is to remember this surgical technique in the effective treatment of Erythroplasia Queyrat. To date there are only four published studies reporting the use of CO2 laser in the treatment of this lesion.KEYWORDS – Erythroplasia; Lasers; Laser Therapy; Carbon Dioxide.

We present the case of a 67-year-old patient observed with multiple painful violaceous plaques with central pustules on distal lower limbs, rapidly transforming into deep ulcers with infiltrated undermined borders and centrifuge progression, associated with mucous bloody diarrhea, oral erosions and hyperthermia in the previous three months. Histopathologic skin examination was consistent with the diagnosis of pyoderma gangrenosum (PG). Subtotal colonoscopy showed a severe continuous rectocolitis, consistent with unspecific inflammatory bowel disease (IBD). Due to colonic perforation, the patient was submitted to left colectomy, and afterwards to total proctocolectomy. Treatment with topical corticosteroids was performed and complete ulcer healing was observed three months after surgery, without recurrence in the following 2 years. Pustular PG is a rare condition; the relevance of this case is supported not only by the synergic evolution of severe pustular PG and IBD, but also by the prompt regression of the former after proctoco- lectomy.KEYWORDS – Pyoderma Gangrenosum; Inflammatory Bowel Diseases; Proctocolectomy.

Background: The cutaneous changes related to the carpal tunnel syndrome are rare. Case report: We describe the case of a 77 years old, male patient who had lesions limited to the sesnsorial area of his left hand’s median nerve. The lesions were ulcerations in the second and third fingers, cutaneous hyperkeratosis, dys- trophic changes in the nails, pus-filled inflammation, shrinkage of the distal phalanxes and acral osteolysis displayed in the hand’s radiography. The patient, who until that time refused the decompressive surgery of the median nerve, was once more redirected to an Orthopaedic consult. Discussion: Bouvier was the first to describe the ulcerative and mutilating variant of carpal tunnel syndrome, whi- ch includes skin (atrophy, anhidrosis, erythema, swelling, blisters, sclerodactyly, and indolent ulcers), nail and bone changes(acro-osteolysis). Surgical decompression is the definitive treatment for this severe form of the disease, leading to a considerable improvement. However,osteolysisis irreversible.KEYWORDS – Carpal Tunnel Syndrome; Acral-osteolysis; Nails, Malformed; Skin Ulcer.

Reflectance Confocal Microscopy (RCM) allows a high resolution imaging for in vivo non-invasive evalu- ation of skin lesions. Confocal imaging diagnostic criteria for BCC are described and two case reports presented. The authors review this topic and emphasize the RCM role as a non-invasive tool for diagnosis, no disease assumption and monitoring of recurrences after treatment.KEYWORDS – Microscopy, Confocal; Carcinoma, Basal Cell.

Basal cell carcinomas arising on the genitalia and over 5 cm in size are exceedingly rare. We report a case of a 60-year-old man with a lesion on the scrotum which had been slowly enlarging over the previous year. On examination he had an erythematous plaque 6.0x5.0cm in size with a pedunculated nodule. We performed an incisional biopsy. The histopathological diagnosis was basal cell carcinoma. The tumor was surgically removed. This is the second reported polypoid basal cell carcinoma occurring on the scrotum but the first scrotal giant polypoid basal cell carcinoma.KEYWORDS – Carcinoma, Basal Cell; Genital Neoplasms, Male; Scrotum; Skin Neoplasms.

The recent resurgence of syphilis and the diversity of its cutaneous presentations are mandatory to heighten clinical suspicion of this entity, even in the presence of concomitant diseases. The authors describe the case of a 58 year-old man, with a longtime history of psoriasis, that developed a secondary syphilis after the introduction of cyclosporine for a presumed flare of his chronic cutaneous disease. Possible ethologic mechanisms underlying the clinical picture are discussed. The importance of screening for syphilis every patient proposed for immunosuppressive treatment is highlighted, particularly nowadays, when they are being largely used by dermatologists.KEYWORDS – Syphilis, Cutaneous; Psoriasis; Cyclosporine; Immunosuppressive Agents.

Prolidase deficiency is a rare, autosomal recessive disease resulting from a mutation of the prolidase gene (PEPD) located on chromosome 19. The deficiency of this enzyme impairs proline recycling and consequently the synthesis of collagen. This defect may be asymptomatic or associated with different clinical manifestations, being the most frequently reported chronic skin ulcers, recurrent infections, hepatosplenomegaly, mental retardation and a cha- racteristic facies, which commonly emerge during pediatric age. The authors describe a case of a 14-year-old boy with the diagnosis of prolidase deficiency, who was sent to the department of Pediatric Dermatology due to the appearance of an ulcer in the external maleolar region of the left foot. Surgical debridement was performed and he started treatment with 5% glycine and 5% proline ointment. Complete healing one month later was observed.KEYWORDS – Dipeptidases, Deficiency; Leg Ulcer.

Congenital Volkmann's ischemic contracture is a rare disease observed in infants soon after birth, charac- terized clinically by a necrotic plaque usually located on an upper limb and accompanied by flaccid paralysis. It occurs in the intrauterine period and arises due to mechanical compression of the limb. The malpositioning of the limb, the constriction by amniotic band, the presence of oligohydramnios and dystocia are some of the possible factors involved. The compression leads to a compartment syndrome that induces ischemia and necrosis of the skin, muscles and nerves. The treatment is surgical, requiring debridement of the necrosis and possible use of a skin graft. We report a case of a 2-days-old newborn with a congenital Volkmann ischemic contracture of the left arm, induced by the presence of oligohydramnios.KEYWORDS – Ischemic Contracture/Congenital; Infant, Newborn; Fat Necrosis; Skin Ulcer.

Introduction: Infantile hemangioma is the benign tumor more frequent in pediatric age. The majority was a good outcome however, depending on location they can distort important anatomic structures or take to local or systemic complications. In this context, since Léauté-Labréze published in 2008 their experience with propranolol, multiple case reports and small series have been reported in international literature where this drug is used “off-label” as first line therapeutic agent. The present work aims to report the experience of a department with propranol as first line drug in infantile hemangioma treatment in 2 patients. Clinical cases: The patient 1 was a female with infantile hemangioma since 5 weeks old localized at the nose. The patient 2 was a male with two ulcerated infantile hemangiomas: one at the face, and another at the scrotum. Both underwent therapeutic induction with propranol on an inpatient basis, with a target dose of 2-3 mg/Kg/day. After a 6 months follow-up period, a good response was achieved with no complications noted. Discussion: Propranol is a safe and effective alternative in hemangioma treatment. Although no complications were noted, they are described and occur mainly during the therapeutic induction, making important the clinical vigilance during this period.KEYWORDS – Infant, Hemangioma; Propranolol; Skin Neoplasms; Therapy.

Charles Calnan died

Chronic wounds represent a serious public health problem and a cause of great consumption of health resources. Recent advances in the understanding of the mechanism of healing led to the development of new treatments. Define the role and effectiveness of these new treatments is the next step. The authors of this study sought to address some therapeutic beyond compression therapy and dressing material, in the healing of chronic wounds. KEYWORDS – Wound healing; Skin ulcer, regeneration; Wounds and Injuries; Cicatrix. 

Chronic immunosuppression is a known risk factor for tuberculosis. Our aim was to reach a consensus on screening and prevention of tuberculosis in patients with immune mediated inflammatory diseases candidates to biolo- gic therapy. Methods: Critical appraisal of the literature and expert opinion on immunosuppressive therapies and risk of tuberculosis. Results and Conclusion: The currently recommended method for screening is the tuberculin skin test and the interferon gamma assay, after exclusion of active tuberculosis. Positively screened patients should be treated for la- tent tuberculosis infection. Patients may start biological therapy after 1 to 2 months, as long as they are strictly adhering to and tolerating their preventive regimen. KEYWORDS – Latent tuberculosis; Immunologic factors; Biological therapy; Tumor necrosis factor-alpha; Immunosup- pressive agents; Immune system diseases. 

Postherpetic Neuralgia (PHN) is a common complication of acute Herpes Zoster, particularly in elderly pa- tients. Being a complex disorder of difficult control, experts have been trying to establish guidelines for pharmacological treatment of PHN. Recently, the European Federation of Neurological Societies (EFNS) gathered one of these work groups with this same purpose. In this paper, the authors intend to review and update this subject discussing the role of drugs like antivirals, antidepressants, certain anticonvulsants (gabapentin and pregabalin) and topical lidocaíne, whose therapeutic efficacy is well established in PHN. The role of opioids and capsaicin is also subject of reflection, as well as certain thera- peutic strategies recently identified as promising alternative options. Among these, the authors highlight transcutaneous electrical nerve stimulation (TNS), botulinum toxin and inhibitors of tumor necrosis factor alpha. It is widely recognized that control of pain in PHN often proves to be a challenge, requiring a delicate balance between therapeutic efficacy and side effects commonly experienced by an elderly population, often polymedicated and with multiple comorbidities. KEYWORDS – Drug therapy; Combination; Neuralgia, Postherpetic/drug therapy; Guideline. 

Introduction: Mastocytosis is a broad term that includes a set of clinically distinct entities characterized by the accumulation of mast cells in tissues. The skin is the organ most frequently involved. There are four clinical pat- terns of cutaneous mastocytosis: urticaria pigmentosa (UP), diffuse cutaneous mastocytosis, mastocytoma and telan- giectasia macularis eruptiva perstans. In childhood, the disease is usually limited to the skin. Material and Methods: Retrospective study of patients with cutaneous mastocytosis of the Pediatric Dermatology Outpatient Clinic at Hospital de Curry Cabral between 2001 and 2010. Results: Thirty-two patients were included (20 male and 12 female). In 90.6% of the cases, the manifestations began before two years of age. Only urticaria pigmentosa (53.1%) and mastocytomas (46.9%) were observed. The trunk and proximal portion of the limbs were the preferred locations. Darier ́s sign was pre- sent in 87.5% of cases (94.1% of UP and 80% of mastocytomas). The associated manifestations were pruritus (40.6%), blistering (28.1%), flushing (18.8%) and dermographism (12.5%). There were no cases of systemic mastocytosis. Two patients had a family history of cutaneous mastocytosis. No significant laboratory abnormalities were detected. In the 16 cases determined, serum levels of alpha-tryptase were within normal range. Discussion: These results are consistent with the literature, particularly in relation to common clinical forms, the usual locations, high frequency of Darier ́s sign and early age of onset. Once determined, the serum levels of alpha-tryptase were normal, which is consistent with the absence of systemic involvement. The higher prevalence in males has been reported before.KEYWORDS – Mastocytosis, cutaneous; Child. 

Introduction: The chronic leg ulcers (CLU) are frequent reasons for indiscriminate antibiotics prescribing which has contributed to increase the bacterial resistance to many drugs. Objective: Retrospective characterization of the bacterial population and antimicrobial susceptibility profile in patients with CLU admitted between 2007 and 2011 (5 years). Methods: Review of clinical charts and statistical study of the variables gender, age, etiology and location of the ulcers, species and antibiotic profile. Results: Seventy-eight swab specimens from 23 (31%) men and 51 (69%) women (both gender mean age of 70.5 years) were sent to the medical microbiology laboratory. The cultures were posi- tive in 72 (92.3%) cases, being isolated 13 species. Pseudomonas aeruginosa (n=34, 47.2%), Proteus mirabilis (n=11, 15.3%), Staphylococcus aureus (n=10, 13.9%), being methicillin-resistant Staphylococcus aureus (MRSA) seven (70%), and Enterobacter cloacae (n=5; 6.9%) were the most observed. For the former, the antimicrobial profile was as follows: piperacillin/tazobactum (92%), ceftazidime (90.6%), gentamicin (92.9%), imipenem (96.7%), meropenem (100%) and ciprofloxacin (53.3%). For the second one: piperacillin/tazobactum (75%), amoxicillin/clavulanic acid (77.8%), cefo- taxime (100%), ciprofloxacin (22.2%), cotrimoxazol (36.4%) and meropenem (100%). For the third one: ciprofloxacin (11.5%), cotrimoxazol (80%), vancomycin (80%), fusidic acid (90%), linezolid (100%) and tigecycline (100%). For the lat- ter one: piperacillin/tazobactum (80%), ceftazidime (80%), cefotaxime (80%), gentamicin (100%), ciprofloxacin (100%), cotrimoxazol (80%), imipenem (100%) and meropenem (100%). Conclusion: The Gram-negative bacteria were the main isolated agents. In general, meropenem, cefotaxime, linezolid and tigecycline showed greater sensitivity for the tested agents.KEYWORDS – Leg ulcer; Anti-bacterial agents; Drug resistance; Pseudomonas aeruginosa; Proteus mirabilis; Staphylo- coccus aureus. 

Introduction: Cryosurgery is a safe and effective treatment modality for non-melanoma skin cancers of the eyelids and periocular area, with a reported 5-year overall cure rate above 95%. Aim: Retrospective characterization of patients with non-melanoma skin cancer of eyelids and periocular regions diagnosed and treated with cryosurgery at our Department, between 1988 and 2004. Material and Methods: Review of the clinical records and statistical analysis of the following variables: age, sex, occupation, skin type, tumour characteristics, treatment modalities, aesthetic and functional outcomes and follow-up. Results: We treated 78 primary malignant neoplasms, in 78 Caucasian patients, 30 men and 48 women with a mean age of 75.5 years. Seventy-six of the seventy-eight tumours (97.4%) were nodular basal cell carcinoma (BCCs) and two were (2.6%) squamous cell carcinomas. More than half of the tumours were loca- ted in the inner canthus. Fractional cryosurgery was used in 52 cases (66.7%), conventional cryosurgery in 17 (21.8%) and segmental cryosurgery in nine (11.5%). The mean follow-up was 5 years with two relapses observed. There were no functional complications and the cosmetic results were excellent. The overall cure rate was of 97.4%. Conclusions: Fractional cryosurgery was the most used procedure. We achieved excellent functional and aesthetic results and a 97% five-year cure rate.KEYWORDS – Eyelid neoplasms; Cryosurgery; Carcinoma, Basal cell; Carcinoma, Squamous cell; Skin neoplasms.