Hospital Dermatology: analysis of dermatological consultations in a tertiary teaching hospital

Abstract Background In hospital settings, dermatology can offer substantial clinical support for the diagnosis and management of skin conditions, reducing morbidity and mortality. Thus, the study aimed to analyze the profile of referrals and consultations performed by the Dermatology Service of the Santa Casa de Misericordia de Porto Alegre, from August 2018 to January 2020. Methods This study is descriptive, quantitative, and retrospective, conducted through data collection and review of medical records and referrals. The variables included were clinical data of referrals, in-patients profiles, dermatological diagnoses, complementary exams, therapeutic conduct, and recommended follow-ups. Results A total of 1020 referrals were analyzed, which resulted in 641 consultations (328 men, 313 women). The most prevalent skin disease groups were 'Dermatitis and Eczema' (33.1%) and 'Other infectious skin diseases (21.8%), while the most frequent ICD-10 were 'Drug eruptions - L27' (9.9%) and 'Other and unspecified dermatitis - L30' (6.6%). Corticoids were the most recommended treatments (27.7%), followed by antifungals (13.1%). 'Consultation Discharge' (44%) and 'Outpatient' Dermatology follow-up (27%) were the most frequent causes for ending consultation. Study limitations Among the study limitations, the authors highlight its retrospective nature, with data analysis based on referrals and medical records, which may present inaccurate or incomplete information. In addition to this, the study may demonstrate a certain degree of subjectivity due to the review and interpretation process conducted by the researchers. However, the definition of objective criteria based on previous studies attenuates such possible bias. Furthermore, considering that the Dermatology teams are composed of a preceptor dermatologist and residents, the established diagnoses were not submitted to third-party verification, except in the cases of skin biopsies and cultures. Thus, the professional's experience and skills may have influenced the dermatological diagnoses. Conclusions These findings underlie the importance of Dermatology in hospital assistance, contributing to the management of a wide range of skin conditions.

Calcinose em área de queimadura tardia: relato de caso e discussão da conduta / Calcinosis in an area of late burn: a case report and management discussion

Introdução: Calcinose cutânea é uma doença rara caracterizada por precipitações de cristais de cálcio no tecido cutâneo. Pode ser localizada ou generalizada, distrófica, metastática, iatrogênica ou idiopática. Relato do Caso: Paciente feminina, 66 anos, vítima de queimaduras de segundo e terceiro graus por fogo em abdome inferior e coxas aos 8 anos de idade atingindo 25% de superfície corpórea. Após 58 anos, recebeu o diagnóstico de calcinose distrófica na cicatriz da queimadura, contemplado através de biópsia e análise histopatológica. Submetida a exérese cirúrgica associada a rotação de retalho dermogorduroso de abdome superior e enxertia de pele total para correção de cicatrizes. Conclusão: Embora a melhor escolha terapêutica ainda não seja clara, o tratamento de complicações que podem culminar em incapacidade funcional é fundamental para reduzir a morbidade e aumentar a qualidade de vida do paciente.

Introduction: Cutaneous calcinosis is a rare disease characterized by the precipitation of calcium crystals in the skin tissue. It can be localized, generalized, dystrophic, metastatic, iatrogenic, or idiopathic. Case Report: Female patient, 66 years old, victim of second and third-degree burns by fire in the lower abdomen and thighs at 8 years old, reaching 25% of the body surface. After 58 years, she was diagnosed with dystrophic calcinosis in the burn scar, which was confirmed through biopsy and histopathological analysis. She underwent surgical excision associated with rotation of the upper abdomen dermal-fat flap and total skin graft for scar correction. Conclusion: Although the best therapeutic choice is still unclear, treating complications leading to functional disability is essential to reduce morbidity and increase the patient's quality of life.

Paracoccidioidomycosis: an uncommon clinical presentation

Abstract Paracoccidoiomycosis is a systemic mycosis with a higher incidence in males with history of exposure to the rural environment; its classic clinical manifestation is an oro-pulmonary lesion. The authors report a case of a female, urban, 76-year-old patient with atypical clinical-dermatological presentation and diagnostic conclusion after histopathological examination. The clinical response was quick and complete after treatment with itraconazole 400 mg/day in the first month, decreased to 200 mg/day until the sixth month of treatment.

Síndrome de piel indurada en un paciente pediátrico: un desafío terapéutico. Presentación de un caso / Stiff skin syndrome in a pediatric patient: a therapeutic challenge. Clinical case

El síndrome de la piel indurada es un trastorno esclerosante crónico, infrecuente, que se presenta en la infancia, caracterizado por la induración progresiva de la piel. Esta afección puede provocar restricciones torácicas y dificultad respiratoria, limitaciones en la movilidad articular y trastornos en la marcha, con importante deterioro de la calidad de vida. Debido a que sus opciones terapéuticas son escasas y poco eficaces, es fundamental que el paciente inicie precozmente una terapia física para prevenir estas complicaciones y que se continúe estudiando esta enfermedad a fin de poder ofrecer a los pacientes más y mejores tratamientos. Se presenta el caso de una paciente de 9 años con síndrome de la piel indurada y su desafío terapéutico.

Stiff skin syndrome is a chronic, rare sclerosing disorder that occurs in childhood, characterized by progressive induration of the skin that can cause thoracic restrictions and respiratory distress, limitations in joint mobility and gait difficulties, with significant deterioration of the quality of life. Because their therapeutic options are scarce and ineffective it is essential to start an early physical therapy to prevent these complications and to continue studying this condition to be able to offer patients more and better treatments. We present the case of a 9-year-old patient with indurated skin syndrome and its therapeutic challenge.

Rol del PET/CT con 18FDG en patología no neoplásica / Role of 18FDG PET/CT in non-malignant diseases

La Tomografía por emisión de positrones/tomografía computada (PET/CT) se ha vuelto fundamental para la evaluación oncológica. En los últimos años se ha hecho evidente su utilidad para evaluar otras patologías inflamatorias no neoplásicas, las cuales pueden presentar aumento del metabolismo medible. El PET/CT tiene la ventaja de poder detectar enfermedades incluso cuando no tienen un correlato en las imágenes morfológicas, permitiendo además localizar de manera precisa estas alteraciones. Entre estas patologías se encuentran el estudio de fiebre de origen desconocido, enfermedades inflamatorias, enfermedades del tejido conectivo, vasculitis y también en el seguimiento y diagnóstico de algunas patologías infecciosas. Se realizará una revisión en la literatura de la utilidad del PET/CT en estas patologías complementada con casos clínicos.

Histiocytoid Sweet's syndrome presenting with annular erythematous plaques

Abstract Histiocytoid Sweet's Syndrome is a rare inflammatory disease described in 2005 as a variant of the classical Sweet's Syndrome (SS). Histopathologically, the dermal inflammatory infiltrate is composed mainly of mononuclear cells that have a histiocytic appearance and represent immature myeloid cells. We describe a case of Histiocytoid Sweet's Syndrome in an 18-year-old man. Although this patient had clinical manifestations compatible with SS, the cutaneous lesions consisted of erythematous annular plaques, which are not typical for this entity and have not been described in histiocytic form so far. The histiocytic subtype was confirmed by histopathological analysis that showed positivity for myeloperoxidase in multiple cells with histiocytic appearance.

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.

Vascular structures in dermoscopy

AbstractDermoscopy is an aiding method in the visualization of the epidermis and dermis. It is usually used to diagnose melanocytic lesions. In recent years, dermoscopy has increasingly been used to diagnose non-melanocytic lesions. Certain vascular structures, their patterns of arrangement and additional criteria may demonstrate lesion-specific characteristics. In this review, vascular structures and their arrangements are discussed separately in the light of conflicting views and an overview of recent literature.

Tumor of follicular infundibulum with unique features

Tumor of the follicular infundibulum is a rare benign cutaneous adnexal neoplasm with variable clinical presentation. In most cases the diagnosis is made with the help of histopathology, due to lack of a characteristic clinical presentation. The most common form is a solitary lesion, but it can be multiple or eruptive, then called infundibulomatose. This case report illustrates a patient with multiple lesions of tumor of the follicular infundibulum with bizarre aspect and atypical location.

Musculoskeletal and cutaneous sarcoidosis: exuberant case report

Sarcoidosis is a multisystem granulomatous disease of unknown cause. The osteoarticular involvement in sarcoidosis is rare and is often associated with cutaneous and long-standing chronic multisystem disease. More common in black women, osseous sarcoidosis is difficult to diagnose, with an incidence of 3 to 13%. The most characteristic radiological clinical picture evidences rounded, well-defined cysts, with no periosteal reaction and without peripheral sclerosis. The small bones of hands and feet are the most frequently involved sites. This report aims to demonstrate a rare case of osteoarticular sarcoidosis with characteristic clinical presentation, and highlight the importance of detecting osteoarticular involvement in this pathology.

Porphyria cutanea tarda and Sjogren's syndrome

Porphyria cutanea tarda is prevalent in connective tissue disease, common in systemic lupus erythematosus. However, the co-existence of primary sjogren's syndrome and porphyria cutanea tarda is rare and poses diagnostic and therapeutic challenges. We report a case of porphyria cutanea tarda associated with primary sjogren's syndrome.

Diffuse systemic sclerosis with bullous lesions without systemic manifestations / Esclerose sistemica difusa bolhosa sem acometimentos sistemicos

Here, we describe an atypical case of systemic sclerosis in its diffuse cutaneous form with acute and rapid progression of the cutaneous condition, without any systemic manifestations and the infrequent formation of bullae, showing the importance of diagnosis and early treatment in such cases. This case also shows that special measures should be taken for bullous cutaneous lesions and ulcerations resulting from serious sclerosis, which are entry points and increase morbidity and risk of death. Other prognostic factors include age, ESR and renal and pulmonary involvement. Capillaroscopies can be useful predictors of greater severity of systemic scleroderma, revealing a greater link with systemic, rather than cutaneous, involvement.

Descrevemos um caso atípico de esclerose sistêmica em sua forma cutânea difusa com instalação aguda e rápida progressão do quadro cutâneo sem qualquer acometimento sistêmico e a infrequente formação de bolhas, demostrando a importância do diagnóstico e tratamento precoce frente a casos semelhantes e mostrando, com a experiência deste caso, que cuidados especiais devem ser tomados com as lesões cutâneas bolhosas e as ulcerações decorrentes da grave esclerose que são portas de entrada e aumentam a morbidade e risco de morte. Outros fatores prognósticos descritos são idade, VHS e envolvimento pulmonar e renal. A capilaroscopia pode ser preditor de maior gravidade da esclerodermia sistêmica, guardando maior relação com o envolvimento sistêmico do que cutâneo.

Congenital agminated melanocytic nevus - case report / Nevo melanocitico congenito agminado - relato de caso

Agminated nevus is a cluster group of melanocytic nevi confined to a localized area of the body. There are many pigmented lesions described in the literature as agminated, such as blue nevi, multiple lentigines and Spitz nevi, but only a few cases of congenital agminated melanocytic nevi have been described. We report a case of a male child who presented with congenital agminated nevi, emphasizing the importance of physical examination, dermoscopy, histopathological evaluation, differential diagnosis and follow up to rule out the possibility of dysplastic or malignant changes.

Nevo agminado é um conjunto de lesões melanocíticas confinadas a uma área do corpo. Existem muitas lesões descritas na literatura como agminada s, como nevos azuis, lentigos múltiplos, nevo de Spitz, mas existem poucos casos de nevos melanocíticos agminados congênitos descritos. Relatamos o caso de um paciente do sexo masculino que se apresentou com um nevo agminado congênito, enfatizando a importância do exame físico, dermatoscopia, avaliação histológica, diagnóstico diferencial e seguimento para descartar a possibilidade de alterações displásicas ou malignas.

Pioderma gangrenoso refractario: utilidad de la terapia combinada. Enfoque en beneficio de la terapia hiperbárica en su tratamiento / Refractory pyoderma gangrenosum: Utility of combined therapy. Focus on benefits of hyperbaric therapy in its treatment

Resumen El Pioderma Gangrenoso (PG) es un tipo de dermatosis neutrofílica que tiene un componente idiopático, o puede tener asociación con patologías subyacentes sistémicas. Es el resultado de una respuesta exagerada contra estímulos específicos y no específicos. Su primera línea de terapia son los GC; sin embargo, en algunos pacientes, no se logra control de su patología con éste tratamiento (local o sistémico), y se debe recurrir al uso de medicamentos inmunomoduladores, agentes biológicos Anti-TNFα, y en casos refractarios, esquemas no convencionales, como el uso de la terapia hiperbárica con oxígeno (THBO). En el caso actual, un varón de 42 años de edad previamente sano, debuta con lesión ulcerada en extremidad inferior derecha, manejado inicialmente con GC con mala respuesta. Requirió cambio de manera secuencial a múltiples inmunomoduladores sintéticos sin eficacia terapéutica. Se opta por inicio de terapia Anti-TNFα con fracaso terapéutico al uso de etanercept, infliximab y adalimumab en esquema regular. Finalmente, se modifica la temporalidad de adalimumab a uso semanal sin respuesta favorable; se adiciona: mofetilmicofenolato, y cincuenta sesiones de THBO, con control exitoso de la patología.

Abstract Pyoderma gangrenosum is a type of neutrophilic dermatosis that has an idiopathic component, or can be associated with other underlying systemic pathologies. It is the result of an exaggerated response against specific and non specific stimuli. The first line of therapy are glucocorticoids (GC); however, in some patients, control of the pathology is not achieve with this treatment (local or systemic), and it is needed a step-up therapy going through several immuno-modulating treatments, biologic agents Anti - TNFα, and in refractory cases, the use of non conventional therapies such as Hyperbaric Oxygen Therapy (THBO). In this case, a previously healthy 42 year old man, debuts with an ulcerated lesion in his right lower limb, and he is initially treated with GC with poor response. He then required the use of several synthetic immune modulators without therapeutic efficacy. We opted to iniciate Anti-TNFα therapy obtaining therapeutic failure with the use of etanercept, infliximab, and adalimumab given in regular drug regimens. Finally, it is modify the frecuency of adalimumab to one dose per week without appropriate response; it is then added micofenolate mofetil, and fifty sessions of THBO, achieving successful control of this pathology.

Queratose folicular espinulosa decalvante: relato de caso / Keratosis follicularis spinulosa decalvans: case report

A queratose folicular espinulosa decalvante é afecção rara, de transmissão genética ligada ao X ou esporádica, caracterizada por hiperqueratose folicular e alopecia cicatricial. Inicia-se, geralmente, na primeira infância, exacerbando-se na adolescência. As terapias são pouco efetivas, com tratamento frustrante, quando já há alterações predominantemente cicatriciais. Relata-se caso de criança com quadro de alopecia cicatricial intensa, com alterações precoces (já ao nascimento) e rápida evolução para alopecia difusa cicatricial do couro cabeludo, o que tornou o tratamento limitado e desapontador.

Keratosis follicularis spinulosa decalvans is a rare disease, with genetic transmission either X-linked or sporadic, characterized by follicular hyperkeratosis and cicatricial alopecia. The disease usually begins in early childhood exacerbating throughout adolescence. The therapies are somewhat effective, with frustrating treatment when there are changes which are predominantly cicatricial. It is reported a case of child with intense cicatricial alopecia, with precocious changes (already present at birth) that rapidly evolved to diffuse cicatricial alopecia on the scalp, which has limited the treatment, with disappointing results.

Caso para diagnóstico / Case for diagnosis

A discromatose simétrica hereditária (acropigmentação de Dohi) é alteração pigmentar rara, genética, com padrão de herança autossômica dominante. Caracteriza-se por máculas hiper e hipocrômicas com padrão mosqueado e distribuição acral. Apresenta-se paciente masculino, 13 anos, com máculas hiper e hipocrômicas disseminadas no dorso das mãos e pés, além de efélides na face e lesões atróficas lineares periorbitárias. É necessário o diagnóstico diferencial com as outras pigmentações reticuladas.

Dyschromatosis symetrica hereditaria (reticulate acropigmentation of Dohi) is a rare autosomal dominant disease. It starts as hyperpigmented and hypopigmented macules in reticular pattern on the extremities. We present a case of a 13-year old boy that showed hyper and hypopigmented macules distributed on the dorsal aspects of the extremities, freckle-like pigmented macules on the face and periorbital atrophic linear lesions. Differentiation with others reticulate pigmentation manifestations is necessary.