RCAAP Repository

Vitamin D plays an important role in calcium homeostasis and bone metabolism. Recently, vitamin D was shown to play an important part in cancer pathology and, more specifically, in melanoma. Seric deficiency of 25(OD)D3, active precursor of vitamin D, has been linked to higher incidence and poorer melanoma prognosis. In vitro studies of several tumors showed that vitamin D supplementation has anti-inflammatory and pro-apoptotic properties, induces differentiation, inhibits proliferation and sensitizes tumoral cells to anti-tumoral therapies. Also, the modulation of the expression of vitamin D receptors (VSR) seems to be implied on vitamin D anti-tumoral effect. The relationship between vitamin D and melanoma becomes more controversial when vitamin D synthesis through UV radiation is associated with increased melanoma risk. In this article we review present bibliography and present clinical suggestions concerning solar exposure, seric blood levels of vitamin D and reduction of melanoma incidence and prognosis.

Introduction: Psoriasis is a chronic inflammatory dermatosis with significant impact on quality of life and multiple comorbidities, with recognition especially given to cardiovascular risk factors. Recently it has been highlighted the high prevalence of psychiatric comorbidities.Methods: The primary outcome was to assess the prevalence of psychotropic drugs in the chronic medication of patients with diagnosis of psoriasis. We performed a case-control study at the Department of Dermatology of Coimbra Hospital and University Centre, between 2010 and 2015. The results were compared with age- and gender-matched controls. The medication was grouped according to the INFARMED. The secondary outcome was to compare the prevalence of treatments for cardiovascular risk factors in both groups and to compile the information on psychiatric comorbidities available in the medical records of the psoriasis patients included in this study. The data were processed by STATA 14 and statistical significance was considered when p<0.05. Results: The sample consisted of 79 patients, 67% male and 33% female, mean age of 59.30±17.17 years. There was association (p<0.01) between psoriasis and psychotropic drugs, especially anxiolytics and antipsychotics, with 63% of patients with at least one psychotropic drug. It was found an association between psoriasis and antihypertensive drugs (p<0.05). Frequently, psychiatric diagnoses were not mentioned or were inaccurately described in the medical records.Conclusion: The results highlight the high prevalence of psychotropic drugs and reinforce previous studies about the lack of assessment of psychopathology in dermatology, a topic of high relevance in patients with psychodermatologic diseases, such as psoriasis.

Introduction: Occupational allergic contact dermatitis (ACD) is frequent among health care workers (HCW) and culprit allergens may vary with time, occupational setting and exposure hazards.Objectives and Methods: In order to characterize the main contact allergens in HCW with dermatitis and its occupational relevance, we performed a retrospective analysis of clinical data and patch test (PT) results from HCW who were studied in the Department of Dermatology of Coimbra Hospital and University Centre (CHUC) between 2010-2015. All patients were tested with a baseline and additional series, according to the tasks developed.Results: Among 1858 patch tested patients, 125 (6.7%) were HCW, 114 females/11 males, mean age 39,26±12,5 years, mainly nurses (56), technical assistants (48) and doctors (21), 71 with hand dermatitis (56,8%), 22 with atopic dermatitis and/or other atopic symptoms (17,6%). Ninety patients (72%) had at least one positive PT, 47 (37,6%) with occupational relevance. Patients with hand dermatitis were significantly more likely to have positive PT (76.1%). We observed 51 positive PT to metals (Ni-41, most with past relevance, Co-8; Cr -2), 30 to fragrances (FM-I-10; Myroxylon pereirae-8; lyral-5; FM-II-4; citronellol-3), 29 to preservatives (mostly methylisothiazolinone (MI) and/or chloromethylisothiazolinone (MCI)-20), 24 to rubber chemicals (P-phenylenediamine (PPD)/Isopropyl-PPD-9), and 14 to topical medicaments (iodopovidone - 5; caine mix - 4). The main occupational causes of ACD were hand soaps/disinfectants and patients’ hygiene products (15), protective gloves/shoes-9 and topical or systemic drugs (antiseptics-8 and parenteral antibiotics-3). Main allergens with occupational relevance were MI and/or MCI/MI (15), although isolated MI was tested only after mid 2012, lanolin and/or amerchol L101 (9), formaldehyde and/or formaldehyde releasers (7), iodopovidone (5), thiuram mix (5), carbamates (4), FM-I (3), cephalosporins (3) and (meth)acrylates (3 dentists/dental technicians). In 37 out of 42 evaluated cases there was marked improvement/resolution of the dermatitis, namely after eviction of the hospital hand soap which contains MCI/ MI under the designation of Acticide® MV.Conclusions: Hand dermatitis was the main presentation of ACD in HCW with no apparent relation with atopy. Isothiazolinones and formaldehyde releasers induced more positive PT and were more frequent among HCW than in the whole population studied very probably due to the cumulative exposure to these preservatives in personal and occupational hand soaps and hygiene products. PT was important to orient eviction in each individual case but also for the hospital community to understand the presence of moderate or potent sensitizers in the work place and, therefore, establish the most adequate preventive measures.

Introduction: Sexual transmitted infections (STI) are an important health problem and increase the risk for acquisition and transmission of HIV. We aimed to identify STIs diagnosed in patients with known human immunodeficiency virus (HIV) infection and in newly diagnosed ones.Methods: Retrospective analysis of medical charts of individuals attending a specialized STI Clinic from 2009 to 2013.Results: A total of 680 patients were included, accounting for 8% of the patients observed during the study period. The majority (638, 92%) were male and men who have sex with men (MSM) (489, 72%). Almost half (304, 45%) were migrants. Overall, 270 (40%) patients were diagnosed with at least one STI, syphilis was the most common (123, 18%), followed by Chlamydia trachomatis (46, 7%), Neisseria gonorrhoeae infection (42, 6%) and genital warts (32, 5%). Concerning HIV status, 329 (48%) patients had known infection and 351 (52%) were newly diagnosed during the study period. The newly diagnosed patients were significantly younger (37.3±9.7 vs 32.4± 9.5 years) and more frequently sought attention for screening. Past history of STIs, partner referral, symptoms and being diagnosed with at least one concomitant STI were significantly more common in previously known HIV patients.Conclusion: At least one new STI (other than HIV) was diagnosed in 40% of the patients. This represents an important problem not only because concomitant STIs increase the risk of HIV acquisition (for the new diagnosed cases) but also because patient with known HIV infection maintain a high-risk behaviour pattern.

Vitiligo is an acquired prevalent pigmentary disorder characterized by its chronicity, refractoriness and significant psychosocial burden. Concerning its pathogenesis, several genetic, environmental, oxidative stress mechanisms and immune disturbances combine in an intricate, complex way. Diverse immunemediated comorbidities do occur in a variable yet significant manner, so as to fully justify the careful approach and follow-up of these patients. polyglandular autoimmune syndrome type II – Schmidt`s syndrome – is defined by the association of Addison`s disease with immunemediated thyroid disease and/or type 1 diabetes mellitus. The case of a 64year old Caucasian female patient with a long lasting history of several immunemediated disorders (namely Hashimoto thyroiditis and hypothyroidism, atrophic gastritis, lichen planus and stable acrofacial vitiligo) is reported. who For the last 3 months her vitiligo had suffered significant extension and morphologic changes – confettilike lesions, trichromic vitiligo and Koebner`s phenomenon – along with discrete and subtle generalized hypermelanosis. Laboratory work up disclosed a state of hypocortisolism –further confirmed by functional, immunological and image studies: autoimmune Addison`s disease in the context of Schmidt`s syndrome. An effective endocrine insufficiency correction prompted for a quick patient`s recovery as far as hydroelectrolytic and metabolic metabolism, with a concomitant reversion of the hypermelanosis and a stabilization of the vitiligo. In this case it is noteworthy the rapid expansion of a previous stable vitiligo along with the acquisition of peculiar new morphologic features, in the context of a subtle diffuse hypermelanosis in a patient with a past history of several immunemediated disorders. We underline the need to acknowledge the possible association of vitiligo with immunemediated comorbidities, particularly whenever atypical semiological or evolutive features are present.

Infectious dermatitis is a severe, chronic and relapsing dermatitis, associated with human T-cell lymphotropic virus type 1 (HTLV-1). Although most reported cases have onset in childhood, adult cases of infectious dermatitis have been reported. The dermatological framework mimics common conditions such as seborrheic dermatitis, atopic dermatitis, contact dermatitis, impetigo and mycosis fungoides. In endemic countries for HTLV-1, like Brazil, it is essential that the infectious dermatitis is considered as a differential diagnosis in these cases. Early diagnosis is important to prevent the dissemination and provide appropriate monitoring and treatment of possible complications associated with the virus, such as HTLV-1 associated myelopathy or tropical spastic paraparesis, and Adult T-cell leukemia / lymphoma. We report two female patients with adult-onset infectious dermatitis. In order to enrich the report, we also presented the daughter's photos from one of the patients, with the same diagnosis.

Classical lichen planus and lichen striatus represent separate entities within the group of lichenoid dermatoses with clinical and histologic well-defined differences. A possible relationship between both has been proposed. We present a case of a 38-year-old woman with a consecutive diagnosis of lichen striatus followed by classical lichen planus within three months. Some authors have questioned whether there is an intermediate form between these two entities or if they represent different states or opposite ends of the same disease spectrum. These questions are unlikely to be resolved until the pathophysiology of these two diseases is clarified.

The term pseudoainhum is used to describe constricting band(s) around one or more digits in relation to several congenital or acquired diseases. Systemic sclerosis, keratoderma, psoriasis, Reynolds syndrome among others, has been reported to be associated with pseudoainhum development. We report a case of a 54 years old woman with annular constricting bands and micronychia on the fourth and fifth digits of her both hands associated with bilateral distal acrosclerosis. Raynaud’s phenomenon with some years of evolution and, more recent, fatigue and recurrent inflammatory polyarthritis and also antinuclear and anti-U1 nuclear ribonucleoprotein antibodies were present. Therefore, the diagnoses of pseudoainhum with a likely association with mixed connective tissue disease were proposed. Whenever in the presence of pseudoainhum, a detailed workup, including autoimmune disorders screening, is mandatory in order to rule out possible associated syndromes or underlying diseases. The authors present this case as the association between pseudoainhum and mixed connective tissue disease has not been previously reported in the literature.

Lymphomatoid papulosis is a rare primary T-cell lymphoproliferative cutaneous disorder, mostly affecting adults. Although histopathology suggests a malignant disease, in most cases, lymphomatoid papulosis is a self-limited condition with a good prognosis. We describe the case of an 8-year-old boy, otherwise healthy, who presented with a 4-6 week history of polymorphic cutaneous lesions disseminated over the whole body. Histology and immunohistochemistry confirmed the diagnosis of lymphomatoid papulosis type A. The authors discuss the main challenges in follow-up, treatment and the risk of progression of lymphomatoid papulosis to secondary lymphomas in this age group.

Pseudoxanthoma Elasticum (PXE) is a rare hereditary autosomal recessive disorder with a molecular defect in the ABCC6 gene. This dysfunction causes accumulation of calcium that causes degeneration of the elastic fibers, mainly in the eyes, cardiovascular system and skin. The case of a 61-year-old patient with PXE, with decreased visual acuity for 5 years and asymptomatic yellowish papules in the underarms and neck for 30 years is presented.

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Bullous pemphigoid, the most common autoimmune subepidermal blistering disease, is due to autoantibodies against BP180/230 present in the hemodesmosomes of the basal keratinocytes that typically causes pruritus and tense cutaneous bullae on an erythematous or normal skin It affects predominantly the elderly, often in association with neurologic or neoplastic disease. The association with the human immunodeficiency virus infection is rare. We present a case of a young VIH+ patient under antiretroviral therapy with undetectable viral load and normal CD4+ T-cell count who developed an extensive bullous pemphigoid refractory to pulses of corticosteroids, oral steroids and methotrexate and improved only after the infusion of rituximab, an anti-CD20 monoclonal antibody.

We report a case of a 34-year-old female with asymptomatic and recurrent erythematous papules localized exclusively in her left forearm, for three years. Histopathology showed a predominantly lymphocytic inflammatory infiltrate, with scattered pleomorphic CD30+ cells and occasional mitotic figures. These findings are consistent with agminated lymphomatoid papulosis considered by some authors as a distinct entity, although we believe it represents a rare presentation of lymphomatoid papulosis.

Papillary syringocystoadenoma is an uncommon benign adnexal neoplasm, which is preferentially located on the scalp and face, and is associated with sebaceous nevus in 40% of cases. Although rare, its transition to basal cell carcinoma and ductal carcinoma may occur. The authors describe the case of a 7-year-old male patient with a linear papular dermatosis in the neck from birth. Dermatological examination showed erythematous, crateriform, confluent papules, arranged in a band, 3 x 2 cm in the cervical region. The lesion was excised for therapeutic and diagnostic purposes. Histopathology demonstrated epidermal cystic invagination and papillary projections surface by glandular epithelium, with decapitation secretion and abundant lymphoplasmocytic infiltrate. The clinical and histological findings were compatible with the diagnosis of papillary syringocystoadenoma. Despite the clinical variability of this entity, the histopathology is characteristic and the treatment consists in the excision of the lesion.

Thiurams are used as additives that are added to natural or synthetic latex in the manufacture of rubber products. Hypersensitivity to thiurams is a delayed type IV reaction, mediated by T lymphocytes. The authors present a case of a 9-year-old girl with recurrent episodes of edema and erythema of the eyelids, lips and perioral region, associated with eczema-like lesions, all with previous exposition to rubber materials. Epicutaneous patch test was positive for thiuram mix. With the eviction of these products the girl did not have any more lesions. Many patients referenced for contact dermatitis to rubber products are hypersensitive to rubber additives such as thiurams and carbamates and not to latex.

Multiple myeloma is a proliferative clonal disorder of plasma cells. The clinical presentation is highly variable, with recurrent infections, anemia, renal insufficiency or bone pain from osteolytic lesions as the main initial manifestations. Skin manifestations are unusual and mostly unspecific. We describe two patients with cutaneous lesions as the first sign of this hematologic malignancy: nodular deposits of amyloid in the external ear duct and diffuse plane xanthoma.

Behçet's disease is a systemic vasculitis with a chronic-relapsing course, which can lead to significant morbidity and mortality. From the often-compelling challenge of making a prompt diagnosis comes the difficulty in its treatment. We report the case of a patient with an acneiform skin eruption revealing Behçet's disease that was refractory to conventional therapy and later completely responded to adalimumab. Although randomized controlled clinical trials are lacking in the literature, there is already significant evidence supporting anti-TNF agents as a major therapeutic advance in Behçet's disease, particularly in cases that are severe, refractory or intolerant to classical immunosuppression.

HIV predisposes infected patients to multiple skin diseases that frequently exhibit atypical clinical presentations. The authors report the case of a 57-year-old man with severe HIV-related immunosuppression who developed a generalized pruritic dermatosis during prolonged hospitalization. Taking into account the patient’s status, his complaints and distribution of lesions, diagnosis of scabies was considered, although lesions were not typical and there was no suggestive epidemiological context. Two treatments with a benzyl benzoate lotion induced only transient improvement. Only a second biopsy confirmed hyperinfestation with Sarcoptes scabiei. Complete recovery followed treatment with ivermectin. The authors present a brief review of some particular aspects regarding diagnosis and treatment of crusted scabies.

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