Reconstrução perioral após cirurgia micrográfica de Mohs: análise de 108 casos / Perioral reconstruction after Mohs micrographic surgery: analysis of 108 cases

Introdução: a região perioral é comumente acometida por câncer de pele não melanoma. A cirurgia micrográfica de Mohs é o tratamento de escolha nessa área, com as maiores taxas de cura e preservação de tecido sadio. Há inúmeros métodos de reconstrução da região perioral, sendo sua escolha influenciada por características da ferida operatória e preferência do cirurgião. Objetivos: descrever a experiência dos autores na reconstrução perioral após cirurgia micrográfica de Mohs e analisar os métodos de reconstrução mais utilizados. Métodos: estudo retrospectivo de casos de reconstrução perioral submetidos à cirurgia de Mohs. Resultados: foram incluídos 103 pacientes, totalizando 108 casos. O número médio de estágios da cirurgia micrográfica de Mohs foi de 1,4, e o tamanho médio dos defeitos, de 16mm. O fechamento primário foi a técnica mais empregada para reconstrução, seguido por retalhos, principalmente V-Y avanço simples e rotação. A associação entre métodos de reparo foi utilizada em 28,7%. Quatro pacientes tiveram complicações (necrose e infecção do enxerto, trapdoor e deiscência parcial de sutura). Conclusões: fechamento primário foi o método mais frequente de reparo, seguido pelos retalhos. Conhecer as estratégias de reconstrução e possibilidades de associações é fundamental para a adequada restauração da região perioral, mantendo-se funcionalidade, sensibilidade e estética do local.

Introduction: The perioral region is commonly affected by non-melanoma skin cancer. Mohs micrographic surgery is the treatment of choice in this area because it has the highest cure rate and preserves healthy tissue. Several methods are available for restoring the perioral region, and their selection is influenced by the surgical wound characteristics and the surgeon's preference. Objective: Describe the authors' experience in perioral reconstruction after Mohs micrographic surgery and analyze the repair methods most frequently performed. Methods: Retrospective study of consecutive cases submitted to Mohs surgery and perioral reconstruction. Results: The study included 108 cases from 103 patients. The mean number of Mohs surgery stages was 1.4, and the mean defect size was 16 mm. Primary closure was the most used technique for reconstruction, followed by flaps (mainly V-Y, single advancement, and rotation). The association of repair methods was used in 28.7% of cases, mostly combined with flaps. Four patients had complications (necrosis and graft infection, trapdoor effect, and partial wound dehiscence). Conclusion: Primary closure was the most frequent repair method, followed by flaps. Knowing reconstruction strategies and possibilities of associations is essential for proper restoration of the perioral region, maintaining its functionality, sensitivity and aesthetics.

Criocirurgia intralesional em lesões vasculares benignas: boa opção para angioma rubi e hamartomas sobre mancha vinho do Porto / Intralesional cryosurgery in benign vascular lesions: a good option for cherry angioma and hamartomas over port-wine stain

A criocirurgia é uma técnica de vasto conhecimento e uso entre dermatologistas. A aplicação intralesional já é utilizada no tratamento de queloides e tem como vantagem restringir a zona de ação das baixas temperaturas do nitrogênio líquido. O uso da criocirurgia de contato em lesões vasculares é relatado, mas não há publicações sobre a técnica intralesional nesses tipos de lesões. Aqui, relatamos dois casos: 1- Hamartomas sobre mancha vinho do Porto em um paciente de 61 anos; e 2 - Angioma rubi em um paciente de 70 anos, ambos tratados de forma satisfatória e segura com criocirurgia intralesional.

Cryosurgery is a technique widely known and used among dermatologists. Intralesional application is already used to treat keloids and has the advantage of restricting the zone of action of low temperatures of liquid nitrogen. The use of contact cryosurgery in vascular lesions is well reported in the literature, but there are no intralesional technique publications on these types of lesions. Here, we report two cases, one of port-wine stain hamartomas in a 61-year-old patient and another of a cherry angioma in a 70-year-old patient, safely and satisfactorily treated with intralesional cryosurgery

Nail clipping in onychomycosis and comparison with normal nails and ungual psoriasis

Abstract: Background: Of all nail disorders seen in dermatology offices, half of them are due to onychomycosis. The main differential diagnosis is nail psoriasis. The objective of this study was to compare the microscopic findings, other than the presence of fungi, in the clipping of onychomycosis versus normal nails and nail psoriasis. Methods: Cross-sectional study of onychomycosis cases, analyzed by clipping and compared with data on normal nails and those with nail psoriasis. Results: Sixty-two onychomycosis samples were compared with 30 normal nails and 50 nails with psoriasis. In onychomycosis, measurement of subungual region, serous lakes, neutrophils and number of layers of parakeratosis are more intense than in psoriasis. Onychocariosis is less common in psoriasis, while bacteria are more frequent. The nail transition zone is more commonly blurred and irregular in onychomycosis. Conclusion: Clipping helps in the differential diagnosis of onychomycosis and nail psoriasis and may be useful even when fungi are not found.

Dermatosis neglecta

Dermatosis neglecta is the name of a skin condition characterized by papules and polygonal plaques, which are sometimes warty, brownish and hyperpigmented, adherent and symmetric, though removable with ethyl or isopropyl alcohol. It occurs due to inadequate skin cleansing causing accumulation of sebum, sweat, keratin and impurities. Its occurrence, though little reported, is frequent. The main differential diagnosis is the Terra fi rma-forme dermatosis. The treatment is simple, with exfoliation, moisturizing and even rubbing of alcohol. Causes of negligence on the patient’s side, which can range from hygiene carelessness to psychiatric disorders, local hypersensitivity, limbs negligence or motor paralysis, should be investigated. We illustrate the case of dermatosis neglecta in a 45-years old patient admitted with pulmonary sepsis.

Histopathological analysis of the therapeutic response to cryotherapy with liquid nitrogen in patients with multiple actinic keratosis

Abstract Actinic keratoses are premalignant lesions of the skin caused by excessive sun exposure. Lesions may become mainly squamous cell carcinoma. Cryotherapy with liquid nitrogen is one of the main treatments. In order to evaluate the response of actinic keratosis to cryotherapy by histopathology, two lesions were selected in each of 14 patients with multiple actinic keratoses. In one lesion a biopsy was performed and in the other lesion a biopsy was performed after cryotherapy. Subsequently, both biopsies were compared histologically. Of the thirteen patients who completed the study, the best results were obtained in lesions undergoing cryotherapy concerning the atypia of keratinocytes, epithelial thickness and corneal layer and lymphocytic infiltrate. Despite the small number of patients, it was concluded that, if performed correctly, cryotherapy has high efficacy in the treatment of actinic keratoses.

Primary cutaneous follicle center lymphoma simulating basal-cell carcinoma on the nasal ala

Primary cutaneous B-cell lymphomas (PCBCLs) constitute 25% of all primary cutaneous lymphomas. They present in the skin with no evidence of systemic or extracutaneous disease at the time of diagnosis, after adequate staging. Primary cutaneous B-cell lymphomas differ significantly from their nodal counterparts in relation to both clinical behavior and prognosis. The distinction between primary and secondary B-cell lymphomas is essential for defining prognosis/course of action. Such distinction is also very difficult to make, since primary and secondary B-cell lymphomas are clinically and histologically indistinguishable. We report the case of a patient with primary cutaneous follicle center lymphoma who underwent surgical excision.

Efficacy of gabapentin in the improvement of pruritus and quality of life of patients with notalgia paresthetica

BACKGROUND: notalgia paresthetica is a subdiagnosed sensory neuropathy presenting as a condition of intense itching and hyperchromic macule on the back that interferes with daily habits. OBJECTIVES: To determine the efficacy of treatment of notalgia paresthetica using oral gabapentin, assessing the degree of improvement in itching and influence on quality of life. Moreover, to evaluate the signs and symptoms associated with notalgia paresthetica. METHODS: We conducted an experimental, non-randomized, parallel, non-blinded study including 20 patients with clinical and histopathological diagnosis of notalgia paresthetica. After application of the visual analogue scale of pain adapted for pruritus and of the questionnaire of dermatology life quality index (DLQI), ten patients with visual analogue scale > 5 were given treatment with gabapentin at the dose of 300 mg/day for four weeks. The other ten were treated with topical capsaicin 0.025% daily for four weeks. After the treatment period, patients answered again the scale of itching. RESULTS: The use of gabapentin was responsible for a significant improvement in pruritus (p=0.0020). Besides itching and hyperchromic stain on the back, patients reported paresthesia and back pain. It was observed that the main factor in the worsening of the rash is heat. CONCLUSION: Gabapentin is a good option for the treatment of severe itching caused by nostalgia paresthetica. .

Classic Kaposi's sarcoma treated with elastic stockings and outpatient follow-up of a 90-year-old patient / Sarcoma de Kaposi classico tratado com meias elasticas e acompanhamento ambulatorial numa paciente de 90 anos

Kaposi's sarcoma is a multifactorial angioproliferative disorder. The herpes virus 8 human contributes to its pathogenesis, but it is uncertain whether these lesions are only reactive hyperplasia to the virus or neoplasia. Four clinical types are described: classic, endemic, iatrogenic and HIV-associated. Classic Kaposi's sarcoma has no standard staging or treatment protocols. Some studies have shown the use of compression stockings in the treatment of lymphedema associated with Kaposi's sarcoma. We report the case of a 90 year-old patient with classic Kaposi's sarcoma treated with compression stockings who showed a satisfactory response.

O sarcoma de Kaposi é uma desordem angioproliferativa de causa multifatorial. O vírus herpes 8 participa na sua patogenia, porém há dúvidas se a origem das lesões é apenas por hiperplasia reacional ao vírus ou uma neoplasia propriamente dita. Quatro tipos clínicos são descritos: clássico, endêmico, iatrogênico e associado ao HIV. O tipo clássico de sarcoma de Kaposi mantém-se sem padronização de estadiamento ou protocolos de tratamento. Há alguns estudos mostrando o uso de meias compressivas no tratamento do linfedema associado ao Kaposi Comunicamos um caso de uma paciente de 90 anos com sarcoma de Kaposi clássico tratado com meias elásticas compressivas, mostrando uma resposta satisfatória.

Case report of cutaneous histiocytic sarcoma: diagnostic and therapeutic dilemmas / Relato de um caso de sarcoma histiocitico cutaneo: dilemas diagnosticos e terapeuticos

Histiocytic sarcoma is a rare hematologic malignant neoplasia originating from histiocytic or dendritic cell clones. The lesions may be in nodal or extranodal sites, most commonly in the gastrointestinal tract. A small number of cases presents as unique cutaneous lesions. The definitive diagnosis is made by positivity for the immunohistochemical markers CD163, CD68, CD4 and lysozyme. The treatment is controversial, often with combined systemic chemotherapy. This is a case of cutaneous histiocytic sarcoma in an 82-year-old patient presenting two nodular lesions in the breast and right arm which were treated with simple excision and multidisciplinary follow-up, avoiding aggressive management and exhaustive investigations. Although most studies report aggressive evolution, the patient had good and stable clinical status during the twelve-month follow-up period.

Sarcoma histiocítico é uma rara entidade neoplásica maligna hematológica originada de clones celulares dendríticos ou histiocitários. As lesões podem ser nodais ou extranodais, mais comumente no trato gastrintestinal. Um pequeno número de casos apresenta lesões cutâneas exclusivas. O diagnóstico definitivo é feito pela positividade dos marcadores imunohistoquímicos CD163, CD68, CD4 e lisozima. O tratamento é controverso, geralmente com quimioterapia combinada sistêmica. Este é um caso de sarcoma histiocítico cutâneo em uma paciente de 82 anos apresentando duas lesões nodulares na mama e braço direitos, tratadas com exérese simples e seguimento multidisciplinar, evitando-se condutas intempestivas e investigações exaustivas. Apesar de a maioria dos estudos relatar evolução agressiva, a paciente apresenta quadro clínico bom e estável no período de doze meses de seguimento.

Cutaneous neonatal lupus with cutis marmorata telangiectatica congenita-like lesions / Lúpus cutâneo neonatal com lesões semelhantes à cutis marmorata telangiectatica congênita

Neonatal lupus is a rare disease caused by the transplacental transfer of maternal autoantibodies to the foetus, characterized by transient clinical manifestations such as cutaneous, haematological, and hepatobiliary events or permanent such as congenital heart block. The typical cutaneous manifestations include erythematous, scaly, annular or arched lesions on the face, with slight central atrophy and photosensitivy, clinically and histologically similar to subacute cutaneous lupus. However, in some cases, the lesions may resemble those in cutis marmorata telangiectatica congenita, although this phenomenon is rare and only eight such cases have been reported to date. We report a case of cutaneous neonatal lupus with atypical lesions on the limbs, which had a reddish-purple marbled appearance, resembling the lesions in cutis marmorata telangiectatica congenita.

Lúpus neonatal é uma doença rara causada pela transferência de auto-anticorpos maternos para o feto, caracterizada por manifestações clínicas transitórias como cutâneas, hematológicas e hepatobiliares, ou permanentes como o bloqueio cardíaco congênito. As manifestações cutâneas típicas incluem lesões fotossensíveis descamativas, anulares ou arqueadas na face, com discreta atrofia central, clinica e histopatologicamente similares ao lúpus cutâneo subagudo. Entretanto, em alguns casos, as lesões podem lembrar aquelas da cutis marmorata telangiectatica congênita, mas esse fenômeno é raro e somente oito casos foram reportados até hoje. Nós relatamos aqui um caso de lúpus cutâneo neonatal com lesões atípicas nos membros de cor vermelho-purpúricas e aparência marmórea, semelhantes às lesões da cutis marmorata telangiectatica congênita.