Patch tests and hand eczema: retrospective study in 173 patients and literature review

Abstract Background Hand eczema (HE) is a highly prevalent, recurrent, and multifactorial disease. It encompasses a group of eczematous diseases that affect the hands, etiologically classified into irritant contact dermatitis (ICD), allergic contact dermatitis (ACD) and atopic dermatitis (AD). Few epidemiological studies in Latin America have investigated the characteristics of patients with this condition and the origin of the disease. Objectives To analyze the profile of patients diagnosed with HE submitted to patch tests aiming to determine its etiology. Methods A retrospective descriptive study was carried out on epidemiological data and patch tests of patients with HE treated at a tertiary hospital in the city of São Paulo from January 2013 to December 2020. Results A total of 173 patients were studied, whose final diagnosis was 61.8% of ICD, 23.1% of ACD and 5.2% of AD, with diagnostic overlap in 42.8% of the cases. The main positive and relevant patch tests were: Kathon CG (42%), nickel sulfate (33%), and thiuram mix (18%). Study limitations The number of treated cases and socioeconomic profile was limited to a vulnerable population group. Conclusion HE is a diagnosis in which overlapping etiologies are frequent, with the main sensitizers identified in ACD being Kathon CG, nickel sulfate and thiuram mix.

Human sporotrichosis: recommendations from the Brazilian Society of Dermatology for the clinical, diagnostic and therapeutic management

Abstract Background: The increase in the zoonotic epidemic of sporotrichosis caused by Sporothrix brasiliensis, which started in the late 1990s in Rio de Janeiro and is now found in almost all Brazilian states, has been equally advancing in neighboring countries of Brazil. Changes in the clinical-epidemiological profile, advances in the laboratory diagnosis of the disease, and therapeutic difficulties have been observed throughout these almost 25 years of the epidemic, although there is no national consensus. The last international guideline dates from 2007. Objectives: Update the clinical classification, diagnostic methods and recommendations on the therapeutic management of patients with sporotrichosis. Methods: Twelve experts in human sporotrichosis were selected from different Brazilian regions, and divided into three work groups: clinical, diagnosis and treatment. The bibliographic research was carried out on the EBSCOHost platform. Meetings took place via electronic mail and remote/face-to-face and hybrid settings, resulting in a questionnaire which pointed out 13 divergences, resolved based on the opinion of the majority of the participants. Results: The clinical classification and laboratory diagnosis were updated. Therapeutic recommendations were made for the different clinical forms. Conclusions: Publication of the first national recommendation, carried out by the Brazilian Society of Dermatology, aimed at the Brazilian scientific community, especially dermatologists, infectologists, pediatricians, family medicine personnel, and laboratory professionals who work in the management of human sporotrichosis.

Rhino-orbito-cerebral mucormycosis caused by Rhizopus microsporus var. microsporus in a diabetic patient with COVID-19

Abstract COVID-19 disease caused by the SARS-CoV-2 coronavirus causes a wide range of clinical manifestations, ranging from mild to severe, with the main ones affecting the respiratory tract, such as pneumonia. In patients with greater severity, the high frequency of bacterial and fungal coinfection stands out, a situation related both to the patient's pre-existing comorbidities and due to the hospitalization itself. Cases of mucormycosis associated with COVID-19 were highlighted in the lay and scientific media, with the increase in mycosis cases being directly and indirectly attributed to the viral infection. This report describes a case of rhino-orbito-cerebral mucormycosis in a diabetic patient hospitalized for COVID-19, whose diagnosis was confirmed by identifying the agent Rhizopus microsporus var. microsporus through culture for fungi and PCR examination.

Epidemiological and geographical distribution profile of urban sporotrichosis in the city of São Paulo

Abstract Background Sporotrichosis is the most frequent subcutaneous mycosis in Latin America, where it is considered endemic. At the end of the 20th century, the first cases of zoonotic transmission were described in Rio de Janeiro, triggering an epidemic outbreak that spread to other regions of Brazil. The lack of disease notification omits its real occurrence in the country, which happens in its most populous city, São Paulo. Objective To evaluate the epidemiological aspects of the patients seen at a hospital in São Paulo aiming at establishing the geographic distribution of this disease. Methods This is a retrospective study that analyzed data from medical records of patients with a clinical and laboratory diagnosis of sporotrichosis attended at a tertiary hospital in the city of São Paulo between 2012 and 2020. Results Twenty patients were included. As for zoonotic surveillance, 30% denied contact with an animal, and 70% reported previous contact with a sick cat, with no other animals being mentioned. One case was allochthonous and the others autochthonous, showing a dissemination behavior from a focus in the eastern area of the capital. Study limitations The present study was based on data from only one hospital. Studies that include data from other hospitals and other regions must be carried out to obtain a complete picture of this disease. Conclusions As in other regions of the country, zoonotic sporotrichosis presents itself as an endemic disease with an increase in the number of cases. The findings highlight epidemiological characteristics of great importance so that public health policies can contain disease progression.

Chronic mucocutaneous anogenital herpes: series of ten cases and literature review

Abstract Anogenital herpes is one of the most prevalent sexually transmitted infections worldwide. It has several clinical manifestations, from cases of primary herpes infection to recurrent forms, among them chronic mucocutaneous herpes. This presentation is rare, characterized by a duration of more than four weeks, usually associated with immunosuppression and resistance to classic anti-herpetic treatment. The present study presents a series of ten cases of chronic mucocutaneous herpes with a discussion about its clinical, laboratory, and therapeutic aspects.

Natural history of primary syphilis: clinical and serological aspects of chancre concurrent with Follmann's balanitis / Evolução natural dos aspectos clínicos e sorológicos de um caso de cancro duro concomitante com balanite de Follmann

Introduction: Primary syphilis is classically represented by a hard chancre, but other rare forms such as Follmann's balanitis are occasionally described. Objective: To show an iconography of the clinical presentations of the classic hard chancre and Follmann's balanitis, in parallel with the serological results in the course of diagnosis and treatment. Methods: Descriptive case report of a patient of an outpatient clinic for sexually transmitted infections in a tertiary hospital in the city of São Paulo, SP, Brazil. Conclusion: Syphilis lesions acquire different clinical expressions according to the natural evolution of the disease. Recognizing these presentations, as well as knowing how to interpret the serological results, is essential for the diagnosis and adequate treatment of the infection.

Introdução: A sífilis primária é representada classicamente pelo cancro duro, porém outras formas raras, como a balanite de Follmann, são ocasionalmente descritas. Objetivo: Apresentar uma iconografia dos estágios evolutivos da lesão clássica de cancro duro e da balanite de Follmann em paralelismo com os resultados sorológicos no curso do diagnóstico e do tratamento. Métodos: Relato descritivo evolutivo de paciente atendido em ambulatório de atendimento de infecções sexualmente transmissíveis de hospital terciário da cidade de São Paulo (SP), Brasil. Conclusão: As lesões da sífilis adquirem expressões clínicas diversas conforme a evolução natural da doença. Reconhecer essas apresentações, bem como saber interpretar os resultados sorológicos, é fundamental para o diagnóstico e o tratamento adequado da infecção.

The correct nomenclature of Zirelí sign in the propaedeutics of pityriasis versicolor (in memoriam)

Abstract Aiming at disclosing the semiotic method used in the diagnosis of pityriasis versicolor, the authors go through the history of the creation of Zirelí sign, describing the method, its usefulness and practicality in dermatological clinical practice, whether public or private, and to give credit to the author of this semiological maneuver, in memoriam.

Presence of hyphae in chromoblastomycosis examinations: an enigma to be solved

Abstract The detection of muriform cells in direct mycological or anatomopathological examination is considered pathognomonic for chromoblastomycosis. The morphological aspect that these fungal structures acquire were called "Borelli spiders", when associated with hyphae. Reports of this association have been described for decades, initially related to more pathogenic agents of this mycosis. More recent studies have shown aspects related to the host's immunity that participate in this process, as well as an association with a worse disease prognosis. The present study discloses the findings of complementary examinations with the presence of "Borelli's spiders" in a patient diagnosed with chromoblastomycosis.

Ocular involvement in sporotrichosis: report of two cases in children

Abstract Sporotrichosis is a subcutaneous mycosis that affects humans and animals, with a typically subacute or chronic evolution, caused by Sporothrix spp., a dimorphic fungus. Although the cutaneous form is the most frequent presentation, the ocular involvement has been more frequently diagnosed in endemic areas, affecting mainly children and the elderly. Approximately 80% of affected patients have the lymphocutaneous form, while only 2.3% have conjunctival lesions, with 0.7% showing primary ocular involvement. We describe two cases of sporotrichosis with ocular involvement in children through inoculation by felines, with a good response to antifungal treatment.

Diagnosis of cutaneous tuberculosis (lymph node scrofuloderma) using the Xpert MTB/RIF® method

Abstract Cutaneous tuberculosis is a rare infection that is difficult to diagnose, because it shows less sensitivity and specificity in classic complementary exams when compared with the pulmonary form. The Xpert MTB/RIF® method offers an early diagnosis that identifies the DNA of Mycobacterium tuberculosis and the main mutations that give the bacterium resistance to rifampicin. The authors present a case of scrofuloderma whose diagnosis was quickly obtained through the secretion of a cervical lesion, allowing an early diagnosis and the initiation of appropriate treatment.

Immunoreactive cutaneous sporotrichosis

Abstract Sporothrix spp. infection can occur through the inoculation of the organism in the skin through direct contact with the soil (sapronotic infection), through contact with animals, such as infected cats and dogs (zoonotic infection), or less frequently via inhalation. With a subacute or chronic evolution, approximately 80% of patients affected by the disease present with the lymphocutaneous form; episodes associated with a hypersensitivity reaction are rare. The authors report the case of a 12-year-old child with immunoreactive sporotrichosis manifested clinically as erythema nodosum lesions in the lower limbs, associated with an ulcerated lesion in the left arm.

Identification of Leishmania species by high-resolution DNA dissociation in cases of American cutaneous leishmaniasis

Abstract Background American cutaneous leishmaniasis is an infectious dermatosis caused by protozoa of the genus Leishmania, which comprises a broad spectrum of clinical manifestations depending on the parasite species involved in the infections and the immunogenetic response of the host. The use of techniques for amplification of the parasites DNA based on polymerase chain reaction polymerase chain reaction and the recent application of combined techniques, such as high-resolution DNA dissociation, have been described as a viable alternative for the detection and identification of Leishmania spp. in biological samples. Objectives To identify the Leishmania species using the polymerase chain reaction high-resolution DNA dissociation technique in skin biopsies of hospital-treated patients, and compare with results obtained by other molecular identification techniques. Methods A retrospective study assessing patients with suspected American cutaneous leishmaniasis seen at a hospital in São Paulo/Brazil was conducted. The paraffin blocks of 22 patients were analyzed by polymerase chain reaction high-resolution DNA dissociation to confirm the diagnosis and identify the species. Results Of the 22 patients with suspected American cutaneous leishmaniasis, the parasite was identified in 14, comprising five cases (35.6%) of infection by L. amazonensis, four (28.5%) by L. braziliensis, two (14.4%) by L. amazonensis + L. infantum chagasi, two (14.4%) by L. guyanensis, and one (7.1%) by Leishmania infantum chagasi. In one of the samples, in which the presence of amastigotes was confirmed on histopathological examination, the polymerase chain reaction high-resolution DNA dissociation technique failed to detect the DNA of the parasite. Study limitations The retrospective nature of the study and small number of patients. Conclusions The method detected and identified Leishmania species in paraffin-embedded skin biopsies with a sensitivity of 96.4% and could be routinely used in the public health system.

Aspects of Langerhans cells and TNF-α in the cutaneous immunity of anogenital warts

Abstract Background: Anogenital warts are the leading sexually transmitted infection in patients seeking care at specialized clinics. They may display a vast array of forms, according to the interaction of the virus with the host's immunity. Cellular immunity is the epithelium's main form of defense against the virus, involving an active participation of the Langerhans cells and pro-inflammatory cytokines such as TNF-α. Objective: To assess the epithelial immune response of anogenital warts in males, according to the number of lesions presented. Methods: This is a prospective, cross-sectional study carried out at the dermatology outpatient clinic in a tertiary hospital. We included male patients over 18 years of age without comorbidities who had anogenital condylomata and no previous treatments.In order to evaluate the local epithelial immunity, the lesions were quantified, then removed and employed in CD1a immunohistochemistry assays for assessing the morphometry and morphology of Langerhans cells; TNF-α; reaction was used for determining cytokine positivity in the epithelium. Results: 48 patients were included in the study. There was no statistically significant difference as to the number of Langerhans cells, in their morphology, or the presence of TNF-α. However, patients presenting with more Langerhans cells in the lesions had cells with a star-like and dendritic morphology, whereas in those with a lower cell count had cells with a rounded morphology and no dendrites (p < 0.001). Study limitations: Small number of patients analyzed. Conclusion: There was no difference in epithelial immunity between patients having few or many anogenital condyloma lesions as measured by the morphology and morphometry of Langerhans cells and TNF-α; positivity. Such an assessment employing immunity markers differing from the usual ones is expected to yield useful results.

Doença de Dowling-Degos: desordem genética e espectral de hiperpigmentação reticular / Dowling-Degos Disease - Genetic and spectral disorder of reticular hyperpigmentation

A doença de Dowling-Degos (DDD) é uma genodermatose rara, caracterizada principalmente por hiperpigmentação reticular progressiva de áreas flexurais, que pode estar associada a um grande espectro de lesões benignas e neoplasias cutâneas. Pode ocasionar prejuízo psicossocial devido ao potencial de deformidade das lesões e dano estético significativo. Apresentamos dois casos de pacientes, ambos do sexo masculino, com máculas hipercrômicas, múltiplos comedões, cistos epidérmicos, cicatrizes cribriformes em: face, região cervical, dorso, tórax anterior, axilas e região genital, além de tumorações desfigurantes, características da DDD

Dowling-Degos disease (DDD) is a rare genodermatosis. Progressive reticular hyperpigmentation of flexural areas mainly characterizes the disease, which may be associated with a large spectrum of benign lesions and cutaneous neoplasms. It may cause psychosocial impairment due to the deformity caused by the lesions with significant aesthetic damage. We present two cases of male patients with hyperchromic macules, multiple comedones, epidermal cysts, cribriform scars on the face, cervical region, dorsum, anterior thorax, armpits, genital region, and disfiguring tumors, characteristic of DDD

Tumor de Buschke-Lowenstein perianal: relato de dois casos tratados com podofilina em vaselina sólida 25% / Perianal Buschke-Lowenstein tumor: report of two cases treated with 25% podophyllin ointment

O tumor de Buschke-Lowenstein (TBL) é variante extremamente rara do condiloma acuminado que, apesar de manifestar-se clinicamente por lesões de grandes proporções, apresenta comportamento biológico e características histológicas benignas. Existem diversas abordagens terapêuticas disponíveis, muitas delas apoiando-se em abordagens cirúrgicas extensas e mutilantes. Apresentamos dois casos de pacientes com TBL tratados com podofilina tópica, cujas respostas terapêuticas foram extremamente favoráveis em ambos os casos.

Buschke-Lowenstein tumor (BLT) is an extremely rare variant of condylomata acuminata that despite being clinically presented by large lesions, presents a benign biological behavior and histological characteristics. There are a number of therapeutic approaches available, many of which rely on extensive and mutilating surgical procedures. We present two cases of patients with BLT treated with topical podophyllin whose therapeutic responses were extremely favorable in both cases.

In vivo and ex vivo dermoscopy of lesions from implantation of human papillomavirus in tattoos: report of two cases

Abstract The number of individuals with tattoos has been increasing worldwide, alongside with reports of complications varying from reactions to the injected pigments to infections caused by agents inoculated in the pigmentation process. The diagnosis of such unwanted events can be obtained through complementary non-invasive methods, preserving the maximum of the tattoo design. The authors present two cases of patients with warts on tattooing, and correlate their clinical aspects to in vivo and ex vivo dermoscopy, and to the findings in the histopathological examination, aiming to determine patterns that aid the diagnosis of these lesions without performing biopsy.

Paracoccidioidomycosis in a child: exuberant presentation due to the inadvertent use of systemic corticosteroids

Abstract: Paracoccidioidomycosis is a fungal infection that occurs in immunocompetent patients and are classified into two forms: the acute-subacute form, predominantly in young patients, and the chronic adult form that may present classic ulcerated lesions to rare sarcoid ones. We present the case of a boy whose infection began with sarcoid lesions but, after being mistakenly diagnosed with cutaneous sarcoidosis and treated (for three years) with prednisone, developed painful ulcerations throughout the body. After the correct diagnosis, with evidence of the fungus in histopathological and mycological examinations, the patient was properly treated with itraconazole for eight months and evolved with total remission of the disease.

Uso do imiquimode para tratamento da doença de Paget extramamária: série de quatro casos / Imiquimod use for the treatment of extramammary Paget disease: series of four cases

Introdução: A doença de Paget extramamária é constituída por adenocarcinoma da pele em áreas de glândulas apócrinas. Trata-se de neoplasia rara cujo tratamento cirúrgico aparenta resultados satisfatórios. Devido às altas taxas de recorrência, entretanto, as cirurgias são potencialmente mutilantes. O imiquimode é imunoestimulador tópico utilizado no tratamento de verrugas anogenitais e carcinomas in situ. Seu uso tem sido descrito na literatura científica para terapia da doença de Paget extramamária com resultados satisfatórios. Objetivo: Descrever a evolução de quatro casos de doença de Paget extramamária tratados com imiquimode, para avaliação da evolução e resposta terapêutica. Métodos: Foi realizado estudo retrospectivo em serviço de dermatologia da cidade de São Paulo com revisão de prontuários de todos os pacientes com diagnóstico de doença de Paget extramamária e tratados com imiquimode de janeiro de 2011 a julho de 2018. Resultados: Foram incluídos quatro pacientes, três com lesão vulvar e um com lesão em bolsa escrotal. Duas mulheres evoluíram com resolução total da doença, uma não apresentou alteração, e o homem evolui com regressão de 70% da lesão, sendo submetido à exérese cirúrgica de área consideravelmente menor do que a da lesão inicial. Conclusões: O imiquimode se apresenta como método terapêutico válido no tratamento da doença de Paget extramamária.

Introduction: Extramammary Paget disease consists of a cutaneous adenocarcinoma in areas of apocrine glands. It is a rare neoplasia, and its surgical treatment yields satisfactory results. However, due to the high recurrence rates, surgeries are potentially disfiguring. Imiquimod is a topical immune-stimulant used for the treatment of anogenital warts and in situ carcinomas. Its use has been described in the scientific literature for the treatment of Extramammary Paget disease with satisfactory results. Objective: Describe the course of four cases of Extramammary Paget disease treated with imiquimod, to evaluate evolution and therapeutic response. Methods: A retrospective study was performed in a service of dermatology in the city of São Paulo, with the review of medical records of all patients diagnosed with Extramammary Paget disease and treated with imiquimod from January 2011 to July 2018. Results: Four patients were included, three with vulvar lesion and one with scrotal lesion. Two women presented completed resolution of the disease, one did not respond and the man progressed with 70% regression of the lesion, having undergone surgical excision of a considerably smaller area than the initial lesion. Conclusions: Imiquimod presents as a valid therapeutic modality for the treatment of Extramammary Paget disease.

Métodos diagnósticos da escabiose / Diagnostic methods for scabies

Escabiose é infecção cutânea contagiosa causada pela penetração do ácaro Sarcoptes scabiei var. hominis na epiderme. A suspeita diagnóstica é feita pela história, distribuição clínica das lesões e sua aparência, porém sua confirmação se dá com a identificação do parasita. Apresentamos os aspectos dos métodos diagnósticos da escabiose, desde a identificação por microscopia óptica de raspados cutâneos de lesão ou pelo uso de fita adesiva sobre as lesões, à identificação com uso do dermatoscópio, ferramenta presente na maioria dos consultórios dermatológicos e que, mesmo em mãos inexperientes, possui sensibilidade e especificidade aceitáveis.

Scabies is a contagious cutaneous infection, caused by burrowing of the mite Sarcoptes scabiei var. hominis in the epidermis. The clinical suspicion is due to the history, clinical distribution of lesions and its aspect; however, the confirmation is with the detection of the parasite. We present the features of the diagnostic methods for scabies, from its detection through direct microscopy of skin scrapings from a lesion or with the use of an adhesive tape on the lesions, to its detection using the dermatoscope, a tool available in most dermatology clinics, which, even in unexperienced hands, has acceptable sensitivity and specificity.