Consensus on the therapeutic management of atopic dermatitis ‒ Brazilian Society of Dermatology: an update on phototherapy and systemic therapy using e-Delphi technique

Abstract This publication is an update of the "Consensus on the therapeutic management of atopic dermatitis - Brazilian Society of Dermatology" published in 2019, considering the novel, targeted-oriented systemic therapies for atopic dermatitis. The initial recommendations of the current consensus for systemic treatment of patients with atopic dermatitis were based on a recent review of scientific published data and a consensus was reached after voting. The Brazilian Society of Dermatology invited 31 experts from all regions of Brazil and 2 international experts on atopic dermatitis who fully contributed to the process. The methods included an e-Delphi study to avoid bias, a literature search and a final consensus meeting. The authors added novel approved drugs in Brazil and the indication for phototherapy and systemic therapy for AD. The therapeutical response to systemic treatment is hereby reported in a suitable form for clinical practice and is also part of this updated manuscript.

Consensus on the therapeutic management of atopic dermatitis - Brazilian Society of Dermatology

Abstract: BACKGROUND: Atopic dermatitis is a highly prevalent inflammatory and pruritic dermatosis with a multifactorial etiology, which includes skin barrier defects, immune dysfunction, and microbiome alterations. Atopic dermatitis is mediated by genetic, environmental, and psychological factors and requires therapeutic management that covers all the aspects of its complex pathogenesis. OBJECTIVES: The aim of this article is to present the experience, opinions, and recommendations of Brazilian dermatology experts regarding the therapeutic management of atopic dermatitis. METHODS: Eighteen experts from 10 university hospitals with experience in atopic dermatitis were appointed by the Brazilian Society of Dermatology to organize a consensus on the therapeutic management of atopic dermatitis. The 18 experts answered an online questionnaire with 14 questions related to the treatment of atopic dermatitis. Afterwards, they analyzed the recent international guidelines on atopic dermatitis of the American Academy of Dermatology, published in 2014, and of the European Academy of Dermatology and Venereology, published in 2018. Consensus was defined as approval by at least 70% of the panel. RESULTS/CONCLUSION: The experts stated that the therapeutic management of atopic dermatitis is based on skin hydration, topical anti-inflammatory agents, avoidance of triggering factors, and educational programs. Systemic therapy, based on immunosuppressive agents, is only indicated for severe refractory disease and after failure of topical therapy. Early detection and treatment of secondary bacterial and viral infections is mandatory, and hospitalization may be needed to control atopic dermatitis flares. Novel target-oriented drugs such as immunobiologicals are invaluable therapeutic agents for atopic dermatitis.

Carcinoma de células escamosas cutâneo-invasivo - relato de caso / Invasive cutaneous squamous cell carcinoma - Case report

O carcinoma de células escamosas cutâneo é resultante da proliferação maligna dos queratinócitos. Costuma surgir da evolução de lesões precursoras, mas pode crescer espontaneamente na pele normal ou cronicamente inflamada. O carcinoma de células escamosas invasivo corresponde à segunda forma mais comum de câncer da pele não melanoma e representa 20% de todas as neoplasias cutâneas. Este trabalho relata um caso clínico de carcinoma de células escamosas cutâneo, rapidamente progressivo e com metástases regionais, que mesmo com a ressecção completa e esvaziamento ganglionar, apresentou pouca resposta terapêutica e evoluiu a óbito.

Cutaneous squamous cell carcinoma (SCC) results from malignant proliferation of keratinocytes. It usually arises from the development of precursor lesions, however it may grow spontaneously on normal or chronically inflamed skin. Invasive SCC is the second most common type of non-melanoma skin cancer and accounts for 20% of all cutaneous neoplasms. The present paper reports a clinical case of cutaneous SCC, rapidly progressive and with regional metastases, which, even after complete resection of the tumor and regional lymph nodes, showed little therapeutic response and evolved to death.

Ocular manifestations of psoriasis / Manifestações oculares observadas em pacientes com psoríase

ABSTRACT Purpose: We aimed to report the ocular manifestations observed in patients with psoriasis. Methods: Patients were included and referred to our ophthalmology clinic from dermatology clinics of Universidade do Estado do Pará between October 2013 and August 2014. Clinical interviews were conducted to identify relevant epidemiological data, clinical features, and treatment details, and data were recorded using the same protocol. Subsequent dermatological examinations were performed and disease severity was rated using the Psoriasis Area and Severity Index and the Dermatological Life Quality Index. Complete eye examination was conducted, including visual acuity, biomicroscopy, tonometry, fundoscopy, Schirmer I test, tear breakup time, rose bengal staining, ocular surface disease index, and glaucoma tests. Results: In total, we included 43 patients with psoriasis and 86 controls. Patients with psoriasis had statistically higher incidences of dry eye (16.28%), likely dry eye (32.56%), and blepharitis (16.28%). Furthermore, the rose bengal and ocular surface disease tests were more abnormal in patients with psoriasis (p<0.05). Conclusions: Patients with psoriasis should undergo regular eye exams, regardless of risk factors, to monitor for the progression of symptomatic or asymptomatic ocular manifestations.

RESUMO Objetivos: Relatar as manifestações oculares observadas em pacientes com psoríase atendidos no Ambulatório de Dermatologia da X e encaminhados ao Y, no período de outubro de 2013 a agosto de 2014. Métodos: A amostra foi constituída por um grupo composto por 43 pacientes com psoríase e um grupo controle com 86 pacientes sem psoríase. Foi realizada uma entrevista clínica com dados epidemiológicos, aspectos clínicos da doença e terapia empregada, sendo todas as informações registradas em protocolo próprio. Posteriormente, realizou-se o exame dermatológico, no qual foi avaliado o índice de gravidade da Psoríase por área (PASI) e índice dermatológico de qualidade de vida (DLQI), e o exame oftalmológico completo, incluindo: Acuidade Visual, Biomicroscopia, Tonometria, Fundoscopia, Teste de Schirmer I, Tempo de Ruptura do Filme Lacrimal (TBUT), rosa bengala, índice de doença da superfície ocular (OSDI) e exames para glaucoma. Resultados: Observou-se que nos pacientes com psoríase houve frequência estatisticamente maior de envolvimento ocular, como olho seco (16,28%), provável olho seco (32,56%) e blefarite (16,28%). Além disso, os valores do rosa bengala e do OSDI apresentaram-se mais alterados nos pacientes com psoríase (p<0,05). Conclusão: Dessa forma, sugere-se que esses pacientes realizem exames oftalmológicos periódicos, já que as manifestações oculares podem progredir sem sintomatologia e ocorrer independentemente de fatores de risco.

Efeito do óleo de copaíba associado ao microagulhamento na pele de ratos: um estudo comparativo / Effect of copaiba oil associated with microneedling on the skin of rats: a comparative study

Introdução: O microagulhamento é técnica cuja finalidade é o estímulo do colágeno, bem como de drug delivery. O óleo de copaíba apresenta efeitos cicatrizantes e anti-inflamatórios que já foram demonstrados em vários modelos animais. Objetivo: Avaliar o efeito do óleo de copaíba associado ao microagulhamento na pele de ratos. Métodos: Foram utilizados 30 ratos distribuídos em seis grupos com cinco animais cada, submetidos a: microagulhamento isolado, microagulhamento associado a óleo mineral e microagulhamento associado a óleo de copaíba. Foram realizadas biópsias em todos os animais 14 dias e 30 dias após. Os parâmetros avaliados foram presença de colágeno, fibroblastos e vasos, classificada em ausente (0), leve (1), moderada (2) ou intensa (3). Resultados: Houve diferença estatisticamente significante entre os grupos em relação ao colágeno com 14 (p = 0,0091) e 30 dias (p = 0,0357) e fibroblastos com 30 dias (p = 0,0357). O grupo que utilizou microagulhamento e óleo de copaíba, apresentou, após 30 dias, maior produção de colágeno e de fibroblastos. Conclusões: o óleo de copaíba associado ao microagulhamento foi capaz de estimular maior produção de colágeno e de fibroblastos na pele de ratos.

Introduction: Microneedling is a technique aiming at stimulating the production of collagen as well as serving as drug delivery. Copaiba oil has healing and anti-inflammatory effects that have already been demonstrated in several animal models. Objective: To evaluate the effect of copaiba oil associated with microneedle removal on the skin of rats. Methods: Thirty rats were distributed in six groups of five animals each, subsequently undergoing: isolated microneedling, microneedling associated to mineral oil, and microneedling associated with copaiba oil. Biopsies were carried out in all animals at 14 and 30 days after the procedure. The parameters evaluated were: presence of collagen, fibroblasts and vessels, according to the following ratings: absence (0), mild (1), moderated (2) or intense (3). Results: There was a statistically significant difference between the groups regarding the production of collagen at 14 days (p = 0.0091) and 30 days (p = 0.0357); and fibroblasts at 30 days (p = 0.0357). the group that used microneedling and copaiba oil, presented, after 30 days, a greater production of collagen and fibroblasts. Conclusions: Copaiba oil associated with microneedling was capable of stimulating a greater production of collagen and fibroblasts in the skin of rats.

Development of metrics for articles published in professional master's course / Desenvolvimento de métricas para artigos publicados no mestrado profissional

Objective: Propose metric to qualify the production conveyed through articles published in Professional Master's Programs and, from there, to establish guidance for the evaluation of postgraduate programs of Medicine III. Method: Analysis of the documents of 2013 area graduate programs strict sense concerning the application and measurement of score the articles published, and creation of proposal for metric of the theme with the quadrennial review of Medicine III. Results: Were evaluated the medicines area documents I, II and III; Biological Sciences (I) and Interdisciplinary, as well as the 2013 reports of CAPES. All programs establish metrics for "Classification of Published Articles" within its bibliographic production although with different percentages respecting its specificities. With these data collected and correlating their relevance with the surgical areas, was drafted proposal for quantification of the quality of the published articles to "Professional Postgraduate Programs" at surgical area that have specific characteristics according to their guidelines, directing their scientific production to technique journals preferably. Conclusion: The metric suggested for published articles, that should be included in intellectual production of the Area Document, should be considered for the extract A1 = 100 points; A2 = 85 points; B1 = 80 points; B2 = 70 points; B3 = 60 points; B4 = 40 points and B5 = 20 points.

Objetivo: Propor métrica para qualificar a produção veiculada através de artigos publicados em programas de mestrado profissional e, a partir daí, estabelecer orientação para a avaliação dos programas de pós-graduação da Medicina III. Método: Análise dos documentos de área de 2013 dos programas de pós-graduação senso estrito no que concerne à aplicação e mensuração de pontuação a artigos publicados, e criação de proposta para métrica do tema com vistas à avaliação quadrienal da Medicina III. Resultados: Foram avaliados os documentos de área das Medicinas I, II e III; Ciências Biológicas I e Interdisciplinar, assim como os relatórios de 2013 da CAPES. Todos os programas estabelecem métrica para "Classificação de Artigos Publicados" dentro de sua produção bibliográfica embora com percentuais diferentes respeitando suas especificidades. Com esses dados levantados e correlacionando-se sua pertinência com as áreas cirúrgicas, foi elaborada proposta de quantificação da qualidade dos artigos publicados para "Programas de Pós-graduação Profissionais" na área cirúrgica que possuem características próprias de acordo com suas diretrízes, direcionando assim sua produção científica preferencialmente para revistas técnicas. Conclusão: A métrica sugerida para artigos publicados, que deve ser incluída na produção intelectual do Documento de Área, deverá ser considerada para o extrato A1 = 100 pontos; A2 = 85 pontos; B1 = 80 pontos; B2 = 70 pontos; B3 = 60 pontos; B4 = 40 pontos e B5 = 20 pontos.

Evaluation of cases of pemphigus vulgaris and pemphigus foliaceus from a reference service in Pará state, Brazil

BACKGROUND: Pemphigusis a bullous, rare and chronic autoimmune disease. There are two major forms of pemphigus: vulgaris and foliaceus. Epidemiological data and clinical outcome in patients diagnosed in the Brazilian Amazon states are still rare. OBJECTIVES: To study the occurrence of the disease during the study period and analyze the epidemiological profile of patients, the most common subtype of pemphigus, and the clinical evolution of patients. METHODS: Retrospective analysis of medical records of hospitalized patients with pemphigus foliaceus and pemphigus vulgaris in the period from 2003 to 2010 in Dermatology Service of Hospital Fundação Santa Casa de Misericórdia do Pará, Belém, Northern Brazil. RESULTS: We found a total of 20 cases of pemphigus during the study period, 8 of which were of foliaceus pemphigus and 12 of vulgaris pemphigus. Pemphigus foliaceus had the predominance of male patients (75%), showed satisfactory clinical evolution, and was characterized by absence of pediatric cases. Pemphigus vulgaris affected more women (66.7%), showed mean hospital stay of 1 to 3 months (50%), and there were three cases of death (25%). The prescribed immunosuppressive drugs included prednisone with or without combination of azathioprine and/or dapsone. Sepsis was associated with 100% of the deaths. CONCLUSIONS: The occurrence of the disease is rare, there are no familiar/endemic outbreaks in the sample. Evolution is usually favorable, but secondary infection is associated with worse prognosis. The choice of best drugs to treat pemphigus remains controversial. .

Tissue immunostaining for factor XIIIa in dermal dendrocytes of pityriasis alba skin lesions

BACKGROUND: Pityriasis alba affects 1% of the world population and about 9.9% of the children in Brazil. However, its etiology remains uncertain. OBJECTIVE: The objective of the present study was to evaluate the immunoexpression of factor XIIIa in dermal dendrocytes of skin lesions of pityriasis alba. METHOD: Twenty patients with pityriasis alba and 20 patients with atopic dermatitis underwent biopsy. The dermal dendrocytes marked by factor XIIIa were counted by means of immunohistochemical analysis. RESULTS: The mean amount of dermal dendrocytes found in the patients with pityriasis alba was 2, whereas in the patients with atopic dermatitis it was 4, with a statistically significant difference between them. A cutoff point of 3 cells/square inch was established to differentiate pityriasis alba from atopic dermatitis, with 80% sensibility and 90% specificity. CONCLUSION: We believe that pityriasis alba and atopic dermatitis should be considered different clinical forms within the spectrum of atopic disease, in which sun radiation plays an important role by modulating the progression of the disease. .

Clinical, epidemiological, and therapeutic profile of dermatophytosis

BACKGROUND: The cutaneous mycoses, mainly caused by dermatophyte fungi, are among the most common fungal infections worldwide. It is estimated that 10% to 15% of the population will be infected by a dermatophyte at some point in their lives, thus making this a group of diseases with great public health importance. OBJECTIVE: To analyze the clinical, epidemiological, and therapeutic profile of dermatophytosis in patients enrolled at the Dermatology service of Universidade do Estado do Pará, Brazil, from July 2010 to September 2012. METHOD: A total of 145 medical records of patients diagnosed with dermatophytosis were surveyed. Data were collected and subsequently recorded according to a protocol developed by the researchers. This protocol consisted of information regarding epidemiological and clinical aspects of the disease and the therapy employed. RESULTS: The main clinical form of dermatophyte infection was onychomycosis, followed by tinea corporis, tinea pedis, and tinea capitis. Furthermore, the female population and the age group of 51 to 60 years were the most affected. Regarding therapy, there was a preference for treatments that combine topical and systemic drugs, and the most widely used drugs were fluconazole (systemic) and ciclopirox olamine (topical). CONCLUSION: This study showed the importance of recurrent analysis of the epidemiological profile of dermatophytosis to enable correct therapeutic and preventive management of these conditions, which have significant clinical consequences, with chronic, difficult-totreat lesions that can decrease patient quality of life and cause disfigurement. .

Psoriasiform Keratosis - Case report

Psoriasiform Keratosis is a rare clinic entity. The etiopathogenesis remains unknown and the disease is characterized by a solitary, scaly or keratotic papule, or plaque mainly located on the extremities. Histopathological features closely resemble those of psoriasis. We report the case of a 70-year-old woman presenting a solitary and asymptomatic keratotic plaque, located on the back of the left leg, unresponsive to topical corticosteroids. We performed an excisional biopsy and histopathology was consistent with psoriasiform keratosis.

Soroprevalence of rapid tests in leprosy cases and household contacts in endemic municipalities of Pará state / Soroprevalência de testes rápidos em caso de hanseníase e contatos intradomiciliares em municípios endêmicos do estado do Pará.

Objective:This is a transversal study of series of cases in endemic areas for leprosy in the Sate of Pará, estimating the seroprevalence of antiPGL-1, through ML-Flow rapid test in leprosy cases and their household contacts. Method: from april 2011 to october 2012, 73 new leprosy cases and 165 household contacts were recruited in the reference units for treatment of leprosy in the municipalities of Marituba, Belém, Igarapé-Açú and Santarém. Results: seropositivity was observed in 53.42% of index cases; of them were MB cases and among 12.1% household contacts. Conclusions: the results indicate that the introduction of the rapid test, as auxiliary instrument, serves for classification of index cases and household contacts of cases involved in this study, allowing to conclude that leprosy cases and their contacts are important elements in the epidemiology of the disease.

Objetivo: Trata-se de um estudo transversal, do tipo série de casos em áreas endêmicas para hanseníase no estado do Pará, estimando a soroprevalência de anticorpos antiPGL-1 através do teste rápido ML-Flow em casos de hanseníase e seus contactos intradomiciliares. Método: de abril de 2011 a outubro de 2012, 73 novos casos de hanseníase e 165 contactos intradomiciliares foram recrutados nas unidades de referência para tratamento da hanseníase nos municípios de Marituba, Belém, Igarapé-Açú e Santarém. Resultados: a soropositividade foi observada em 53,42% dos casos índices; deles eram casos MB e 12,1% entre os contactos intradomiciliares. Conclusões: os resultados indicam que a introdução do teste rápido, como instrumento auxiliar, serve para a classificação dos casos índices e contactos intradomiciliares dos casos envolvidos no estudo, o que permite concluir que os casos de hanseníase e seus contactos são elementos importantes na epidemiologia da doença.

Pyoderma gangrenosum in a newborn - case report / Pioderma gangrenoso em recem - nascido - relato de caso

Pyoderma gangrenosum is a rare, inflammatory, chronic and recurrent disease of unknown etiology, characterized by noninfectious, necrotizing and painful cutaneous ulcers. Usually it affects adults aged between 25 and 54 years old and rarely children (less than 4%), in which it mainly affects the head, face, buttocks, genital and perianal region. The disease presents a quick response to systemic corticosteroids. We report a case of a newborn with hemorrhagic and necrotic ulcers, distributed in the abdomen, buttocks and genital region with rapid and effective response to oral prednisone.

O Pioderma gangrenoso é uma doença inflamatória rara, crônica e recorrente, de etiopatogenia desconhecida, caracterizada por uma ulceração não-infecciosa, necrotizante e dolorosa da pele. Geralmente, afeta adultos na faixa de 25 a 54 anos e raramente crianças (menos de 4%), nestes acomete preferencialmente cabeça e face, nádegas, região perianal e genital. Apresenta rápida resposta à corticoterapia sistêmica. Relata-se um caso de recém-nascida com lesões ulceradas de pioderma gangrenoso de fundo hemorrágico e necrótico distribuídas em abdômen, região genital e glútea com resposta rápida e efetiva à prednisona oral.

Tufted angioma in ear auricle: importance of the differential diagnosis / Hemangioma em penacho no pavilhao auricular: importancia do diagnostico diferencial

Tufted angioma is an acquired vascular proliferation with specific histological characteristics. The most common clinical features are erythematous macules. It occurs predominantly in children and young adults, especially in the chest and neck. We report the case of a male patient, 12 years old, with an increased right ear auricle associated with erythematous macules and increased local temperature, referred with a diagnosis of lepromatous leprosy; however, this diagnosis was questioned. Histopathology was consistent with tufted angioma.

O Hemangioma em penacho é uma proliferação vascular adquirida de características histológicas peculiares. Sua característica clínica mais comum são máculas eritematosas. Ocorre predominantemente em crianças e adultos jovens, principalmente no tórax e pescoço. Relata-se o caso de paciente do sexo masculino, 12 anos, com aumento do pavilhão auricular direito associado a máculas eritematosas e aumento da temperatura local, encaminhado com diagnóstico de Hanseníase Virchowiana, entretanto, tal diagnóstico foi questionado. Histopatologia compatível com Hemangioma em penacho.

Xeroderma pigmentoso: um estudo de revisão / Xeroderma pigmentosum: article review

Estudo de revisão sobre xeroderma pigm en toso (XP), realizado por levantamento bibliográfico nas bases dedadas MEDLINE e LILACS. Trata-se de genodermatose rara, ocasionada por defeito no sistema de excisão e reparo de nucleotídeos (NER), que ocasiona dano celular após exposição solar. Caracteriza-se por alterações cutâneas, oftalmológicas, neurológicas, ósseas e grande associação com neoplasias. O diagnóstico é clínico, pode ser confirmado por teste de síntese anormal de DNA. Não há cura e o controle da patologia deve ser feito através de fotoproteção extrema, e em alguns casos pode-se fazer uso de retinóides para preveni-los

Xeroderma pigmentoso: relato de caso / Xeroderma pigmentosum: a case report

Objetivo: descrever a evolução, as manifestações clínicas, o diagnóstico e o manejo de um caso de xeroderma pigmentoso. Relato do caso: criança de três anos, sexo masculino, que apresentava pápulas hipercrômica. isoladas e agrupadas, entremeadas de manchas hipercrômicas e acrômicas de tamanhos variados, ceratoses hipercrômicas, disseminadas pelo tegumento, atingindo especialmente áreas fotoexpostas. O diagnóstico baseou- se nas apresentações clínicas. Realizados exames complementares diversos e o paciente foi acompanhado durante dois anos. Considerações finais: o paciente ainda é acompanhado por equipe multidisciplinar e sua mãe recebe constantemente orientações sobre fotoproteção e manejo precoce das alterações cutâneas

Neurofibromatose: relato de caso com neurofibroma plexiforme / Neurofibromatosis: case report with plexiform neurofibroma

A Neurofibromatose (NF) é uma condição genética de transmissão autossômica dominante, representando, nesta categoria, a de maior incidência na espécie humana. Diversas formas de apresentação clínica de grande variação na expressão do gen responsável pela doença, mapeado no locus 17q11.2. Os autores apresentam caso de neurofibromatose do tipo 1 (NF-1) ou doença de Von Recklinghausen, observado em menina de 7 anos, que portava volumoso neurofibroma plexiforme histologicamente confirmado na região occipital, com extensão à nuca. O tumor exercia compressão extrínsica sobre o esôfago, traquéia e vértebras cervicais, conforme demonstraram exames por imagem, compreendendo raios X simples, tomografia computadorizada e ressonância magnética nuclear. A paciente foi ainda referenciada a ginecologista, neurologista, ortopedista, oftalmologista e geneticista para avaliação mais detalhada de sua condição e pesquisa de eventuais manifestações extracutâneas da doença. Um procedimento neurocirúrgico foi proposto, mas recusado pelos familiares

Esclerodermia generalizada: apresentaçäo de um caso e revisäo da literatura / Generalized scleroderma: case report

A esclerodermia generalizada é uma patologia rara, limitada à pele, sem etioliogia definida, com influência de fatores imunológicos. Estuda-se uma paciente do sexo feminino, de quarenta anos de idade, com quadro clínico de Esclerodermia generalizada, cujo diagnóstico foi confirmado através da histopatologia e exames laboratoriais. Discutem-se os principais aspectos dessa entidade, ressaltando-se a raridade e a exuberância das lesões clïnicas

Terapêutica da dermatite atópica / Therapeutic of atopic dermatitis

Revisäo dos conhecimentos atuais sobre a terapêutica da dermatite atópica, discutindo as principais opçöes com a finalidade de se chegar ao consenso sobre o assunto.