Indication guidelines for Mohs micrographic surgery in skin tumors.

Mohs micrographic surgery is a technique used to excise skin tumors based on comprehensive surgical mapping, in which the surgeon removes the tumor, followed by a complete histological evaluation of the tumor's margins. The correlation of the presence of a tumor in histological examinations and its precise location on the surgical map result in a complete removal of the tumor with maximum normal tissue preservation. The present article seeks to provide general practitioners and healthcare specialists with guidelines regarding recommendations for Mohs micrographic surgery to treat skin tumors, based on the most reliable evidence available in medical literature on the subject. This bibliographic review of scientific articles in this line of research was conducted based on data collected from MEDLINE/PubMed. The search strategy used in this study was based on structured questions in the Patient, Intervention, Control, and Outcome (PICO) format. MeSH terms were used as descriptors. The indications of this technique are related to recurrence, histology, size, definition of tumor margins, and location of tumors. These guidelines attempt to establish the indications of Mohs surgery for different types of skin tumors.

Indication guidelines for Mohs micrographic surgery in skin tumors

Abstract: Mohs micrographic surgery is a technique used to excise skin tumors based on comprehensive surgical mapping, in which the surgeon removes the tumor, followed by a complete histological evaluation of the tumor's margins. The correlation of the presence of a tumor in histological examinations and its precise location on the surgical map result in a complete removal of the tumor with maximum normal tissue preservation. The present article seeks to provide general practitioners and healthcare specialists with guidelines regarding recommendations for Mohs micrographic surgery to treat skin tumors, based on the most reliable evidence available in medical literature on the subject. This bibliographic review of scientific articles in this line of research was conducted based on data collected from MEDLINE/PubMed. The search strategy used in this study was based on structured questions in the Patient, Intervention, Control, and Outcome (PICO) format. MeSH terms were used as descriptors. The indications of this technique are related to recurrence, histology, size, definition of tumor margins, and location of tumors. These guidelines attempt to establish the indications of Mohs surgery for different types of skin tumors.

Brazilian guidelines for diagnosis, treatment and follow-up of primary cutaneous melanoma - Part II.

The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In this second part, the following clinical questions were answered: 1) which patients with primary cutaneous melanoma benefit from sentinel lymph node biopsy? 2) Follow-up with body mapping is indicated for which patients? 3) Is preventive excision of acral nevi beneficious to patients? 4) Is preventive excision of giant congenital nevi beneficious to patients? 5) How should stages 0 and I primary cutaneous melanoma patients be followed?

Brazilian guidelines for diagnosis, treatment and follow-up of primary cutaneous melanoma - Part II

Abstract The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In this second part, the following clinical questions were answered: 1) which patients with primary cutaneous melanoma benefit from sentinel lymph node biopsy? 2) Follow-up with body mapping is indicated for which patients? 3) Is preventive excision of acral nevi beneficious to patients? 4) Is preventive excision of giant congenital nevi beneficious to patients? 5) How should stages 0 and I primary cutaneous melanoma patients be followed?.

Guidelines of the Brazilian Dermatology Society for diagnosis, treatment and follow up of primary cutaneous melanoma - Part I

Abstract: The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In the first part, the following clinical questions were answered: 1) The use of dermoscopy for diagnosis of primary cutaneous melanoma brings benefits for patients when compared with clinical examination? 2) Does dermoscopy favor diagnosis of nail apparatus melanoma? 3) Is there a prognostic difference when incisional or excisional biopsies are used? 4) Does revision by a pathologist trained in melanoma contribute to diagnosis and treatment of primary cutaneous melanoma? What margins should be used to treat lentigo maligna melanoma and melanoma in situ?.

Guidelines of the Brazilian Dermatology Society for diagnosis, treatment and follow up of primary cutaneous melanoma--Part I.

The last Brazilian guidelines on melanoma were published in 2002. Development in diagnosis and treatment made updating necessary. The coordinators elaborated ten clinical questions, based on PICO system. A Medline search, according to specific MeSH terms for each of the 10 questions was performed and articles selected were classified from A to D according to level of scientific evidence. Based on the results, recommendations were defined and classified according to scientific strength. The present Guidelines were divided in two parts for editorial and publication reasons. In the first part, the following clinical questions were answered: 1) The use of dermoscopy for diagnosis of primary cutaneous melanoma brings benefits for patients when compared with clinical examination? 2) Does dermoscopy favor diagnosis of nail apparatus melanoma? 3) Is there a prognostic difference when incisional or excisional biopsies are used? 4) Does revision by a pathologist trained in melanoma contribute to diagnosis and treatment of primary cutaneous melanoma? What margins should be used to treat lentigo maligna melanoma and melanoma in situ?

Non-cultured melanocyte/keratinocyte transplantation for the treatment of stable vitiligo on the face: report of two cases.

There are many alternatives to treat vitiligo, including surgical procedures, which are recommended for patients resistant to other therapies. The melanocyte/keratinocyte transplantation consists in the separation of epidermal cells obtained from a donor site and spreading these cells on the depigmented and dermabraded recipient area. Two patients were submitted to transplantation, showing more than 70% repigmentation in the treated areas after four months, both with excellent degree of satisfaction. The method requires some laboratory skills, but represents a simple and safe procedure.

Non-cultured melanocyte/keratinocyte transplantation for the treatment of stable vitiligo on the face: report of two cases / Transplante de suspensao celular de melanocitos/queratinocitos para o tratamento de vitiligo estavel na face: relato de dois casos

There are many alternatives to treat vitiligo, including surgical procedures, which are recommended for patients resistant to other therapies. The melanocyte/keratinocyte transplantation consists in the separation of epidermal cells obtained from a donor site and spreading these cells on the depigmented and dermabraded recipient area. Two patients were submitted to transplantation, showing more than 70% repigmentation in the treated areas after four months, both with excellent degree of satisfaction. The method requires some laboratory skills, but represents a simple and safe procedure.

Existem várias alternativas para o tratamento do vitiligo, incluindo procedimentos cirúrgicos, que são indicados para pacientes refratários aos outros tipos de tratamento. O transplante de suspensão celular de melanócitos/queratinócitos consiste na separação de células da epiderme obtidas de área doadora, e aplicação destas células na área receptora despigmentada, após dermoabrasão. Dois pacientes com vitiligo estável foram submetidos ao transplante de suspensão de melanócitos/queratinócitos, apresentando repigmentação acima de 70% nas áreas tratadas após quatro meses, ambos com excelente grau de satisfação. O método requer alguma habilidade laboratorial, mas representa um procedimento simples e seguro.

Atualização no tratamento de hiperidrose axilar / Axillary hyperhidrosis treatment update

Introdução: Hiperidrose axilar é problema comum que pode afetar a vida profissional e social. A história clínica e o exame físico são ferramentas importantes na avaliação da gravidade e para indicação da terapia mais apropriada para cada caso. Existem vários tratamentos, incluindo terapia tópica e sistêmica, iontoforese, toxina botulínica e procedimentos cirúrgicos. Os autores apresentam revisão das opções terapêuticas mais importantes.

Anestésicos tópicos / Topical Anesthetics

Introdução: Os anestésicos tópicos, de indiscutível utilidade na rotina do dermatologista, têm sido cada vez mais utilizados pela população, nem sempre com prescrição e supervisão médica. Seu uso pode envolver complicações ligadas, principalmente, à aplicação inadequada, seja em pele lesada ou inflamada, em grandes áreas corporais, em mucosas ou em pacientes de risco. As reações adversas podem variar desde efeitos locais transitórios, reações alérgicas e/ou irritativas, até quadros mais graves, embora raros, como metemoglobinemia, arritmias e insuficiência cardiorrespiratória. Este artigo visa discutir as preparações comerciais de anestésicos tópicos hoje disponíveis, seu histórico, farmacologia, aplicação clínica e complicações.

Introduction: The use of topical anesthetics, has increased in recent years.While they are undoubtedly useful when recommended appropriately by a dermatologist, the improper use of topical anesthetics may result in complications, mainly due to inadequately applying them to wounded or inflamed skin; use on large areas of the body or mucus membranes; or use by high-risk patients. Adverse reactions can include transient local effects, allergic and/or irritative reactions, or more severe (though rare) effects, such as methemoglobinemia, arrhythmias, and cardiorespiratory failure. This paper discusses the commercial formulations of topical anesthetics currently available, their history, pharmacology, clinical use, and potential side effects.

Tratamento de carcinoma basocelular com associação de terapia fotodinâmica e cirurgia micrográfica de Mohs / Treatment of basocellular carcinoma with the association of photodynamic therapy and Mohs micrographic surgery

O tratamento de carcinomas basocelulares mal delimitados, recidivados, extensos, localizados em áreas de risco, em pacientes com várias comorbidades representa sempre um desafio para o cirurgião dermatológico.A cirurgia micrográfica de Mohs, geralmente utilizada nesses casos, apresenta riscos inerentes a uma cirurgia extensa, além da dificuldade no fechamento da ferida operatória, que muitas vezes se estende além dos limites clínicos da lesão. Demonstra-se, em paciente com 90 anos, diabética e hipertensa, a utilização da terapia fotodinâmica anterior à cirurgia micrográfica de Mohs, visando à diminuição e melhor delimitação da lesão para posterior exérese.

The treatment of extensive, recurrent and poorly delimited basocellular carcinomas, located in highrisk areas of the body in patients with several comorbidities, is a challenge for the dermatologic surgeon. Mohs micrographic surgery is usually employed in such cases, presenting the risks inherent to large surgeries, in addition to the difficulties of closing the operative wound ­ which very frequently extends beyond the clinical limits of the lesion. In this paper, we report the use of photodynamic therapy prior to Mohs micrographic surgery in a 90-year-old diabetic and hypertensive female patient, with the objective of reducing and better delimiting the lesion for the subsequent exeresis.

Cirurgia dermatológica e procedimentos cosmiátricos na gestação ­ Revisão sistemática / Dermatologic surgery and cosmetic procedures during pregnancy - A systematic review

Considerações especiais são necessárias antes de qualquer procedimento cirúrgico durante a gravidez. Os cirurgiões dermatológicos devem considerar a melhor abordagem para minimizar os riscos e prestar o cuidado ideal para mãe e feto.Tratamentos não emergenciais devem ser adiados até o término da gestação. Quando a cirurgia for necessária, é prudente a utilização de drogas e técnicas bem documentadas na literatura especializada.

Special considerations are necessary to contemplate any surgical procedure during pregnancy. Dermatologic surgeons must consider the best approach in order to minimize risks and provide optimal care to the mother and fetus. Nonemergency treatments should be postponed until after childbirth. When surgery is required, it is prudent to apply techniques and drugs that are well documented in the specialized literature.

Laser fracionado de CO2: uma experiência pessoal / Fractional CO2 laser: a personal experience

Diversos métodos têm sido utilizados para rejuvenescimento facial. O resurfacing facial, após mais de 20 anos de existência, passou por fase de amadurecimento e busca de novas tecnologias que viessem complementar as falhas inerentes ao procedimento e atualmente, após seu fracionamento volta a ter o destaque que já teve no passado. Essa fase, porém, iniciou-se com a expectativa de um procedimento com a mesma eficácia do resurfacing ablativo tradicional e 100% seguro, infelizmente isso não aconteceu. O resurfacing fracionado ablativo tem-se mostrado um procedimento muito valioso porém os resultados não são os mesmos do resurfacing tradicional; o fracionamento realmente diminuiu os efeitos colaterais,mas esses não devem ser desprezados.Nesse artigo falamos sobre a nossa experiência pessoal, falamos detalhadamente sobre os possíveis efeitos colaterais, como evitálos e tratá-los.

Over the last 20 years, a number of methods have been used for facial rejuvenation; there is currently a search for new technologies that can overcome flaws inherent in the procedure. With the fractioning of the CO2 laser, the technique has gained renewed prominence. Nevertheless, the expectation of an improved procedure that is as effective as traditional ablative resurfacing and 100% safe has not been met. Although fractional ablative resurfacing has proven to be a considerably valuable procedure, results do not match those of the traditional procedure. And while the fractioning of the laser decreases side effects, they must not be overlooked. In this article we describe in detail our personal experience, including possible side effects and how to avoid and treat them.

Fotoproteção / Photoprotection

Introdução: Nas últimas décadas, a incidência de câncer de pele aumentou significativamente, correspondendo a um problema de saúde pública em diversos países. A pele é o órgão mais atingido pelos efeitos deletérios da radiação ultravioleta, e é bem documentada a associação entre fotoexposição e neoplasias cutâneas. Objetivo: Realizar uma revisão abrangente sobre as principais medidas de fotoproteção. Método: Realizaram-se buscas na base de dados MEDLINE, no período de 22 de junho a 18 de agosto. Estudos descritivos, de revisão e comparativos foram analisados em conjunto. Resultados: Foram selecionados 11 artigos que continham revisão sobre fotoproteção, os efeitos da radiação ultravioleta sobre a pele e a prevalência do uso de filtros solares e medidas comportamentais entre adultos e adolescentes. Conclusões: O uso de fotoprotetores de largo espectro, além de medidas comportamentais simples, parecem causar grande impacto na prevenção do câncer de pele.

Introduction: Incidence of skin cancer has increased signifi cantly in recent decades, corresponding to a public health problem in many countries. Skin is the organ most affected by the deleterious effects of ultraviolet radiation and the association between sun exposure and skin cancer is well-documented. Objective: To conduct a comprehensive review of the main photoprotection measures. Method: We conducted searches on MEDLINE from June 22 through August 18. Descriptive studies, review, and comparative studies were analyzed together. Results: Eleven articles about a review of photoprotection, effects of ultraviolet radiation on the skin, prevalence of the use of sunscreens, and behavioral measures among adults and adolescents were reported were selected. Conclusions: The use of broad-spectrum sunscreens, besides simple behavioral measures, appears to have a major impact on prevention of skin cancer.

Síndrome do epitelioma basocelular múltiplo / Multiple basal-cell epithelioma syndrome

Relato de caso de um paciente portador da sindrome do epitelioma basocelular múltiplo ou síndrome de Gorlin-Goltz. Incluem o histórico das publicaçöes, as manifestaçöes clínicas mais importantes (epiteliomas basocelulares múltiplos, disceratose palmo-plantar, cistos de mandíbula e malformaçöes esqueléticas), a patogênese e alguns estudos genéticos realizados sobre a síndrome em questäo. Assim embasados, sugerem que os termos nevo ou nevóide, impróprios, devendo ser evitados na sinonímia da síndrome.

A formaçäo do cirurgiäo dermatológico / The formation of dermatologic surgeon

A dermatologia clínico-cirúrgica já é uma realidade irreversível. Porém o tipo de formaçäo que o Cirurgiäo Dermatológico recebe ainda näo foi definido claramente. Este trabalho é uma compilaçäo das opiniöes e idéias expostas em um debate sobre o assunto, ocorrido em maio de 1991 na sede da AMMG, do qual participaram Cirurgiöes Gerais e Plásticos, Dermatologistas e um professor de Pedagogia Médica. A questäo mais polêmica girou em torno do limite de açäo do Cirurgiäo Dermatológico. Säo ainda aqui expostas as posiçöes do autor com respeito à sua proposta de formaçäo do Cirurgiäo, que consta basicamente de maior atençäo à técnica cirúrgica, anatomia e técnica anestésica, durante o período normal da residência em Dermatologia. O terceiro ano opcional, ficaria reservado apenas ao aluno que desejasse se tornar Cirurgiäo Dermatológico