Reflectance confocal microscopy - Consensus terminology glossary in Brazilian Portuguese for normal skin, melanocytic and non-melanocytic lesions

Abstract Background: Currently, there is no uniform and official terminology in Portuguese for reflectance confocal microscopy analysis, despite the increasing number of Brazilian dermatologists using this new tool. Objective: To present the terminology in Brazilian Portuguese for the description of reflectance confocal microscopy and establish the first Brazilian consensus on terms related to normal skin and cutaneous tumors. Methods: 10 Brazilian specialists from different institutions and states of Brazil were selected to evaluate the best corresponding terms in Portuguese for normal skin, melanocytic and non-melanocytic tumors. The terms used were translated from international consensuses in the English language. The modified Delphi method was used to create the consensus in 3 steps. Results: The terms considered the most appropriate in the Portuguese language to describe the findings of normal skin, melanocytic and non-melanocytic lesions in the reflectance confocal microscopy analysis were presented. Study limitations: The limitations of the present study include the number of participants and limited regional representation (only two of the five Brazilian regions were represented). Conclusion: This Brazilian consensus represents an opportunity for dermatologists and physicians specializing in cutaneous oncology to become familiar with reflectance confocal microscopy, propagating the technique in clinical and research environments to stimulate national and international publications on this subject.

Acurácia da teledermatoscopia móvel na avaliação de lesões cutâneas pigmentadas / The accuracy of mobile teledermatoscopy in the assessment of pigmented skin lesions

Neste estudo transversal, comparamos o diagnóstico feito por meio da teledermatoscopia ao diagnóstico histopatológico. Fotos convencionais e dermatoscópicas de 31 lesões pigmentadas foram enviadas a um dermatologista experiente por meio do aplicativo WhatsApp® Messenger. Todas as lesões foram excisadas e examinadas por um dermatopatologista. A acurácia global da teledermatoscopia móvel foi de 90,32%. Em relação à capacidade de a teledermatoscopia definir malignidade da lesão pigmentada, a especificidade foi de 81,8% e a sensibilidade de 100%. Nossos resultados fornecem evidências adicionais sobre a confiabilidade da teledermatoscopia móvel, com alta sensibilidade e precisão.

In this cross-sectional study, we compared the diagnosis made through teledermatoscopy with histopathological diagnosis. Conventional and dermoscopic photos of 31 pigmented lesions were taken and sent to an experienced dermatologist using the WhatsApp® Messenger application. A dermatopathologist excised and examined all lesions. The global accuracy of mobile teledermatoscopy was 90.32%. Regarding the ability of teledermatoscopy to define malignancy of the pigmented lesion, the specificity was 81.8% and the sensitivity was 100%. Our results provide additional evidence of the reliability of mobile teledermatoscopy with high sensitivity and accuracy.

Melanonychia associated with subungual follicular inclusions: report of three cases

Abstract Melanonychia is the change in the coloration of the nail plate resulting from the deposition of melanin. Among its causes are melanocytic hyperplasia, melanocytic activation and nail melanoma. Subungual follicular inclusions are histological findings of unknown etiology, possibly related to trauma. We present three cases of melanonychia of different etiologies with subungual follicular inclusions, an association that has not been well described and with an indefinite pathogenesis.

Combined high-frequency and Doppler ultrasound in early diagnosis of atrophoderma of Pasini and Pierini

Abstract: Atrophoderma of Pasini and Pierini is a skin disorder affecting dermal collagen and is clinically characterized by well-defined plaques of depressed skin. Histopathological changes are subtle, and in most cases, the diagnosis requires a comparative study with healthy skin from the same anatomical site. High frequency ultrasound is a useful imaging method for diagnosis of atrophic skin changes. A case is presented in which ultrasound can support the clinical and the histopathological diagnosis of atrophoderma of Pasini and Pierini.

Descriptive dermoscopy terminology in Portuguese language in Brazil: a reproducibility analysis of the 3rd consensus of the International Dermoscopy Society

Abstract: Background: Dermoscopy is a noninvasive complementary diagnostic method largely used in dermatology. Feasibility, accuracy, and reproducibility are key elements for a diagnostic method to be useful, hence the importance of the terminology used to describe dermoscopic criteria. Objective: To evaluate the reproducibility of the English descriptive terminology proposed for dermoscopic criteria at the 3rd Consensus Meeting of the International Dermoscopy Society in Brazilian Portuguese. Methods: Nine Brazilian dermatologists independently analyzed the translation of sixty dermoscopic descriptive terms proposed at the 3rd Consensus Conference of the International Society of Dermoscopy. Interobserver agreement index was analyzed using the Fleiss' kappa test. Results: The interobserver agreement of the descriptive terminology in Brazilian Portuguese was considered weak (κ = 0.373; p < 0.05). The interobserver agreement of the descriptive terminology used to describe morphology and arrangement of vascular structures was considered moderate (κ = 0.43; p < 0.05). Study limitations: Our study limitations include the small number of participants and limited regional representation (only 2 out of 5 Brazilian regions were represented). Conclusions: The descriptive English terminology proposed at the 3rd Consensus Conference of the International Dermoscopy Society revealed weak reproducibility and the morphology and arrangement of vascular structures presented moderate reproducibility in Brazilian Portuguese. Despite small regional differences, metaphoric terminology in dermoscopy seems to be the most useful and reproducible system to be adopted in Brazilian Portuguese.

The importance of direct immunofluorescence in pemphigus herpetiformis diagnosis

Abstract Pemphigus herpetiformis is an autoimmune bullous disease, that combines clinical features of dermatitis herpetiformis and linear IgA bullous dermatosis and immunological characteristics of pemphigus, which makes this disease peculiar and this diagnosis rarely suspected in the first evaluation of the patient. The reported case is of a patient with clinically bullous disease similar to dermatitis herpetiformis, whose multiple biopsies were inconclusive, and only after direct immunofluorescence with a pemphigus pattern (intraepidermal intercellular pattern) the confirmation of the diagnosis was possible.

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.

Multiple cutaneous melanomas associated with gastric and brain metastases

Abstract The occurrence of multiple primary melanomas in a single individual is rare. Most commonly, malignant melanocytic lesions subsequent to the initial diagnosis of melanoma are secondary cutaneous metastases. We report a patient with gastrointestinal bleeding from gastric metastasis of cutaneous melanoma. During clinical evaluation and staging, we discovered a brain metastasis associated with 3 synchronous primary cutaneous melanomas. We suggest the research on the mutation in the cyclin-dependent kinase inhibitor 2A (CDKN2A) (INK4a) in such cases. We also emphasize the importance of clinical examination and dermoscopy of the entire tegument, even after a malignant melanocytic lesion is identified.

High frequency ultrasound with color Doppler in dermatology

Abstract: Ultrasonography is a method of imaging that classically is used in dermatology to study changes in the hypoderma, as nodules and infectious and inflammatory processes. The introduction of high frequency and resolution equipments enabled the observation of superficial structures, allowing differentiation between skin layers and providing details for the analysis of the skin and its appendages. This paper aims to review the basic principles of high frequency ultrasound and its applications in different areas of dermatology.

Study of the skin anatomy with high-frequency (22 MHz) ultrasonography and histological correlation / Estudo da anatomia cutânea com ultrassom de alta frequência (22 MHz) e sua correlação histológica

AbstractThe present essay is aimed at getting the radiologist familiar with the basic histological skin structure, allowing for a better correlation with sonographic findings. A high-frequency (22 MHz) ultrasonography apparatus was utilized in the present study. The histological analysis was performed after the skin specimens fixation with formalin, inclusion in paraffin blocks and subsequent staining with hematoxylin-eosin. The authors present a literature review showing the relationship between sonographic and histological findings in normal cutaneous tissue, and discuss the technique for a better performance of the sonographic scan. High-frequency ultrasonography is an excellent tool for the diagnosis of different skin conditions. However, as this method is operator-dependent, it is crucial to understand the normal skin structure as well as the correlation between histological and sonographic findings.

ResumoO objetivo deste trabalho é familiarizar o radiologista com a estrutura histológica cutânea, o que torna possível uma melhor correlação dos achados ultrassonográficos da pele. Para o exame radiológico foi utilizado aparelho de ultrassom de alta frequência (22 MHz). O exame histológico foi realizado após fixação do material em formol, inclusão em parafina e coloração com hematoxilina-eosina. Os autores fazem uma revisão da literatura, demonstram a relação dos achados ultrassonográficos e histológicos do tecido cutâneo normal e discutem a técnica para o melhor aproveitamento do exame ultrassonográfico da pele. O ultrassom de alta frequência representa uma excelente ferramenta no diagnóstico das diferentes alterações cutâneas. Como o método é operador-dependente, é crucial o perfeito entendimento da pele normal e sua equivalência histológica/ultrassonográfica.

Collision of malignant neoplasms of the skin: basosquamous cell carcinoma associated with melanoma

Collision tumors are characterized by the coexistence of two cancers in the same anatomical site and its pathogenesis remains controversial. Although uncommon, the association of basal cell carcinoma and melanocytic nevus is the most common among combinations of skin tumors. Even rarer is the association of two malignant tumors. We report a case of tumor collision representing melanoma and basosquamous cell carcinoma, a combination not previously described in the literature, since there are no reported cases of melanoma with this type of basal cell carcinoma.

Alopecia secondary to anti-tumor necrosis factor-alpha therapy

Biologic drugs represent a substantial progress in the treatment of chronic inflammatory immunologic diseases. However, its crescent use has revealed seldom reported or unknown adverse reactions, mainly associated with anti-tumor necrosis factor (anti-TNF). Psoriasiform cutaneous reactions and few cases of alopecia can occur in some patients while taking these drugs. Two cases of alopecia were reported after anti-TNF therapy. Both also developed psoriasiform lesions on the body. This is the second report about a new entity described as 'anti-TNF therapy-related alopecia', which combines clinical and histopathological features of both alopecia areata and psoriatic alopecia. The recognition of these effects by specialists is essential for the proper management and guidance of these patients.

Contoured technique for lentigo maligna

The surgical approach to lentigo maligna is a challenge to dermatologists, given the difficulty of clinical delimitation of borders. We report here a case of a 69-year-old female patient presenting with brownish macules on her face, since 10 years ago, with histopathological diagnosis of lentigo maligna. The surgical management employed was excision of visible borders with the contoured technique and immediate submission of these borders for histopathological analysis before complete excision of the tumor. This technique is a variant of staged excision, with lower rates of recurrence and acceptable aesthetic results.

Pigmented Bowen's disease

Pigmented Bowen's disease is rare, though more prevalent in men. It presents as a well-delineated plaque in areas unexposed to sun. There are reports of association with seborrheic keratosis, solar lentigo or exuberant pigmentation of genital and intertriginous regions. A specific dermoscopy finding is the presence of brown or gray dots in regular arrangement and coiled or dotted vessels. Thus, we aim to raise awareness of the diagnosis of pigmented Bowen's disease in pigmented lesions.

Dermatoscopic findings of urticaria pigmentosa / Achados dermatoscopicos na urticaria pigmentosa

Mastocytosis is a rare disease characterized by proliferation and accumulation of mast cells in various organs. The maculopapular cutaneus mastocytosis is divided into three subtypes: papular/plaque variant, urticaria pigmentosa and eruptive macular telangiectasia perstans. Dermoscopic may help to better characterize the different forms of cutaneus mastocytosis. We report a 55 year-old female with urticaria pigmentosa and its dermoscopy.

Mastocitose é uma doença rara caracterizada pela proliferação e acúmulo de mastócitos em vários órgãos. A mastocitose cutanea maculopapular divide-se em três subtipos: variante máculo-papular, urticária pigmentosa e telangiectasia macular eruptiva perstans. A dermatoscopia pode ajudar a caracterizar melhor as diferentes formas de mastocitose cutânea. Relatamos um caso de paciente feminina de 55 anos com urticária pigmentosa e sua dermatoscopia.

Primary systemic amyloidosis, acquired cutis laxa and cutaneous mucinosis in a patient with multiple myeloma / Amiloidose sistemica primaria, cutis laxa adquirida e mucinose cutanea em paciente com mieloma multiplo

A 57-year-old woman presented with periorbital ecchymoses, laxity in skin folds, polyneuropathy and bilateral carpal tunnel syndrome. A skin biopsy of the axillary lesion demonstrated fragmentation of elastic fibers, but with a negative von Kossa stain, consistent with cutis laxa. The diagnosis of primary systemic amyloidosis was made by the presence of amyloid material in the eyelid using histopathological techniques, besides this, the patient was also diagnosed with purpura, polyneuropathy, bilateral carpal tunnel syndrome and monoclonal gammopathy. She was diagnosed as suffering from multiple myeloma based on the finding of 40% plasma cells in the bone marrow, component M in the urine and anemia. The patient developed blisters with a clear content, confirmed as mucinosis by the histopathological exam. The final diagnoses were: primary systemic amyloidosis, acquired cutis laxa and mucinosis, all related to multiple myeloma.

Mulher de 57 anos, com equimose periorbitária, frouxidão cutânea nas dobras, polineuropatia e síndrome do túnel do carpo bilateral.O exame histopatológico da lesão axilar revelou fragmentação de fibras elásticas, porém a coloração de von Kossa foi negativa;o diagnóstico foi de cútis laxa. Amiloidose sistêmica primária foi confirmada pela presença de material amilóide no exame histopatológico da pálpebra, além de púrpura, polineuropatia, síndrome do túnel do carpo bilateral e gamopatia monoclonal. Foi diagnosticada como portadora de mieloma múltiplo por apresentar 40% de plasmócitos na medula óssea, componente M urinário e anemia. A paciente evoluiu com bolhas de conteúdo citrino, cujo exame histopatológico mostrou mucinose. Os diagnósticos finais foram: amiloidose sistêmica primária, cútis laxa adquirida e mucinose, todos vinculados ao mieloma múltiplo.

Agminate lichen aureus / Liquen aureus agminado

Lichen aureus is a rare variant of pigmented purpura, with a chronic and benign course. It is generally asymptomatic and often occurs in the lower limbs, presenting as erythematous brownish, coppery or golden macules and/or papules. The diagnosis is based on clinical and histopathological findings. The dermatoscopic pattern has been considered a useful tool in diagnosis presumption. We describe a case with a confluent morphological pattern, called agminate lichen aureus.

O líquen aureus é uma variante rara das púrpuras pigmentares, com evolução crônica e benigna. A maioria é assintomática e predomina nos membros inferiores. O quadro clínico é constituído por máculas e/ou pápulas eritemato-acastanhadas, acobreadas ou douradas. O diagnóstico é clínico e histopatológico, porém o padrão dermatoscópico vem sendo uma ferramenta útil na presunção do diagnóstico. Descrevemos um caso com um padrão morfológico em que a lesão é confluente, sendo denominado líquen aureus agminado.

Parallel ridge pattern on dermoscopy: observation in non-melanoma cases / Padrao dermatoscopico em cristas paralelas: observacao em casos nao-melanoma

The acral melanoma is the most prevalent type of melanoma in the non-Caucasian population, and dermoscopy is a useful tool for earlier diagnosis and differentiation from benign lesions. The dermoscopic pattern often associated with melanoma on the volar skin is the parallel ridge, with 99% specificity according to the literature. However, this pattern can also occur in several benign acral lesions, so it is important to make a good interpretation of this pattern, along with the clinical history and evolution.

O melanoma acral é o tipo mais prevalente de melanoma na população não caucasiana, sendo a dermatoscopia uma ferramenta útil para um diagnóstico mais precoce e diferenciação com lesões benignas. O padrão dermatoscópico, frequentemente, associado ao melanoma na pele volar é o de cristas paralelas, com 99% de especificidade segundo a literatura. No entanto, também pode ocorrer em diversas lesões acrais benignas, por isso é importante uma boa interpretação deste padrão, associado a história clínica e evolução.

Desmoplastic melanoma associated with an intraepidermal lentiginous lesion: case report and literature review / Melanoma desmoplásico associado a lesão lentiginosa intraepidérmica, com evolução de 10 anos: relato de caso e revisão bibliográfica

Desmoplastic melanoma tends to present as firm, amelanotic papules. Microscopically, it reveals a proliferation of fusiform cells in the dermis and variable collagen deposition, as well as intraepidermal melanocytic proliferation of lentiginous type in most cases. Biopsy in a 61-year-old white male patient, who had received a diagnosis of lentigo maligna on his face 10 years before, revealed a proliferation of dermal pigmented spindle cells and collagen deposition, reaching the deep reticular dermis, with a lentiginous component. Immunohistochemistry with S-100, Melan-A and WT1 showed positivity, but it was weak with HMB45. Desmoplastic melanoma associated with lentigo maligna was diagnosed. Several authors discuss whether desmoplastic melanoma represents a progression from the lentiginous component or arises "de novo". Desmoplastic melanoma represents a minority of cases of primary cutaneous melanoma (less than 4%). Identification of lentigo maligna indicates that desmoplastic melanoma should be carefully investigated.

Os melanomas desmoplásicos apresentam-se como pápulas amelanóticas firmes; à microscopia exibem proliferação de células fusiformes na derme e variável deposição de colágeno, além de proliferação melanocítica lentiginosa, intraepidérmica, na maioria dos casos. Realizada biópsia de pele de paciente masculino, 61 anos, branco, com diagnóstico de lentigo maligno na face, há 10 anos. O exame histopatológico revela proliferação dérmica de células fusiformes pigmentadas e deposição de colágeno, invadindo até a profundidade da derme reticular, associado a componente lentiginoso; presença de positividade imuno-histoquímica com S-100, Melan-A e WT1, e marcação fraca com HMB45. Diagnóstico de melanoma desmoplásico, associado a lentigo maligno. Existe divergência quanto à origem do melanoma desmoplásico, a partir do componente lentiginoso ou "de novo", na ausência de lentigo associado. O melanoma desmoplásico representa uma minoria dos casos de melanoma cutâneo primário (menos de 4%). A presença de lentigo maligno pode servir de sinal de alerta para possível relação com melanoma desmoplásico.