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.

Clinical and laboratory characteristics, staging, and outcomes of individuals with AIDS-associated Kaposi's sarcoma at an university hospital

Abstract: Background: Kaposi's sarcoma continues to be the most common human immunodeficiency virus - associated neoplasm with considerable morbidity and mortality. Objective: To describe the clinical and laboratory characteristics, initial staging, and outcomes of aids patients with Kaposi's sarcoma at an university hospital of Recife, Pernambuco. Methods: This is a descriptive study with analytic character, retrospective, of a case series between 2004 and 2014. Results: Of the 22 patients included in the study, 20 were aged <40 years (72.7%). The majority had CD4+ T lymphocyte counts of <200 cells/mm3 (77.3%) and human immunodeficiency virus loads of <100,000 copies/mL (78.9%). Lesions were most commonly observed on the skin (90%), and internal organs were affected in 11 of the 22 patients. Only 7 (31.8%) of the 22 patients were undergoing antiretroviral therapy (ART) at the time of Kaposis sarcoma diagnosis, and the initial disease staging classification was high risk (Aids Clinical Trials Group Oncology Committee) in 19 of the 22 patients (86.4%). Regarding Kaposi's sarcoma treatment, 17 of 22 patients (77.3%) underwent systemic chemotherapy + ART and 5 were treated exclusively with ART. Eight of the 22 patients died (36.5%); of these, 87.5% had died within one year of Kaposi's sarcoma diagnosis. Limitation of the study: Without a control group, this study cannot be used to generate hypotheses. Conclusions: Despite the association between aids and late Kaposi's sarcoma diagnosis in the study population, including an unfavorable risk at the time of staging, a lower mortality rate was observed relative to other studies; this might be related to access to a specialized health service.

Cutaneous ectopic schistosomiasis: diagnostic challenge

Abstract Cutaneous schistosomiasis is a rare clinical manifestation of schistosomiasis, an infectious and parasitic disease, caused in Brazil by the trematode Schistosoma mansoni. The lesions are due to the deposition of eggs or, rarely, adult worms, usually involving the genital and groin areas. Extra-genital lesions occur mainly on the torso as papules of zosteriform appearance. The case of a patient with ectopic cutaneous schistosomiasis is reported in this article, due to the rarity of its occurrence and its difficult clinical diagnosis.

Cutaneous tuberculosis: diagnosis, histopathology and treatment - Part II

The evolution in the knowledge of tuberculosis' physiopathology allowed not only a better understanding of the immunological factors involved in the disease process, but also the development of new laboratory tests, as well as the establishment of a histological classification that reflects the host's ability to contain the infectious agent. At the same time, the increasing bacilli resistance led to alterations in the basic tuberculosis treatment scheme in 2009. This article critically examines laboratory and histological investigations, treatment regimens for tuberculosis and possible adverse reactions to the most frequently used drugs.

Cutaneous tuberculosis: epidemiologic, etiopathogenic and clinical aspects - Part I

Cutaneous tuberculosis (CTB) is the result of a chronic infection by Mycobacterium tuberculosis, M. ovis and occasionally by the Calmette-Guerin bacillus. The clinical manifestations are variable and depend on the interaction of several factors including the site of infection and the host's immunity. This article revises the current knowledge about this disease's physiopathology and immunology as well as detailing the possible clinical presentations.

Antimicrobial resistance profile of Staphylococcus aureus isolates obtained from skin and soft tissue infections of outpatients from a university hospital in Recife -PE, Brazil / Perfil de resistência antimicrobiana de isolados de Staphylococcus aureus provenientes de infecções de pele e tecidos moles de pacientes ambulatoriais de um hospital universitário em Recife - PE, Brasil

BACKGROUND: Staphylococcus aureus has a notable ability to acquire resistance to antibiotics, and methicillin resistance represents a growing public health problem. Methicillin-resistant S. aureus (MRSA) has also become important outside the hospital environment, particularly in the United States. In Brazil, since 2005, cases of community skin infections caused by MRSA have been reported, but resistance studies involving outpatients are scarce. OBJECTIVE: To know the resistance profile of S. aureus involved in skin and soft tissue infections of patients seen at the Dermatology outpatient clinic of a university hospital in Recife, Pernambuco State, northeastern Brazil. METHODS: Prospective study involving 30 patients with skin and soft tissue infections, seen at the Dermatology outpatient clinic from May until November 2011. To evaluate the susceptibility of S. aureus to antibiotics, the disk diffusion method and oxacillin screening agar were used. RESULTS: From a total of 30 samples of skin lesions, 19 (63%) had positive culture for S. aureus. The following resistance patterns of S. aureus were observed: penicillin, 95%; tetracycline, 32%; erythromycin, 21%; gentamicin, 16%; cefoxitin, 11%; oxacillin, 11%; trimethoprim-sulfamethoxazole, 11%; chloramphenicol, 11%; clindamycin, 5% ; and ciprofloxacin, 0%. One of the identified MRSA was obtained from a patient without risk factors for its acquisition, and was resistant, beyond to the beta-lactams, only to tetracycline. CONCLUSIONS: With regard to the resistance patterns of S. aureus, resistances to tetracycline, erythromycin and gentamicin were the highest. It was documented, for the first time in Pernambuco, a case of skin infection caused by community-associated MRSA.

FUNDAMENTOS: O Staphylococcus aureus possui uma notável habilidade de adquirir resistência antimicrobiana, sendo a resistência à meticilina um problema de saúde pública crescente. O S. aureus resistente à meticilina (MRSA) vem se tornando importante também fora do ambiente hospitalar, particularmente nos Estados Unidos. No Brasil, desde 2005, têm sido relatados casos de infecções cutâneas comunitárias causadas por MRSA, porém estudos de resistência envolvendo pacientes ambulatoriais são escassos. OBJETIVO: Conhecer o perfil de resistência de S. aureus envolvidos em infecções de pele e partes moles de pacientes atendidos no ambulatório de Dermatologia de um hospital universitário de Recife, Pernambuco. MÉTODO: Estudo prospectivo envolvendo 30 pacientes com infecções de pele e tecidos moles atendidos no ambulatório de Dermatologia de maio a novembro de 2011. Para avaliação da suscetibilidade dos S. aureus aos antibióticos foram utilizados teste de disco-difusão e placa de screening de oxacilina. RESULTADOS: Das 30 amostras analisadas, 19 (63%) tiveram cultura positiva para S. aureus. Os seguintes padrões de resistência dos S. aureus foram observados: penicilina, 95%; tetraciclina, 32%; eritromicina, 21%; gentamicina, 16%; cefoxitina, 11%; oxacilina, 11%; sulfametoxazol-trimetoprima, 11%; clorafenicol, 11%; clindamicina, 5%; e ciprofloxacina, 0%. Um dos MRSA identificados foi obtido de paciente sem fatores de risco para sua aquisição, e além de aos betalactâmicos, mostrou-se resistente apenas à tetraciclina. CONCLUSÕES: Em relação aos padrões de resistência dos S. aureus, destacaram-se as resistências à tetraciclina, eritromicina e gentamicina. Documentou-se, pela primeira vez em Pernambuco, um caso de infecção cutânea causada por MRSA associado à comunidade.

Avaliação dos efeitos adversos clínicos e alterações laboratoriais em pacientes com acne vulgar tratados com isotretinoína oral / Evaluation of clinical adverse effects and laboratory alterations in patients with acne vulgaris treated with oral isotretinoin

FUNDAMENTOS: A isotretinoína oral revolucionou o manejo da acne. Os efeitos adversos observados, durante o tratamento, são divididos em dois grupos: mucocutâneos e sistêmicos. Anormalidades laboratoriais, principalmente, as dislipidemias e aumento das enzimas hepáticas são relatados. OBJETIVO: Avaliar a tolerabilidade da isotretinoína oral, com atenção, no metabolismo lipídico, função hepática e reações adversas clínicas. MÉTODOS: Foram incluídos 150 pacientes com diagnóstico clínico de acne submetidos a tratamento com isotretinoína oral. Avaliações clínicas e laboratoriais foram feitas, após um mês e a cada três meses, até completar o tratamento. RESULTADOS: Dos 150 pacientes 48 por cento eram do sexo feminino e 52 por cento do sexo masculino. A idade variou de 15 a 32 anos. Quanto aos efeitos adversos cutâneos e mucosos da isotretinoína, queilite foi o mais frequente, ocorrendo em 94 por cento pacientes. Efeitos clínicos sistêmicos foram bem menos comuns. Os níveis de colesterol, triglicerídeos, transaminases, foram avaliados e não mostraram alterações significativas, ao longo do tratamento. CONCLUSÃO: Os pacientes apresentaram efeitos adversos, compatíveis com os da literatura, e, em sua maioria, controlados com medicações sintomáticas. Podemos concluir que a isotretinoína é uma droga segura, em relação a seus efeitos adversos, tanto clínicos como laboratoriais.

BACKGROUND: Oral isotretinoin therapy has completely changed the treatment of acne. The clinical adverse effects of isotretinoin are classified into two groups: mucocutaneous and systemic toxic. Laboratory alterations such as dyslipidemia and increase of hepatic enzymes are reported. OBJECTIVES: To evaluate the tolerability of oral isotretinoin with special attention to lipid metabolism, hepatic function, and clinical adverse reactions. METHODS: 150 patients clinically diagnosed with acne being treated with oral isotretinoin were included in the study. Clinical and laboratory evaluations were conducted before the start of therapy, one month after, and every three months thereafter until the completion of treatment. RESULTS: Of the 150 patients evaluated, 48 percent were female and 52 percent, male. They were aged from 15 to 32 years. The most prevalent mucocutaneous adverse reaction associated with isotretinoin therapy was cheilitis, reported by 94 percent of the patients. Systemic clinical effects were much less common. Cholesterol, triglyceride, and transaminase levels were assessed and significant changes were not observed during treatment. CONCLUSION: Patients showed adverse effects compatible to those described in the literature, which are mostly controlled with symptomatic medication. Isotretinoin is a safe drug and adverse and laboratory effects are well tolerated.

Tuberculose esplênica durante tratamento de psoríase com infliximabe / Splenic tuberculosis during psoriasis treatment with infliximab

A psoríase é doença crônica que afeta a pele e, eventualmente, as articulações. A terapia biológica age bloqueando citocinas inflamatórias implicadas na patogênese da doença, dentre elas o fator de necrose tumoral alfa. Este também tem papel na defesa do hospedeiro contra o Mycobacterium tuberculosis. Relata-se um caso de psoríase com boa resposta ao infliximabe, porém com desenvolvimento de tuberculose esplênica durante o tratamento.

Psoriasis is a chronic inflammatory disease affecting the skin and occasionally the joints. The biological agents have been engineered to target a specific step in the inflammatory cascade that leads to psoriasis, including tumor necrosis factor, which has a central role in the host defense against Mycobacterium tuberculosis. This is a case report about a psoriatic patient who presented splenic tuberculosis during treatment with infliximab.

Urticária pigmentosa em adulto com apresentação clínica exuberante / Clinically exuberant urticaria pigmentosa in an adult patient

A mastocitose é afecção rara e heterogênea, caracterizada por aumento da densidade dos mastócitos na pele e em outros órgãos, para a qual não há tratamento específico. Descreve-se um caso de urticária pigmentosa em paciente adulta com quadro clínico exuberante.

Mastocytosis is a rare, heterogeneous disorder characterized by marked increase in mast cell density in the skin and other organs. A clinically exuberant case of urticaria pigmentosa in an adult woman is presented.

Dermatoses pediátricas no Hospital das Clínicas da Universidade Federal de Pernambuco / Pediatric dermatoses at the Clinicas Hospital, Federal University of Pernambuco

FUNDAMENTOS: Numerosas condições dermatológicas podem afetar a população pediátrica. Há poucos estudos sobre a dermatologia pediátrica no Brasil. OBJETIVOS: Estudar as dermatoses pediátricas no Hospital das Clínicas do Recife, Pernambuco - Brasil. MATERIAL E MÉTODOS: Durante o período de maio de 1999 a maio de 2000, foram analisados 307 prontuários de crianças atendidas no Ambulatório de Dermatologia da Universidade Federal de Pernambuco. Foram encontrados os dados referentes a caracterização individual, procedência, motivo da consulta, diagnóstico clínico laboratorial e tratamentos previamente realizados. RESULTADOS: As dermatoses alérgicas foram as mais freqüentes (17,64 por cento), seguidas pelas desordens pigmentares (15,54 por cento) e infecções virais (13,44 por cento). CONCLUSÃO: Os dados encontrados estão de acordo com a literatura. Quanto às infecções, representam um grande percentual dos casos analisados, devendo-se isso provavelmente ao baixo nível socioeconômico dos pacientes em estudo. A caracterização da epidemiologia dos problemas cutâneos em crianças deve ser uma prioridade de estudos futuros.

Síndrome de Cowden: relato de um caso

A síndrome de Cowden (SC) ou síndrome de múltiplos hamartomas (SMH) é genodermatose rara de herança autossômica dominante e expressividade variável. É caracterizada por múltiplas lesões hamartomatosas de origem ectodérmica , mesodérmica e endodérmica. O órgão mais acometido é a pele, e as lesões mucocutâneas estão presentes em proporção que varia de 99 a 100 por cento dos casos. Esses sinais precedem o desenvolvimento do câncer em vários anos, servindo como importantes marcadores clínicos na identificação de pacientes com alto rico para desenvolver câncer da mama e tireóide. Devido a associações com malignidades internas o diagnóstico precoce é essencial. O locus gênico para SC foi identificado no cromossomo 10q22-23. As mutações no gene supressor tumoral, PTEN/MMAC1, localizado no cromossomo 10q23, têm sido implicadas no desenvolvimento do câncer mamário. Os autores relatam um caso dessa rara entidade. Trata-se de paciente do sexo masculino com quadro clínico característico dessa síndrome

Acne fulminans: relato de um caso / Acne fulminans: report of a case

Os autores inicialmente, apresentam uma revisäo da literatura concernente a esta forma de acne grave. Em seguida relatam o caso, onde destacam-se o diagnóstico, essencialmente clínico, e a dificuldade de tratamento. Tecem comentários sobre as opçöes terapêuticas na atualidade, seus efeitos colaterais mais importantes e salientam a constataçäo de um efeito sinérgico ente a dapsona e a prednisona, o que constitui um dado importante na conduçäo destes doentes