RCAAP Repository

Lichen striatus is a papulous dermatosis with low prevalence, affecting mainly children and it is more frequent on the female population. Clinically, it evolves with abrupt onset with erythematous violaceous or hypopigmented papules, generally with non-pruritic and with unilateral distribution, with predilection for the extremities, following the Bhlaschko lines. We report a case of lichen striatus with atypical features and in this case, in addition to the histopathological exam, dermoscopy was useful on the diagnostic evaluation.

Bowen's disease (BD) is a form of intraepidermal squamous carcinoma. It occurs in any part of the skin, however the sun-exposed areas are the most prevalent. It might be associated with immunosuppression. A male patient, 46 years-old, diagnosed with AIDS, 55 CD4 cells/mm3. He has reported onset of injury in abdomen, with evolution of six months. On examination, it was nummular plate, erythematous, scaly, in the right flank. The possible diagnoses were seborrheic keratosis irritation, nummular eczema or amelanotic melanoma. From the dermoscopy, it was observed clusters of glomerular blood vessels and white scales. Thus arose the possibility of Bowen's disease. Histopathology was compatible with BD. Dermatoscopy is a noninvasive technique that allows the visualization of morphological structures not visible to the naked eye. In the BD, it is characterized by the presence of vascular structures (glomerular or dotted vessels) and scales on the surface. In this case, dermoscopy was essential to rethink the initial diagnosis of the lesion. Even in non-pigmented lesions, dermoscopy have shown to be an important weapon in the clinical examination of the patient.

Introduction: The published percentage of patients with eyelid dermatitis from cosmetic exposure lies between 2.5% and 26%. Pigmented make-up may contain metal allergens, including nickel, chromium and cobalt.Case report: A 52-year-old atopic woman, hairdresser, with a 7-month history of itching, erythema and scaling of both eyelids. Her medical history revealed earlobe dermatitis in childhood. She was referred for patch-testing in our contact allergy department with baseline series from Portuguese Contact Dermatitis group (GPEDC), cosmetic and hairdresser series and the patient´s own products in semi-open test. Positive reactions were observed to nickel sulphate 5% in petrolatum (++ at D3) and valentina D kejal®, grey eye shadow (++ at D3).Conclusions: Cosmetics are a potentially sensitizing source, on thin facial skin and especially for atopic woman, who have a damaged skin barrier that may favour penetration of allergens, allowing lower nickel concentrations, even as a contaminant, to trigger an eyelid reaction.

Introduction: Allergic contact dermatitis to the constituents of the prosthesis occurs in 5% of patients and may be the etiology of the failure of arthroplasty. The most common sensitizer’s metals are nickel, cobalt and chromium. The components of the cement have also been implicated as allergens.Methods: A retrospective study of patients with arthroplasties, who performed patch tests, after suspicion of allergic contact dermatitis in the last 2 years was done. We carried out tests with the standard battery of the Portuguese Group for the Study of Contact dermatitis and supplemental batteries, including metals, acrylates/methacrylates and topical antibiotics.Results: Fourteen patients were included: 10 underwent knee arthroplasty, 3 hip arthroplasty and 1 ankle arthroplasty. Patients had limited function of joints. The mean age of patients observed was 61.6 years and 12 patients were females and 2 males. The symptoms appeared on average 14.4 months after surgery. Nine patients had positive reactions to nickel, 5 to cobalt, 1 to chromium, 1 to gentamicin and neomycin. In these cases we opted for placing the prosthesis revision with oxinium and/or titanium, with improvement of symptomatology.Discussion and conclusions: This review showed the importance of performing patch tests in patients with clinical signs of failure of arthroplasty, since patients with sensitization to its constituent improved with the replacement of prosthesis.

Introduction: The appearance of pigmented lesions in scars of malignant melanoma is a finding that worries dermatologists/dermatopathologists, because they are faced with the possibility of persistence/recurrence of malignant melanoma.Case reports: We present three cases of patients with melanocytic pigmentation in scars of malignant melanoma and discuss the clinical and histological aspects of these. In all cases, we observed macules similar to lentigo spots, but histologically we observed three different patterns: lentiginous epidermal hyperplasia, lentiginous hyperplasia of melanocytes and malignant melanoma in situ.Discussion: There are three types of pigmentation, which may arise in the scar of malignant melanoma: lentigo type lesions, pigmented streaks and diffuse pigmentation. Histologically, three patterns of melanocytic pigmentation in scars of malignant melanoma, are described: lentiginous epidermal hyperplasia, lentiginous hyperplasia of melanocytes and persistence/ recurrence of malignant melanoma. The scar appears to be responsible for pigmentation by a process of induction acting on epidermal melanocytes.

Introduction: Plaque-type blue nevus is a rare variant of blue nevus, presenting usually as blue-gray plaque with superimposed nodules, beginning at birth or in early childhood and becoming stable during puberty. Its clinical, dermoscopic and even histopathological features may be worrisome and distinction from malignant blue nevus can be difficult, although its prognosis is generally favourable.Case Report: We present a 48 year-old male who had a blue-gray plaque with multinodularity arising in the left scapular region. The lesion had been present since birth, becoming stable during adolescence. Dermoscopy revealed a central structureless polychromatic plaque (blue, gray, black and brown areas) and extensive areas of blue-whitish veil. Adjacent to the central lesion, small blue satellite globules could be seen. Incisional biopsy showed a common blue nevus, and complete excision of the lesion confirmed the presence of a blue nevus predominantly of the common type, and focal cellular areas in its deeper portion. The patient is so far free of recurrence.Conclusion: There are many variants of blue nevus, and plaque-type blue nevus is one of the rarest. Classically regarded as having good prognosis, recent case-reports have shown a tendency towards local and lymph-node recurrence, the reason why recognition of this entity and appropriate follow-up are important.

A 46 year-old male patient with HIV-1/HCV coinfection and liver cirrhosis admitted with fever, prostration, and asthenia. On physical examination, scarce necrotic pustules on an erythematous base on the fingers and toes with swelling, pain and functional limitation of the left tibiotarsal joint were noted. Laboratory revealed only slight elevation of liver enzymology and CRP. We admitted the diagnostic hypotheses of endocarditis, meningococcemia or gonococcemia. After isolation of Neisseria gonorrhoeae from a blood culture, intravenous ceftriaxone was started with clinical improvement. Pharyngeal swab PCR positivity for N. gonorrhoeae confirmed the diagnosis of pharyngeal origin disseminated gonococcemia. Gonorrhea is a sexually transmitted infection caused by Gram-negative diplococcus Neisseria gonorrhoeae. Disseminated gonococcemia in the form of the classical "arthritis-dermatitis" syndrome accompanies only 1-2% of mucosal infections. Pharyngeal gonorrhea is often asymptomatic in men and women, probably constituting an important reservoir of the agent. The rise in gonorrhea incidence makes this case very pertinent in any dermatologist’s clinical practice today.

Introduction: Psoriasis occurs in up to 8% of patients with Down syndrome and, although poorly characterized, appears to be correlated with immune imbalance in cells Th1 and biochemical changes of cyclic nucleotides.Case report: Female patient, 38 years old, with Down syndrome and psoriasis (initial PASI 30) since 18 years. Initially treated with cyclosporine and methotrexate and subsequently with etanercept, adalimumab and ustecinumab because of progressive loss of response (current PASI 10).Conclusion: We describe this case for the poor response to treatment including various biological agents. Potential poor adherence to therapy and immune dysfunction may limit the therapeutic options.

Cutaneus focal mucinosis is a histological reaction pattern described in several diseases, in which an abnormal focal deposition of mucins is found in the dermis. The authors present a case of a 62 years-old patient with asymptomatic flesh colored, infiltrated plaques on the frontal-occipital scalp with 3 month of evolution. Serial biopsies of scalp plaques during the following two years showed a moderated lymphoid infiltrate in dermis with a homogeneous deposition of mucins in the dermis. There were neither alterations of epidermis, pilosebaceous units, epidermotropism or granulomas. Further investigations showed a primary adenocarcinoma of the lung. Cutaneous focal mucinosis can have a wide spectrum of clinical presentation. We report this case to illustrate an unusual presentation of cutaneous focal mucinosis of the scalp and to call the attention to the importance of ruling out a secondary associated disorder. As far as we know this is the first reported case of an association between adenocarcinoma of the lung and cutaneous mucinosis.

A 30-year-old HIV1 positive male, presented with multiple erythematous-violaceous lesions, with elevated borders and an annular configuration, restricted to the penis and scrotum. The lesions were asymptomatic, evolved for 2 weeks, and clinically resembled granuloma annulare. He also had discrete erythematous papules in the trunk that appeared simultaneously.A cutaneous biopsy was made and histopathology revealed a lichenoid infiltrate, mainly of plasma cells. Syphilis screening was positive, with a positive TPHA and a reactive RPR (titer of 1:256). The diagnosis of secondary syphilis was established and the patient was submitted to treatment with 3 weekly doses of intramuscular benzathine penicillin (2.4 million units).HIV co-infection can affect the initial presentation, disease course and hamper syphilis diagnosis. Syphilis, known as “the great imitator”, must be kept in mind, even before unusual presentations, especially in HIV positive patients.

Perforating diseases are characterized by transepidermal elimination of degenerated material, including collagen or elastic fibers. Acquired perforating dermatosis affects patients with diabetes mellitus or renal disease, especially under dialysis. An 86-year-old diabetic patient presents with very pruritic erythematous-violaceus papules and papulo-nodules, with a central crust. Lesions were evoluting for 2 months and were located to both lower extremities. The biopsy revealed a depression with fibrinous material and picnotic cells. Van-Gieson coloration showed elimination of vertical collagen bundles. The patient was treated with topical retinoid, with complete resolution.

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The increasing number of clinical trials in dermatology requires from the dermatologist the ability to evaluate the quality, understand, and synthesize information from multiple sources in order to make decisions regarding the therapeutic/ diagnostic strategies. This medical education article explains basic principles, relevant and adapted to the dermatology area, fundamental to an appropriate interpretation of outcomes of clinical trials. Part II of this article discusses the different analysis methods in clinical trials.

Introduction: Since ancient times, aloe vera is a plant used for medicinal and cosmetic purposes, due to its various properties. Currently, in many countries, the treatment of burns is one of the main indications for its use. However, the clinical evidence is still unclear.Objective: Review the existing evidence concerning the effectiveness of aloe vera in the treatment of skin burns.Data sources: Medline, evidence based medical sites (National Guideline Clearinghouse Guideline Finder, Canadian Medical Association, The Cochrane Database, DARE and Bandolier), Portuguese Index of Medical Journal and references of selected articles.Methods Review: Bibliography search in these databases, using the following combination of MeSH terms: "burns" and "aloe", articles published up to June 2014, in Portuguese, English, French or Spanish. We used the Strength of Recommendation Taxonomy scale for the allocation of levels of evidence and recommendation strengths.Results: We found 236 articles and selected, as meeting the inclusion criteria, one systematic review with meta-analysis and 2 original articles. After analyzing the articles, generally it is verified a faster healing of burns using aloe vera, when compared to the control.Conclusion: The available evidence seems to support the effectiveness of aloe vera in the treatment of skin burns (SOR B). However, due to the heterogeneity of aloe vera formulations and control used in the various studies, it is not possible to draw a clear conclusion about this benefit. More studies with better quality are needed to prove the efficacy of aloe vera in the treatment of burns.

Kaposi’s sarcoma is a rare tumor, mainly affecting skin and mucosa, in some cases the lymph nodes and visceral organs, with great epidemiological and clinical variability. There are four types of tumor (classic, endemic, immunosuppression related and associated with HIV), with differences in population, site and progression rate. Different therapeutic options exist between local intervention strategies, citoreductive surgery, radiotherapy, systemic therapy or therapeutic manipulations regarding the underlying cause, in the forms of disease associated to HIV or to immunosuppressive therapy. The authors used the PubMed database to identify articles published since 1990, in English language, using a predefined set of words, as well as manually identified content of interest, related to Kaposi’s sarcoma treatment. In this article, we highlight the importance of the multidisciplinary approach to the disease, as well as the current state of the art existing therapies, organizing and stratifying the available options in the clinical practice setting.

Psoriasis is a chronic disease, immune-mediated, affecting approximately 2% of the population. It results from a polygenic predisposition in combination with environmental factors, eg trauma, infection, or drugs. All forms of psoriasis may have nail involvement (40-45%), but sometimes this can occur alone (5%). Onychomycosis is an infection of the nail caused by dermatophytes, yeasts, or non-dermatophyte filamentous fungi; the most common agent is Trichophyton rubrum the (T. rubrum). It is still controversy regarding the higher or lower prevalence of onychomycosis in patients with psoriasis. Nail changes caused by psoriasis are sometimes clinically indistinguishable from those for onychomycosis, and we must make the differential diagnosis, because the treatment is different. There are several studies that analyze the possible predisposition of onychomycosis in patients with nail psoriasis and this literature review aims to analysis of these studies, published to date.

Introduction: Ungueal changes in psoriatic patients might occur or worsen due to mycotic infections, which are more likely to happen in the setting of immunosuppressive therapies and nail plate changes. There is still controversy about the prevalence of onychomycosis in psoriatic patients in the literature. The aim of this observational prospective study is to access the prevalence of ungueal mycotic infection in psoriatic patients with nail changes during one-year period.Materials & Methods: Relevant clinical data and samples of affected nails were collected. The biological material was subject to direct mycological exam and culture. Statistical analysis was performed with Excel and R software.Results: Of the 47 patients included, 33 were male. Mean age was 55 years. Twenty-seven patients (55%) had fingernail changes, with mean NAPSI 3.5. Candida albicans was isolated in 6 cultures (22%). Among the studied nail changes, pitting and longitudinal lines correlated with negative culture (p<0.05). Toenail changes were found in 44 patients (94%), with mean NAPSI 3.7. Culture was positive in 11 exams (25%), in seven of which were found dermatophytes. There was no statistical correlation between toenail changes and culture.Conclusions: In our psoriatic population, onychomycosis was more prevalent than the reported data for non-psoriatic population. Pitting and longitudinal lines were negative predictors of fingernail onychomycosis.

Introduction: The sentinel lymph node biopsy is an important tool for staging patients with melanoma, allowing identification of occult regional lymph node involvement and avoidance of unnecessary lymphadenectomies.Objective: To analyze the patterns of recurrence of melanoma in patients with a negative sentinel lymph node biopsy result and identify the clinical and pathological characteristics potentially predictive of recurrence after a negative sentinel lymph node biopsy.Materials and methods: A retrospective study was conducted in patients with cutaneous melanoma who underwent sentinel lymph node biopsy in the Department of Dermatology, Santarém Hospital, between 2005 and 2011.Results: 96 sentinel lymph node biopsy staged patients were evaluated. Of these, 29 patients had a positive sentinel lymph node biopsy result, 66 had a negative sentinel lymph node biopsy result and one patient had an inconclusive result. Among the 66 patients with a negative sentinel lymph node biopsy result, 11 (16.7 % of the negative results) had a recurrence of melanoma at a median of 21.7 months of follow-up (range, 8-51 months). Compared to the patients without recurrence, these patients had an older age at diagnosis (mean 71.8 vs 62.9 years; p=0.021), were predominantly of male sex (54.5% vs 29.1%; p=0,159), and had deeper primary lesions (median thickness 2.92 vs 1.80 mm; p=0.087) that were more likely to be ulcerated (63.6% vs 38.1%; p=0,177) and to have vascular/perineural invasion (40% vs 13%; p=0,207). Nodular melanoma was the most prevalent clinical variant in this group (54.5%), while in the group with recurrence prevailed the superficial spreading type (50.9%).Conclusions: Overall, recurrence of melanoma after a negative sentinel lymph node biopsy result (16.7%) was similar to that in previously reported studies. We identified as possible predictors of recurrence, despite a negative sentinel lymph node biopsy result: older age at diagnosis, male sex, higher Breslow thickness, presence of ulceration, presence of vascular/perineural invasion, and nodular variant.

Introduction: Actinic keratoses are epidermal lesions of keratinocytic dysplasias that arise from chronic cutaneous exposure to ultraviolet radiation, with the potential to transform into squamous cell carcinoma. The normal-appearing skin areas contiguous to actinic keratoses lesions are believed to have the same potential to evolve to squamous cell carcinoma, which has led to the concept of skin “field cancerization”. The aim of this study was to investigate keratinocytic morphologic changes in human skin with and contiguous to actinic keratoses with laser scanning confocal microscopy, and hence validate the concept of field cancerization to human skin.Material and Methods: Observational study performed in four patients. Nine actinic keratoses lesions and four clinically normal skin 1cm contiguous to the referred lesions were analyzed with laser confocal microscopy. Discrimination of photodamaged skin from normal skin was performed according to the diagnostic morphologic criteria described by Horn M et al.Results: Overall, four diagnostic morphologic criteria were visualized in 55% of actinic keratoses lesions, as well as the presence of keratinocyte atypia and inflammatory cells in all normal-appearing adjacent skin areas (“field cancerization”) analyzed.Conclusions: Results obtained validate the concept of field cancerization to the skin, showing subclinical changes in the normal appearing skin surrounding the actinic keratoses. On the other hand the results corroborate the utility of laser confocal microscopy for the in vivo diagnosis of skin damages in normal-appearing areas. As with actinic keratoses, these areas should be monitored and treated as early as possible.