RCAAP Repository

Introduction: Internet access for health information has risen in recent years and is currently used by 30% of Portuguese. Regarding sexually transmitted infections (STI), the information provided on the Internet should focus on preventive education and orientation of patients for medical assistance. Objective: Evaluation of the in- formation concerning STI, provided on Internet resources, accessed by the patients of our Venereology consultation. Methods: Every patient attending this Venereology clinic during a six-month period (August 2010 till January 2011), answered to a questionnaire on the previous use of the Internet to obtain information about STI. The three most often mentioned websites (for the five most common conditions and STI screening) were systematically reviewed and the re- sults displayed as a score (0-8). Results: A total of 127 patients, that used the Internet before attending to the consulta- tion, were included (98 men and 29 women) and the mean age was 31 years (s=11,07). From the mentioned websites, 105 were Portuguese, the most frequent search engine used was Google and Wikipedia was the most popular website. From the 18 websites reviewed, only 17% stated that the acquisition of a STI may be associated with the acquisition of others, only 51% are updated on treatment and suggest sending partners to be treated and 55% refer STI transmission through oral sex. Comments: The information contained in these websites is often extensive, not updated and do not always referral for healthcare services.KEYWORDS – Internet; Information Dissemination; Patient Education; Sexually Transmitted Diseases.

Introduction: Besides morbidity related to skin lesions and pruritus, dermatologic disorders during preg- nancy cause psychological concern and some of them carry a fetal risk. Objective: Assessment of the type, frequency and clinical characteristics of the dermatoses seen in pregnant and postpartum women seeking support from the Emer- gency Department. Methods: Retrospective study of pregnant and postpartum women observed by dermatologists at the Emergency Department between September 2006 and September 2010. Results: The study included 79 pregnant and 7 postpartum women, with a median age of 33 years. Specific dermatoses of pregnancy were diagnosed in 42 patients (48.8%). Polymorphic eruption of pregnancy was the most frequent specific dermatosis (n=16), followed by eczema in pregnancy (n=12), prurigo of pregnancy (n=8), pemphigoid gestationis (n=5), and pruritic foliculitis of pregnancy (n=1). Other dermatoses were diagnosed in 44 patients (51.2%), including: pityriasis rosea (n=11), infections and infestations, dyshidrotic eczema, contact dermatitis, lupus erythematosus and acute generalized exanthe- matous pustulosis. In the cases with an atypical presentation, the biopsy helped in the characterization of the disease. The fetal outcome was assessed in 43 cases, only 3 cases of preterm delivery being registered.Discussion: The onset of the specific dermatoses of pregnancy was more likely to occur in the late pregnancy, especially the third trimester. In pregnant women with exuberant or atypical skin lesions, laboratory and histological study are indispensable for the specific diagnosis, allowing appropriate therapeutic approach and fetal risk assessment.KEYWORDS – Skin Diseases; Pregnancy Complications; Pruritus.

Introduction: Lichen sclerosus (LS) is a chronic idiopathic inflammatory disease that preferentially affects the anogenital region and postmenopausal Caucasian women. Aims: Retrospective characterization of patients with vulvar LS diagnosed and treated at our Department (Vulvar Pathology Consultation), between 1986 and 2004. Material and Methods: A total of 208 Caucasians women were included in the study. We consulted clinical charts and performed statistical analysis of the following variables: age, location, clinical signs and symptoms, association with other disea- ses, treatment modalities, follow-up and complications. Results: The mean duration of LS was 6.3 years. The mean age at diagnosis was 59.6 years. The mean age at development of symptoms was 53 years. One hundred and eighty-two (87.5%) patients were in the postmenopausal period. Pruritus was the predominant symptom (90.9%). Only 39 (18.8%) patients did not developed vulvar atrophy. One hundred and forty-two (68.2%) had not narrowing of the vaginal in- troitus. Histological examination confirmed LS in 185 cases (93.9%) and it was compatible with LS in the remaining 12 (6.1%). Topical testosterone propionate (TP) was used in 88 (42.3%) cases, topical corticosteroids in 24 (11.5%) and both in 76 (36.6%). The mean follow-up was 9.5 years. Nine (4.3%) women developed vulvar SCC and the mean age at diagnosis was 68.2 years. Conclusions: LS prevailed in post-menopausal women. Vulvar pruritus and atrophy were the main clinical findings. Most cases were confirmed by histology. Topical TP was the most commonly used therapy. Malignancy occurred in nine cases.KEYWORDS – Vulvar Lichen Sclerosus; Testosterone Propionate; Glucocorticoids; Carcinoma, Squamous Cell.

Background: Reports indicating incidence of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infections have been increasing. Objectives: To determine the prevalence of CT and NG infected individuals attending a Sexually Transmitted Disease (STD) clinic in a University Hospital. Methods: A cross-sectional study was conducted on attendees of the STD clinic throughout a 10 year period. Diagnoses of CT and NG infections were enabled upon nucleic acid amplification analysis (PCR). Results: In our study population there was a male predomi- nance (83.3%). Overall prevalence of CT and NG infection was 1.6% and 0.8%, respectively. A prevalence of 3% of chlamydia infection was recorded when routine screening was implemented. More so, 53% of individuals displayed asymptomatic infection, 78% of which had chlamydia infection and 22% had gonococcal infection (p<0.05). Routine screening of STD attendees has resulted in the diagnosis and treatment of an average of 13.7 asymptomatic individuals. Conclusion: Unlike gonococcal infection we found an increase of chlamydia infection prevalence when routine screening was implemented. Screening of STD attendees for CT provided the opportunity to identify and treat asymptomatic Chlamydia infections. Systematic screening of STD attendees of both genders for CT should be offered.KEYWORDS – Chlamydia Infections; Chlamydia trachomatis; Gonorrhea; Neisseria gonorrhoeae; Ambulatory Care Facilities.

Introduction: Analysis of patients with syphilis in a sexually transmitted diseases (STD) clinic and characterization of patients with syphilis co-infected with human immunodeficiency virus (HIV) and syphilis in men who have sex with men (MSM). Methods: Retrospective study of social, demographic, clinical and laboratorial data of patients with the diagnosis of syphilis between 1998 and 2009. Results: This study included 880 patients with syphilis, of these 69.9% were male. The mean age was 41.4±13.3 years within 15 to 91 years interval. 56.6% patients had early syphilis (ES) and in 13.0% other STD was simultaneously diagnosed. Eighty-seven (9,9%) patients had HIV infection, of these 33(37,9%) were de novo diagnosis. In the group of HIV positive patients a higher prevalence of MSM (32.6% vs 3.8%) and concomitant STD (36,8% vs 10,6%) were detected in comparison to HIV negative patients group (p<0,05). More patients with ES (70,4%) and concomitant STD (31,5%) were diagnosed in the group with previously known diagnosis of HIV (p<0,05). In MSM (n=56) a higher prevalence of HIV co-infection (50.0% vs 9.9%), ES (78,6% vs 57,4%) and concomitant STD (26.8% vs 15.8%) were observed in comparison to heterosexual men (n=545) (p<0,05). Discussion: In our population, more de novo STD were observed between HIV group, inclusively in those patients with previously known diagnosis. Among MSM a higher prevalence of HIV co-infection, early syphilis and simultaneous diagnosis of other STD were detected. This study emphasizes the need for more campaigns targeted to specific groups, namely patients with HIV infection and MSM.KEYWORDS – Ambulatory Care Facilities; HIV Infections; Homosexuality, Male; Syphilis; Sexual Behavior; Sexually Transmitted Diseases.  

A 77-year-old female patient submitted to excision of a basal cell carcinoma, resulting in an oval shaped defect with 20x25mm in diameter and exposure of the medial portions of alar cartilages. The reconstruction was perfor- med with transposition of muscle flaps from nasalis muscle in order to obtain a suitable vascular bed for a full-thickness skin graft harvested from a glabelar fold. The final result was cosmetically acceptable. Nasalis muscle flap associated with a full-thickness skin graft allows a single step reconstruction of nasal tip when exposure of cartilage without pericondrium occurs. Muscle flaps offer a better vascular supply for the skin graft, being a good alternative to local flaps or interpolated flaps, with a simpler surgical technique and achieving acceptable cos- metic results.KEYWORDS – Nose; Pele; Rhinoplasty; Surgical Flaps.

Idiopathic eruptive macular pigmentation is a rare disorder, characterized by the appearance of multiple brownish macules, asymptomatic, most frequently involving the neck, trunk and proximal region of the members. The incidence appears to be greater during childhood and adolescence. It is a distinct entity from erythema dyschromi- cum perstans. Usually it has spontaneous remission after several months to years without additional treatment or clinical investigation needed.KEYWORDS – Child; Hyperpigmentation; Pigmentation Disorders; Remission, Spontaneous.

The prozone phenomenon is defined as a falsely negative test due to very high titters of antibody, as high titters of antigen or antibody may prevent the formation of antigen-antibody complexes in laboratory tests of many diseases, like syphilis or brucellosis. We describe the case of a 27 year old caucasian male admitted in the emergency room with enlarged palpable lymph nodes and a skin eruption either suggestive of secondary syphilis or primary skin lymphoma. Since initial RPR screen was negative, he was admitted in ward with the latest hypothesis. Skin biopsies were suggestive of syphilis. The laboratory was then contacted to repeat the test under dillutional protocol, which enabled the test to be positive (VDRL 1/256 and TPHA positive). This case illustrates the importance of close contact with the laboratory in order to avoid false negative results, like those given in presence of prozone phenomenon.KEYWORDS – Syphilis, Cutaneous; Syphilis Serodiagnosis; False Negative Reactions.

A 75 year-old obese patient was submitted to anticoagulant therapy for deep vein thrombosis (DVT) of the lower limb: classic intravenous heparin for 3 days and subcutaneous dalteparin for 10 days. Three days after the end of treatment the patient developed eczema-like plaques at the subcutaneous low-molecular-weight heparin (LMWH) injec- tion sites. Prick, intradermal and patch tests were performed using heparins and fondaparinux, and were inconclusive or negative at 30 minutes and at 48 hours, therefore, subcutaneous tests were than performed. At D3 and D7 intradermal tests were positive for fraxiparin, dalteparin and enoxaparin and subcutaneous tests were also positive at D5. All tests were negative for fondaparinux, considered a safe anticoagulant alternative. Allergy testing with several heparins and heparinoids is essential to confirm delayed hypersensitivity to LMWH and identify safe alternatives in case of future need for anticoagulation, as in this patient with risk factors for DVT.KEYWORDS – Anticoagulants; Hypersensitivity, Delayed; Heparin, Low-Molecular-Weight; Drug Eruptions; Skin Tests.

Introduction: Macular arteritis (MA) is the denomination for a new type of cutaneous medium-size vessels vasculitis, clinically characterized by erythemato-violaceous or brownish, reticulated and asymptomatic macules. Histopathological examination demonstrates a lymphocytic arteritis. Case Report: A 35-year-old Caucasian man, with no smoking habits or relevant medical history presented with a 2-months history of cutaneous eruption on his limbs and trunk. He denied other complaints and the general physical examination was regular. The dermatological examination revealed multiples nontender and erythematous-violaceous macules, with linear and reticulated configuration. Cuta- neous periarteritis nodosa (CPN) was the main diagnosis proposed. Laboratory and radiological evaluation showed no underlying systemic disease. Pathological examination revealed a medium-sized vessel at the junction of the deep reticular dermis and the hypodermis, surrounded by a predominantly lymphocytic inflammatory infiltrate and fibrin deposits in the lumen, which were compatible with MA. Conclusion: MA is a poorly reported cutaneous vasculitis in the worldwide literature. The diagnosis is primarily histological and the CPN is the main clinical differential diagnosis.KEYWORDS – Arteritis; Skin Diseases; Hyperpigmentation.

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. Cutaneous involvement can occur and can be classified as specific or nonspecific depending on the presence or absence of granulomas on his- topathology of the skin. The subcutaneous form is a special type of presentation and it is believed to be more often associated with systemic disease.KEYWORDS – Sarcoidosis; Skin Diseases.

Erythema induratum of Bazin is a rare disease, characterized by the appearance of cutaneous erythema- tous nodules, sometimes painful with frequent evolution to ulceration. It is considered to be a hypersensitivity response to Mycobacterium tuberculosis. We describe an 83 years old female patient, with a 3 months history of erythematous subcutaneous nodules involving both legs and, at the same time, of right cervical enlarging nodes.KEYWORDS – Antitubercular Agents; Erythema Induratum; Mycobacterium tuberculosis; Panniculitis; Vasculitis.

KEYWORDS – Child; Elbow; Hypertrichosis.

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Syphilis is still today a major public health problem that requires prompt and appropriate diagnosis and treatment. The diagnosis is mainly based on serological tests – non-treponemal and treponemal. In recent years there has been a major technological advance in this area with the development of several new methods that use specific treponemal antigens, including enzyme immunoassays (EIA), chemiluminescence (CA) and immunochromatografic. Al- though many of these tests have not yet obtained approval from relevant organizations, their performance (high sensi- tivity and specificity) and automation have led many laboratories to adopt an inverse algorithm to the classic algorithm to the screening for syphilis, (non-treponemal first). However, currently available data are insufficient to decide that one has clear advantages over the other. With this paper the authors intend to summarize the changes that the diagnosis of syphilis suffered in the past few ye- ars, particularly with the regard to serological screening, emphasizing the advantages and disadvantages of the new guidelines.KEYWORDS – Syphilis; Serologic Tests; Bacteriological Techniques; Syphilis Serodiagnosis; Guidelines.

Psoriasis is an inflammatory dermatosis, affecting approximately 2% of the population, with predomi- nantly skin and joint involvement but also associated with considerable comorbidities. Approximately 20% to 30% of patients have moderate to severe disease uncontrollable with topical therapy. Traditional systemic therapy – oral PUVA, retinoids, cyclosporin and methotrexate – may induce organ specific toxicity and a significant number of patients are unresponsive, intolerant or have specific contraindications to its use. With the increased understanding of the pathoge- nesis of psoriasis, multiple biologic agents have been introduced. In the last years there has been an increased utiliza- tion of these agents and several studies were designed to evaluate their efficacy and safety. Currently, four biologics have been already approved by EMEA (European Medicines Agency) for the treatment of plaque psoriasis, 3 anti-TNFα (adalimumab, etanercept and infliximab) and one anti-IL12/23p40 (ustecinumab). In the present article we update the prior published guidelines (Trabalhos da SPDV 2010, 68(1): 47-68) due to the recent progress in the knowledge and therapeutic options in these area. These recommendations should be used with caution and treatment should be tailored to meet individual patient’s needs and each specific clinical situation.KEYWORDS – Adalimumab; Etanercept; Guidelines; Infliximab; Psoriasis; Ustekinumab.

Hansen disease, commonly called Leprosy, is an infectious disease caused by Mycobacterium leprae. In the past, the seriousness of the presentation of this disease associated with the inexistence of appropriate treatment, led to the stigmatization of these patients. Fortunately, the way we look now to Hansen disease has changed thanks to the existence of new antibacillary drugs. With migration phenomenon, we see nowadays, in Portugal, more cases in women in fertile age, manly immigrants from Brazil. There are questions to answer in a pregnant woman with Hansen disease, mainly in what regards to therapeutic effects in pregnancy, lactation and also to the delivery. It’s known that the gestation decreases the cellular immunity, which allows the proliferation of the bacilli. The drug choice will stop permanent nervous lesion. The authors report three cases followed in Maternidade Dr. Alfredo da Costa with the Dermatology Unit of Curry Cabral Hospital, in Lisbon. All these pregnant were, at the time of the gestation, under clofazimine and rifampicin. The aim of this review is to demystify Leprae and Pregnancy and stress the importance of a multidisciplinary follow-up.KEYWORDS – Pregnancy; Clofazimine; Rifampicin; Leprosy.

Vulvar skin diseases represent a heterogeneous group of skin diseases which display infectious, inflam- matory or malignant nature. The authors conducted a review of epidemiological, etiopathogenic, clínicopathological, therapeutic and prognostic aspects of five vulvar inflammatory skin diseases, namely lichen sclerosus, eczema, psoriasis, lichen planus and Zoon’s vulvitis. Except for the Zoon’s vulvitis, vulvar inflammatory skin diseases are more common in women compared to their counterparts in males. Their etiopathogenic features remain unknown. Itching and pain are the most common complaints. Extra-genital lesions may be present. The diagnosis of psoriasis and eczema is usually clinical and the definitive diagnosis of lichen sclerosus, Zoon’s vulvitis and lichen planus is primarily histological. Althou- gh mostly treated by dermatologists, vulvar inflammatory skin diseases may require a multidisciplinary approach which includes gynecology, urology, pediatrics, psychology and psychiatry. Superpotent or potent topical corticosteroids are the primarily therapeutic approaches, followed by topical calcineurin inhibitors. The risk of malignancy is present in lichen sclerosus and lichen planus, requiring periodic examination.KEYWORDS – Vulvar Diseases; Skin Diseases; Vulvar Lichen Sclerosus; Psoriasis; Lichen Planus; Vulvitis.

Tele-referral is possible in Dermatology due to the direct access to the target organ. The authors report the experience of tele-referral in a Dermatology Department for one year.KEYWORDS – Dermatology; Remote Consultation; Telemedicine.

Introduction: TNF-α plays an important role in immune defense against Mycobacterium tuberculosis and, as such, the risk of reactivation of latent tuberculosis increases with the TNF-blocking agents. Aims: To determine the prevalence of latent tuberculosis in psoriasis patients undergoing TNF-blocking agents, between 2006 and 2009. Assess the established therapy and their complications. Materials and methods: Review of clinical records and registration of clinical and epidemiological data. The used screening tests were Tuberculin Skin Test, chest x-ray and, in the QuantiFERON®-TB Gold test. Results: Forty-five patients were included in this retrospective study; twenty-seven (60%) had arthritic psoriasis and 18(40%) plaque psoriasis. Only 11% had known epidemiological risk factor for tuberculosis. Tuberculin skin test and chest x-ray were executed in all cases and QuantiFERON®-TB Gold test in four. Latent tuberculosis was confirmed in 18(40%) patients, 16(89%) man and two (11%) women. All of them were treated with isoniazid for nine months. Transient elevation of liver transaminases (mild hepatotoxicity) occurred in four (22%), however no patient developed moderate to severe hepatotoxicity. The entire completed the isoniazid regimen. The average period between the initia- tion of isoniazid therapy and TNF-blocking agent was two months. Mostly (46.7%) received adalimumab. No patients developed active tuberculosis. Conclusion: Latent tuberculosis was diagnosed in 40% of psoriasis patients. All patients completed the isoniazid regimen therapy without relevant complications. No case of active tuberculosis was diagnosed.KEYWORDS – Tumor Necrosis Factor-alpha; Psoriasis; Latent Tuberculosis; Biological Therapy.