Repositório RCAAP

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The curiosity and the interest for knowing what is beyond the human eye led to the birth of dermoscopy. Despite the fact that the wide use of dermoscopy is relatively recent, several documents that reflect different approaches to this technique can be found since the XVI century. These attempts represent not only a great progress to dermoscopy, but also allowed the development of other techniques such as capillaroscopy, currently used in the study of autoimmune diseases, trichoscopy, applied at the beginning for the early diagnosis of cretinism and afterwards used for several indications and, finally, colposcopy, useful for the study of cervix disorders in gynaecology. Ultimately, the optical properties of the epidermis and the development of magnification optical devices allowed to visualize skin lesions in vivo and are the cornerstones of the current dermoscopic technique.

Drug-induced photosensitivity is an abnormal skin reaction to light in individuals exposed to a drug, whom, in the absence of the culprit drug, would tolerate the same amount of light exposure. It can present as an acute or delayed clinical picture, with polymorphic features ranging from an exaggerate sunburn to acute eczema, photoonycholysis, pseudo-porphyria, pigmentation or cutaneous lupus erythematosus. The authors describe the drugs involved in these photosensitivity reactions and their main clinical pictures and discuss the possibility that these drugs can enhance photocarcinogenesis. Clinical recognition of these clinical patterns is of outmost importance in order to avoid the culprit drug and consequently improve or resolve photosensitivity.

Introduction: Acne is a disease with psychological consequences to patients based on personal and social factors and with a strong influence on the quality of life. The lack of information contributes to and nourishes beliefs and misunderstandings on acne that keep growing and find popular support in their mystification worldwide, although mostly without any scientific evidence.Material and Methods: The present study is based on 75 interviews, 45 to Acne patients and 30 to Portuguese healthcare professionals and aims to contribute to a better understanding of acne in Portugal and to develop an instrument that is able to identify the main beliefs on Acne, comprising three dimensions: beliefs, behaviors and treatment.Results: We have identified beliefs that are transversal to different countries in which concerns their influence on acne: diet, stress and lack of hygiene are considered to worsen Acne whereas sunlight and face washing favor its improvement.Conclusions: It is important to know to what extent individuals with acne get information, seek for treatment and how that treatment evolves. A systematic, objective and universal process of data collection is useful to gather and treat pertinent information in order to improve the quality of information and education of Portuguese acne patients.

Pine caterpillar, Thaumetopoea pityocampa, is a phyto-lepidopteran, responsible for the delay in the growth or the death of various types of pine trees. Besides nature damage, pine caterpillar causes dermatological reactions in humans by contact with the irritating hairs of the larvae. Although dermatitis occurs among outdoor professionals, it is primarily non-professional. Means of contamination comprise direct contact with the nest or the processional caterpillar and indirect contact with air dispersed hairs. Dermatitis is generally observed in late spring and particularly from March to June, among campers and tourers. The eruption has its onset 1-12 hours after contact with the hairs and presents with intense and continuous itching. Apart from the skin, T. pityocampa can involve the eyes and rarely the airways. Despite the considerable damages to humans and nature, pine caterpillar infestation is an underestimated problem; medical literature lists few studies and, often, relevant information is referred to local media and popular wisdom.

Introduction: Immunosuppression plays a central role in the pathogenesis of skin cancer in kidney transplant recipients. Recently, the potential for sirolimus to reduce the incidence of non-melanoma skin cancer in this population has been studied.Objective: To analyse the relationship between initial maintenance immunosuppressive regimens and the onset of non-melanoma skin cancer – squamous cell carcinoma and basal cell carcinoma – in kidney transplant recipients.Methods: Retrospective analysis of clinical records belonging to patients submitted to kidney transplantation between years 2002 and 2012, which were subsequently evaluated for the first time, in our Dermatology Department. Kidney transplant recipients were divided in three groups according to the initial maintenance immunosuppressive regimen: group A (sirolimus-based), group B (tacrolimus-based) and group C (cyclosporine-based).Results: Of the 188 patients studied 24.5% (n=46) were diagnosed with 83 non-melanoma skin cancer (42 basal cell carcinoma and 41 squamous cell carcinoma). There were no differences in survival free of non-melanoma skin cancer and basal cell carcinoma, between groups. The survival free of first squamous cell carcinoma was significantly higher in the group A (mean 10.7 years) than in groups B (mean 7.48 years) and C (mean 8.29 years). Crude hazard ratio of squamous cell carcinoma was 7.74 in group C (p=0.05) and 9.02 in group B (p=0.03), comparing with group A. However, after adjustment for age at date of transplantation these values lost statistical significance.Conclusion: Although the switch to sirolimus has been proven to be beneficial in secondary prevention of squamous cell carcinoma in kidney transplant recipients, its use ab initio does not seem to have the same protective effect.

Background: Rosacea, a prevalent chronic facial skin condition, is classically referred to as a “psychodermatosis”, in that psychological factors are relevant both in its initiation and course. Rosacea patients have been described as immature, anxious, with diminished self-esteem and with feelings of guilt and shame, or as psychoneurotic, with hysterical or obsessive compulsive configurations.Objective: In this study we investigated the psychopathological distress experienced by rosacea patients, as compared to a group of dermatological patients suffering from acute, non-conspicuous, accidental dermatoses. One additional purpose was to assess the influence that demographic features and clinical factors had on final results.Patients/Methods: A total of 243 patients with rosacea, aged from 18 to 72 years’ old were enrolled from an outpatient dermatology clinic in a hospital setting. Rosacea was objectively rated and disease duration recorded. The SCL-90 (R) was used to assess participants psychological distress and to record emotional and psycho vegetative complaints.Results: Statistical analysis revealed a definite independent influence of the variables rosacea, gender, school level, and also of the interaction rosacea/gender on the psychometrical variables. Rosacea patients scored higher than controls with respect to interpersonal sensitivity (F[1,241]=3.57, p<0.01). Concerning gender differences, female patients scored always higher than controls in anxiety, depression, interpersonal sensitivity, obsession-compulsion, paranoid ideation and somatization, whereas male patients did so only for interpersonal sensitivity. As to the effects of disease duration, rosacea patients’ for more than one year revealed significantly higher scores of paranoid ideation than patients’ with less than one year duration (F[2,52]=3.79, p<0.05).Conclusions: Patients suffering from rosacea – as opposed to other dermatoses – do experience significant psychosocial distress, which was nevertheless found to be unrelated to disease clinical sub-type.

The Pediatric Dermatology Portuguese Group performed a survey of the national nosologic statistic of the years 2009- 2013, collecting data from 12 national hospitals with a consultation of pediatric dermatology. A total of 22,354 patients were studied. Eczemas were the most common diseases, with 5,104 patients (22.3%), followed by nevi - 4,678 (20.4%), infections - 4,651 (20.3%), adnexal diseases - 2,770 (12.1%), vascular diseases - 1,066 (4.7%) and pigmentary disorders - 1,033 (4.5%). Furthermore, a comparative analysis was performed with nosologic statistics from ten years ago. In our opinion these studies are important since they allow us to know the national prevalence of pediatric cutaneous diseases, their evolution and aid us in establishing comparison with studies from other countries. Finally, they may help to improve preventive medicine.

Cutaneous squamous cell carcinoma is a potentially fatal non-melanocytic skin cancer, which results from the uncontrolled proliferation of keratinocytes. Predominant in the head and neck, it’s intimately connected to sun exposed areas. The diagnosis is based on the clinical presentation of the lesion, supported with the assistance of dermoscopy, needing, however, histological confirmation.This paper reports the case of a 71 year old male evaluated for a hyperkeratotic and infiltrative lower lip injury, suggestive of squamous cell carcinoma. After confirming the suspicion we proceeded with the radical excision of the lesion, whose resulting defect occupied 70% of the lower lip length in its middle portion, reaching its total thickness, and immediate reconstruction using Karapandzic’s sliding and rotating flap technique. The end result was characterized by scarring concealed in the physiological grooves and the maintenance of oral continence as well as the sensitivity and lip mobility.

Introduction: Men who have sex with men, particularly those infected by human immunodeficiency virus (HIV), have an increased risk of anal cancer. Unlike most opportunistic or AIDS-defining events, data have been contradictory regarding impact of antiretroviral therapy, viral suppression and immunologic reconstitution on HPV infection prevention and related cancers. Vaccination against human papillomavirus (HPV) is presently recommended in all HIV-infected patients, whereas there is still an on-going debate about the need for anal cancer screening programmes.Material and methods: The authors performed a retrospective study of anal cancer cases diagnosed between 2000-2015 in HIV patients on follow up at the Infectious Diseases Unit at Hospital de Curry Cabral, in Lisbon. We present the clinical and epidemiological characteristics of anal cancer cases throughout a fifteen-year period.Results: Anal cancer was diagnosed in ten patients, most of them MSM, HIV-infected for an average time of 15.1 years, with an average TCD4+ cell count of de 441 cells/uL. Anal cancer diagnosis was more frequently performed at stage III and treatment most frequently involved surgery, occasionally with radiotherapy. Four patients died.Conclusion: There is a need for consensual anal cancer screening programs, along with a need to reinforce HPV vaccination in men, particularly men who have sex with men, regardless of HIV infection.

Frontal fibrosing alopecia, a variant of lichen planopilaris, was first described by Kossard in 1994. It consists of a cicatricial alopecia characterized by progressive rarefaction of frontotemporal implantation line. Dermoscopy has a great importance to improve diagnosis accuracy and is a relevant tool to distinguish it from other differential diagnosis. Lichen planus pigmentosus is another variant of lichen planus, of uncommon occurrence, that specially affects women with phototypes III and IV, between third and fourth decades of life. In this article, two cases of the rare association of Lichen planus pigmentosus and frontal fibrosing alopecia are reported in two female patients, aged 59 and 76 years melanodermic women, presenting frontotemporal margin hair loss and brown hyperpigmentation on the face, neck and trunk.

Food additives are used intentionally to modify food properties. Sulfites are used in food industry due to its antibacterial action, prevention of oxidation and inhibition of enzymatic and nonenzymatic browning discoloration of food during the process of preparation, distribution and storage. Gallates are used as antioxidants both in food and cosmetics. We report the case of a 36 years-old patient with allergic contact cheilitis to sodium metabisulfite (E223) found in a fruit salad, possibly perpetuated by the antioxidants in her lipsticks.

Pyoderma gangrenosum is an uncommon cutaneous dermatosis of unknown pathogenesis, included in the group of neutrophilic dermatosis. It is characterized as noninfectious, necrotizing and painful cutaneous ulcers. It affects primarily adults and is rare in children (less than 4%) and with few cases reported in literature of involvement in the age group < 1 year. The diagnosis is usually based on clinical evidence and confirmed with the exclusion of others causes of skin ulcerated lesions. This report describes a case of pyoderma gangrenosum in a 4 months old infant presented with multiple cutaneous ulcers on her buttocks, without any systemic involvement and with rapid and effective response to oral corticosteroid.

Originally described by Jadassohn in 1895, it was not until 1932 that the term “nevus sebaceous” was introduced by Robinson. It is a prevalent benign congenital hamartoma that classically evolves through discrete phases of growth and that, from the 4th to the 7th decade of life, can give rise in approximately 10 to 30% of cases to several epithelial neoplasms. Very seldom reported in this context, trichilemmomas are benign appendageal tumours that arise from or differentiate toward the outer root sheath epithelium of the normal hair follicle. Usually solitary, they present as verrucous, keratotic or smooth papules on the face, especially in the vicinity of the nose and lips. On clinical grounds, desmoplastic trichilemmomas, a rare benign histological sub-type of trichilemmomas, are easily taken for basal cell carcinomas, intradermal nevi, verrucae, cutaneous horns, sebaceous hyperplasia and squamous cell carcinomas; as far as pathology, differential diagnosis must include the desmoplastic variants of squamous and basal cell carcinomas, as well as trichilemmal carcinoma. A 56 year old Caucasian male presented with several asymptomatic pearly, translucid nodules and papules that had developed over the last 6 months within a congenital alopecic yellowish plaque of his scalp previously diagnosed, on clinical grounds, as a nevus sebaceous. Histopathological examination allowed to disclose a lobular neoplasm with the classic features of desmoplastic trichilemmoma. The case is iconographically depicted and the relevant literature is reviewed.

Chemotherapy-induced acral erythema is characterized by areas of painful erythema affecting predominantly hands and feet, and in severe cases bullous lesions may develop. Gemcitabine is frequently responsible for cutaneous side effects, but these are usually mild and transient. We report a patient under palliative chemotherapy for pancreatic ductal adenocarcinoma with gemcitabine, who presented large bullous lesions on both feet, but of larger size on the left. Histopathology was consistent with acral erythema. The bullous variant of chemotherapy-induced acral eythema is a rare reaction, and although described for structurally similar cytotoxic agents, it has not been reported in association with gemcitabine. In our case, the patient’s medical history of significant peripheral arterial disease may have also played an important role in the overall clinical presentation.

Marginal palmar keratoderma is characterized by palmar keratoderma affecting the limits of the dorsal and palmar regions of ulnar and radial edges in patients with intense sun exposure. According to the literature it is not considered a pre-malignant lesion. Nevertheless, we report the first case of squamous cell carcinoma on marginal palmar keratoderma in a 57 year-old woman.

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Dysplastic nevus is a controversial identity. The authors make a review of the literature with the aim to characterize what is a dysplastic nevus, the diagnostic criteria, what the relation with melanoma risk is and how to manage a patient with dysplastic nevus.

Psoriasis is a very common, chronic and recurrent, inflammatory systemic disease, which affects the skin and/or joints. It has several clinical variants, but plaque psoriasis is the most common and around 20% of patients have a moderate to severe form. With conventional treatment some patients experience an absence or loss of efficacy, side effects or inadequate response, so with the increasing knowledge on the pathophysiology of psoriasis, drugs with more specific targets have been developed in recent decades. The objective of this paper is to present new treatment options for moderate to severe plaque psoriasis in adults. A literature review was carried out on PubMed database and ClinicalTrials.gov for information on approved drugs, as well as on the results of clinical trials of emerging systemic therapies and currently in phase III. TNF-α inhibitors, a pioneering class of biologicals approved for psoriasis have been used successfully for several years. However, they also have limitations and, therefore, clinical research has been carried out focused on the search for new therapeutic targets. The discovery of participation of IL-23/ Th17 pathway in psoriasis oriented the development of novel immunomodulatory drugs, with encouraging results that validate the pro-inflammatory role of this pathway in the disease. Also, new orally available ‘small molecules’ are in development for the treatment of psoriasis. In practice, there isn’t a single most correct treatment for all patients with moderate to severe plaque psoriasis, in terms of efficacy, safety, dosing regimen and route of administration. Although new drugs have a long way to go before their approval, they represent a promise of more targeted, effective and safe treatment, with less interference with other biological functions and better control of the disease.

Background: Sentinel lymph node biopsy is widely accepted in the staging of melanoma. The prognostic value of this technique seems to be greater in intermediate-thickness melanoma (1-4 mm) than in thick melanoma (>4 mm).Objective: To assess the prognostic value of sentinel node status in patients with thick melanoma.Patients and Methods: The disease-free survival and the overall survival were estimated using Kaplan-Meier curves and a Cox regression model in a sample of patients with thick melanoma.Results: Forty-three patients were included (52.2% male) with a mean age of 63.9 years. Sentinel node biopsy was positive in 20 patients (46.5%). Mean follow-up was 40 months. Patients without sentinel node metastases had a 5-year disease-free survival rate significantly higher than those with positive sentinel node (63% versus 19%, p < 0.05). The 5-year overall survival rate was tendentiously lower in patients with positive sentinel node (52% versus 79%), lacking statistical significance.Conclusion: The sentinel node status was not able to predict the overall survival in our series of thick melanomas, probably due to the high risk of hematic spread. However, sentinel lymph node biopsy provided important prognostic information, since the sentinel lymph node status influenced the disease-free survival.