Ambulatório conjunto de dermatologia e reumatologia para tratamento de psoríase e artrite psoriásica: experiência de um hospital terciário do sul do Brasil / Combined dermatology and rheumatology outpatient clinic for the management of psoriasis and psoriatic arthritis: a Southern Brazilian experience

Introdução: Diversas diretrizes enfatizam as vantagens do manejo multidisciplinar no cuidado ao paciente com psoríase (PSO) e artrite psoriásica (PSA). O diagnóstico precoce de PSA se relaciona com melhores desfechos em 5 anos. No entanto, o diagnóstico precoce de PSA ainda é um desafio. Métodos: Estudo transversal retrospectivo de pacientes com diagnóstico prévio ou suspeito de PSO e/ou PSA atendidos em ambulatório conjunto de dermatologia e reumatologia do sul do Brasil de janeiro de 2013 a janeiro de 2017. Resultados: Entre os 55 pacientes previamente diagnosticados com PSO, 30,9% (n = 17) foram diagnosticados com PSA. Alterações do tratamento foram feitas em 58,5% (n = 48) dos pacientes, principalmente devido ao mau controle da pele e das articulações. Os imunobiológicos foram a classe de medicamentos mais comumente iniciada, correspondendo a 35,4% (n = 17) das modificações terapêuticas. O metotrexato foi o segundo medicamento mais comumente iniciado (18,8%, n = 9) ou com modificação da dose ou via de administração (20,8%, n = 10), totalizando 39,6% (n = 19) de modificações terapêuticas. Houve um aumento na proporção de pacientes em uso de tratamento sistêmico (79,3%, n = 65). Conclusão: Este estudo reforça a importância da abordagem multidisciplinar no diagnóstico precoce da PSA e demonstra que a abordagem conjunta entre dermatologia e reumatologia é possível de ser realizada no Brasil, com resultados semelhantes aos reportados na literatura internacional. (AU)

Introduction: Several guidelines emphasize the advantages of multidisciplinary management of patients with psoriasis (PSO) or psoriatic arthritis (PSA). Early diagnosis of PSA is associated with better outcomes in 5 years. However, early diagnosis of PSA remains a challenge. Methods: We conducted a retrospective cross-sectional study of patients with previous or suspected diagnosis of PSO and/or PSA treated at a combined dermatology and rheumatology outpatient clinic in southern Brazil from January 2013 to January 2017. Results: Of 55 patients previously diagnosed with PSO, 30.9% (n = 17) were diagnosed with PSA. Changes in treatment were made in 58.5% (n = 48) of patients, mainly due to poor control of cutaneous and articular symptoms. Immunobiological agents were the most commonly prescribed class of drugs, corresponding to 35.4% (n = 17) of changes in medical therapy. Methotrexate was the second most commonly prescribed drug (18.8%; n = 9) and the second drug to undergo most changes in dose or route of administration (20.8%; n = 10), accounting for 39.6% (n = 19) of changes in medical therapy. There was an increase in the number of patients undergoing systemic therapies (79.3%; n = 65). Conclusions: This study reinforces the importance of a multidisciplinary approach in the early diagnosis of PSA and demonstrates that a collaborative approach between dermatology and rheumatology is feasible in Brazil, with outcomes similar to those reported in the international literature. (AU)

Case for diagnosis. Penile lesion in HIV-negative patient

Abstract We present the case of an HIV-negative man with asymptomatic penile erythematoviolaceous papules associated with similar slightly verrucous papules in the interdigital space of the right foot. A biopsy of the penile lesion confirmed Kaposi's sarcoma. No other causes of immunosuppression were observed. Penile lesions of KS are rare in HIV-negative individuals but it should also be considered in the differential diagnosis. Careful follow-up is recommended.

Case for diagnosis. Penile lesion in HIV-negative patient.

We present the case of an HIV-negative man with asymptomatic penile erythematoviolaceous papules associated with similar slightly verrucous papules in the interdigital space of the right foot. A biopsy of the penile lesion confirmed Kaposi's sarcoma. No other causes of immunosuppression were observed. Penile lesions of KS are rare in HIV-negative individuals but it should also be considered in the differential diagnosis. Careful follow-up is recommended.

Hirsutism in Polycystic Ovary Syndrome: Pathophysiology and Management.

BACKGROUND: Hirsutism is defined as the presence of terminal hair with male distribution in women, and polycystic ovary syndrome (PCOS) is the most common etiology of hirsutism. METHODS: The aim of this study is to review aspects of hair growth that are relevant for the understanding of hirsutism in PCOS, along with current treatment alternatives. RESULTS: The prevalence of hirsutism in PCOS ranges from 70 to 80%, vs. 4% to 11% in women in the general population. Hirsutism in PCOS is associated with both ovarianderived androgen excess and individual sensitivity of the pilosebaceous unit to androgens. Interventions to decrease hirsutism in PCOS include the suppression of androgen excess by combined oral contraceptives (OCPs). If OCPs are contraindicated, mainly in the presence of insulin-resistance related comorbidities, a second-line option for reducing androgen secretion may be metformin associated with lifestyle changes. Other interventions should be guided by hirsutism severity, determined by the modified Ferriman-Gallwey score, and by the amount of distress hirsutism causes to the patient, and should be maintained for at least 6-12 months. Mild hirsutism is usually treated with a combination of non-pharmacological methods and OCPs, whereas moderate and severe hirsutism may require a combination of antiandrogens and OCPs, or, if OCPs cannot be used, antiandrogens plus a safe contraceptive method. In all cases, strong clinical support is crucial to ensure treatment adherence and success. CONCLUSION: The understanding of the pathophysiology of hirsutism in PCOS, as well as classifying its severity and the distress it causes to each patient is essential to choose the proper treatment. The presence of metabolic comorbidities and menstrual disturbances will also guide the individualized management of hirsutism in women with PCOS.

Case for diagnosis

The Osler-Weber-Rendu syndrome or Hereditary Hemorrhagic Telangiectasia (HHT) is a systemic fibrovascular dysplasia characterized by defects in the elastic and vascular walls of blood vessels, making them varicose and prone to disruptions. Lesions occur in different organs and can lead to hemorrhage in the lungs, digestive tract and brain. We describe the case of a patient with cutaneous manifestations and severe impairment of the digestive tract. It is important for the dermatologist to recognize this syndrome, since the cutaneous lesions may play a key role in diagnosis.

Case for diagnosis. Hereditary Hemorrhagic Telangiectasia.

The Osler-Weber-Rendu syndrome or Hereditary Hemorrhagic Telangiectasia (HHT) is a systemic fibrovascular dysplasia characterized by defects in the elastic and vascular walls of blood vessels, making them varicose and prone to disruptions. Lesions occur in different organs and can lead to hemorrhage in the lungs, digestive tract and brain. We describe the case of a patient with cutaneous manifestations and severe impairment of the digestive tract. It is important for the dermatologist to recognize this syndrome, since the cutaneous lesions may play a key role in diagnosis.