Consensus on the treatment of vitiligo - Brazilian Society of Dermatology

Abstract Background: Vitiligo is a muco-cutaneous, autoimmune, localized, or disseminated disease, which manifests through hypochromic or achromic macules, with loss in quality of life. The prevalence of vitiligo in Brazil was determined to be 0.54%. There is no on-label medication for its treatment. To date, no Brazilian consensus on the treatment of vitiligo had been written. Objectives: The objective of this group of Brazilian dermatologists with experience in the treatment of this disease was to reach a consensus on the clinical and surgical treatment of vitiligo, based on articles with the best scientific evidence. Methods: Seven dermatologists were invited, and each was assigned two treatment modalities to review. Each treatment (topical, systemic, and phototherapy) was reviewed by three experts. Two experts reviewed the surgical treatment. Subsequently, the coordinator compiled the different versions and drafted a text about each type of treatment. The new version was returned to all experts, who expressed their opinions and made suggestions for clarity. The final text was written by the coordinator and sent to all participants to prepare the final consensus. Results/Conclusion: The experts defined the following as standard treatments of vitiligo: the use of topical corticosteroids and calcineurin inhibitors for localized and unstable cases; corticosteroid minipulse in progressive generalized vitiligo; narrowband UVB phototherapy for extensive forms of the disease. Surgical modalities should be indicated for segmental and stable generalized vitiligo. Topical and systemic anti-JAK drugs are being tested, with promising results.

Guia prático da Associação Brasileira de Alergia e Imunologia para o diagnóstico e tratamento das urticárias baseado em diretrizes internacionais / A practical guide of the Brazilian Association of Allergy and Immunology to the diagnosis and treatment of urticaria based on international guidelines

A urticária crônica espontânea afeta mais de um milhão de brasileiros e impacta significativamente em sua qualidade de vida. Para atualizar as recomendações quanto ao seu diagnóstico e tratamento, especialistas de todo o mundo reúnem-se a cada quatro anos em Berlim e revisam todas as novas evidências que justifiquem modificações na diretriz internacional. Este artigo discute as principais recomendações propostas na versão atual da diretriz.

Chronic spontaneous urticaria affects more than one million Brazilians and significantly impacts their quality of life. In order to update the recommendations on diagnosis and treatment, experts from all over the world meet every 4 years in Berlin to review all the new evidence that can support modifications to the international guidelines. This paper discusses the main recommendations proposed in the current version of the guidelines.

Consensus on the diagnostic and therapeutic management of chronic spontaneous urticaria in adults - Brazilian Society of Dermatology

Abstract: Background: Urticarias are frequent diseases, with 15% to 20% of the population presenting at least one acute episode in their lifetime. Urticaria are classified in acute ( ≤ 6 weeks) or chronic (> 6 weeks). They may be induced or spontaneous. Objectives: To verify the diagnostic and therapeutic recommendations in chronic spontaneous urticaria (CSU), according to the experience of Brazilian experts, regarding the available guidelines (international and US). Methods: A questionnaire was sent to Brazilian experts, with questions concerning diagnostic and therapeutic recommendations for CSU in adults. Results: Sixteen Brazilian experts answered the questionnaire related to diagnosis and therapy of CSU in adults and data were analyzed. Final text was written, considering the available guidelines (International and US), adapted to the medical practices in Brazil. Diagnostic work up in CSU is rarely necessary. Biopsy of skin lesion and histopathology may be indicated to rule out other diseases, such as, urticarial vasculitis. Other laboratory tests, such as complete blood count, CRP, ESR and thyroid screening. Treatment of CSU includes second-generation anti-histamines (sgAH) at licensed doses, sgAH two, three to fourfold doses (non-licensed) and omalizumab. Other drugs, such as, cyclosporine, immunomodulatory drugs and immunosuppressants may be indicated (non-licensed and with limited scientific evidence). Conclusions: Most of the Brazilian experts in this study partially agreed with the diagnostic and therapeutic recommendations of the International and US guidelines. They agreed with the use of sgAH at licensed doses. Increase in the dose to fourfold of sgAH may be suggested with restrictions, due to its non-licensed dose. Sedating anti-histamines, as suggested by the US guideline, are indicated by some of the Brazilian experts, due to its availability. Adaptations are mandatory in the treatment of CSU, due to scarce or lack of other therapeutic resources in the public health system in Brazil, such as omalizumab or cyclosporine.

Lâmpada de Wood na dermatologia: aplicações na prática diária / Wood's lamp in dermatology: applications in the daily practice

A prática clínica do dermatologista baseia-se na análise das lesões cutâneas. Essa análise é feita essencialmente pela observação clínica, e atualmente complementada com exames como a dermatoscopia e a microscopia confocal. Apesar de seu baixo custo, a lâmpada de Wood tem sido cada vez menos utilizada como método diagnóstico auxiliar. Apresentamos diversos casos de utilização da lâmpada de Wood sendo de grande auxílio ao dermatologista. Esperamos assim incentivar o uso desse aparelho na prática diária.

The dermatologist's clinical practice is based on the analysis of cutaneous lesions that is carried out mainly by clinical observation, and currently supplemented with tests such as dermoscopy and confocal microscopy. Despite its low cost, the Wood's lamp has been decreasingly used as an auxiliary diagnostic method. The authors of the present study describe several cases of use of the Wood's lamp where it provided valuable assistance to the dermatologist, aiming at encouraging the use of this device in the daily practice.

Qual é o tipo de fototerapia mais comumente indicada no tratamento da psoríase?: UVB banda estreita e PUVA: comportamento da prescrição / What is the most common phototherapy prescription for psoriasis: NB-UVB or PUVA? Prescription behavior

FUNDAMENTOS: Formas moderada e grave de psoríase requerem fototerapia e/ou medicações sistêmicas. Tanto UVB banda estreita quanto fototerapia UVA com psoralênicos (PUVA) podem ser utilizadas no tratamento dessas formas de psoríase, sendo comprovada a efetividade de ambas as terapias. OBJETIVOS: Avaliar as indicações de dois tipos de fototerapia no tratamento da psoríase refratária à terapia tópica: UVB banda estreita e PUVA. MÉTODOS: Entre janeiro de 2006 e dezembro de 2007, os pacientes encaminhados a dois serviços de fototerapia foram incluídos neste estudo. Dados sobre os casos e tipos de prescrição foram coletados de maneira retrospectiva. RESULTADOS: Dentre os 67 pacientes estudados, 51 (76 por cento) foram tratados com UVB banda estreita. As razões para sua indicação foram presença de psoríase em gotas (22 por cento), presença de finas placas (15 por cento), uso de drogas fotossensibilizantes (15 por cento), idade abaixo de 20 anos (9 por cento), fototipo I (9 por cento) e doença hepática (6 por cento). Os 16 (24 por cento) restantes foram tratados com PUVA. A principal indicação dessa terapia foi gravidade da doença (15 por cento), seguida de fototipo IV (9 por cento). CONCLUSÕES: As prescrições de UVB banda estreita excederam as de PUVA devido ao menor número de contraindicações, menor possibilidade de efeitos colaterais, e ainda por ser uma opção mais prática.

BACKGROUND: Moderate and severe forms of psoriasis require phototherapy and / or systemic medications. Both UVA and UVB can be used to treat cases of moderate and severe psoriasis, and the effectiveness of both has been proven. OBJECTIVE: to access the prescription behavior relating to two types of phototherapy for treating psoriasis refractory to topical treatment: narrowband UVB (NB-UVB) or psoralen plus UVA phototherapy (PUVA). METHODS: Between January 2006 and December 2007, patients referred to two phototherapy services were included in this study. Data on the cases and on the type of prescription were collected retrospectively. RESULTS: Among the 67 studied patients, 51 (76 percent) were treated with narrowband UVB. The reasons for the indication were the presence of the guttate type of psoriasis (22 percent), the presence of thin plaques (15 percent), the use of drugs that affected photosensitivity (15 percent), age less than 20 years (9 percent), skin type I (9 percent), and liver disease (6 percent). The remaining 16 (24 percent) were treated with PUVA. The main indication for this therapy was the severity of the disease (15 percent), followed by the presence of skin type IV (9 percent). CONCLUSIONS: Prescriptions of narrowband UVB exceeded those of PUVA because of fewer contraindications and fewer possible side effects, and because it was a more practical option.

Fototerapia na doença enxerto contra hospedeiro / Phototherapy in the graft versus host disease

FUNDAMENTOS: A doença enxerto contra hospedeiro é um dos obstáculos ao sucesso do transplante de medula óssea, e o envolvimento cutâneo é freqüente. A fototerapia é utilizada devido à intensa atividade imunomoduladora local, sendo opção terapêutica adjuvante para as lesões cutâneas resistentes à terapia convencional. OBJETIVO: Realizar análise descritiva do tratamento da doença enxerto contra hospedeiro com fototerapia (Puva ou UVB de faixa estreita). MÉTODOS: Foram atendidos nove pacientes com manifestação cutânea da doença enxerto contra hospedeiro aguda ou crônica. Seis foram tratados com Puva, terapia de primeira escolha, e três com UVB de faixa estreita. As sessões foram realizadas três vezes por semana, e a resposta terapêutica avaliada após 12 sessões. RESULTADOS: Todos os pacientes com doença enxerto contra hospedeiro aguda mostraram melhora, com desaparecimento do eritema e do edema. Naqueles com doença crônica, observaram-se involução das lesões liquenóides e melhora da mobilidade daqueles com a forma esclerodermiforme. Dois pacientes apresentaram doença de evolução grave e foram a óbito. CONCLUSÃO: A fototerapia mostrou-se efetiva no tratamento das manifestações cutâneas da doença enxerto contra hospedeiro aguda e crônica. A Puva permite o controle da doença, podendo a UVB de faixa estreita ser opção para pacientes impossibilitados de usar medicação sistêmica.

BACKGROUND: Graft versus host disease is one of the obstacles to successful bone marrow transplantation. It often affects the skin. Phototherapy has been used because of its strong local immunomodulatory activity and it is an option for adjuvant therapy for skin lesions of graft versus host disease resistant to conventional therapy. OBJECTIVE: To make a descriptive analysis of treating graft versus host disease with phototherapy (PUVA or narrowband UVB). Methods - Nine patients with cutaneous manifestation of acute or chronic graft versus host disease were studied. The first choice therapy was PUVA, applied in six patients, and three were treated with narrowband UVB. The sessions were held three times a week and therapeutic response was evaluated after 12 sessions. RESULTS: All patients with acute graft versus host disease showed improvement, with the disappearance of erythema and edema. In those with chronic graft versus host disease, there was good response to therapy with regression of lichenoid lesions and better mobility of patients with the sclerodermoid form. Two patients had severe progression and died. CONCLUSION: Phototherapy showed to be effective in treating skin manifestations of acute and chronic graft versus host disease. PUVA allows control of the disease. The narrowband UVB is an option for patients who cannot take systemic medications.

Você conhece esta síndrome? / Do you know this syndrome?

Paquidermoperiostose é genodermatose autossômica dominante rara, que afeta pele e ossos, porém sua prevalência e incidência permanecem desconhecidas. Ocorre predominantemente em homens, que também mostram fenótipo mais grave da doença. Descrevese o caso de paciente do sexo masculino, de 60 anos.

Pachydermoperiostosis is a rare autosomal dominant genodermatosis characterized by bone and cutaneous involvement, even though its prevalence and incidence are ignored. It occurs predominantly in men, which present a more serious clinical presentation. We report a case of a 60-year-old man with this disease.