Sleep disturbance and atopic dermatitis: A bidirectional relationship?

Atopic dermatitis (AD) is one of the most common pediatric dermatologic disorders and is associated with an increased risk of recurrent bacterial and viral cutaneous infections, such as impetigo, the most common bacterial infection in children. AD may impair patient quality of life in a number of ways, one of which is its impact on sleep. The way that the condition affects sleep has not yet been fully elucidated; it is clear that the symptoms of the disease such as pruritus and scratching can affect sleep but other factors, such as changes in the immunological system related to the disease can also have an effect. We argue that this relationship may be bi-directional, with changes to the skin barrier (barrier dysfunction, alterations in its microbiome and oxidative stress) and immunological function caused by the condition impairing sleep and leading to imbalanced inflammatory pathways that exacerbate AD and other associated conditions such as impetigo. We highlight the need for further studies to investigate this correlation between AD and sleep to make the role of this relationship clearer.

Cutaneous schistosomiasis and leishmaniasis coinfection: a case report.

BACKGROUND: The polymorphic clinical presentations of schistosomiasis and leishmaniasis allow their inclusion in the differential diagnoses of several conditions. Although an overlap in distribution of these diseases has been reported in endemic areas, coinfection with cutaneous schistosomiasis and cutaneous leishmaniasis in the same patient is rare. OBJECTIVES: We report an unusual case of concomitant cutaneous schistosomiasis and cutaneous leishmaniasis. Actions for the management and diagnosis were proposed. METHODS: A patient presented with cutaneous lesions on the abdomen and left elbow. The presence of degenerated ova of Schistosoma mansoni in the skin biopsy led to perform a complementary investigation with immunohistochemical techniques, rectal biopsy and abdominal ultrasonography. After the left elbow lesions had failed to improve after several weeks of standard treatment, a new biopsy was performed and led to diagnosis of another infection. RESULTS: The patient lived in an endemic area for two infectious diseases (schistosomiasis and leishmaniasis). Biopsies revealed chronic granulomatous dermatitis. Degenerated S. mansoni eggs were found in the abdominal lesion and in a rectal biopsy specimen. Ultrasonography revealed hepatic involvement. Despite combination treatment with oxamniquine and praziquantel, a cutaneous lesion persisted on the left elbow; a new biopsy revealed amastigote forms of Leishmania. The patient was successfully treated with intramuscular and intralesional meglumine antimoniate. CONCLUSIONS: The presence of a similar granulomatous infiltrate in lesions caused by the two different infectious agents led to a delay in the diagnosis of cutaneous leishmaniasis. This report serves as a warning of the unusual possibility of cutaneous schistosomiasis and leishmaniasis coinfection in an endemic area.

Interconsulta hospitalaria en dermatología en una unidad de transplante renal / Inpatient Dermatology Consultations in Renal Transplant Recipients

Introducción: El número de pacientes receptores de trasplante renal (RTR) está en aumento, y estos con frecuencia, además presentarán complicaciones dermatológicas derivadas del trasplante. Si bien el rol del dermatólogo a nivel de la consulta ambulatoria está establecido, no encontramos ningún estudio acerca de interconsultas dermatológicas en pacientes RTR hospitalizados. Objetivos: La finalidad de este estudio fue determinar las características epidemiológicas de las enfermedades dermatológicas que afectan a los pacientes RTR hospitalizados, así como valorar el impacto que tienen las interconsultas dermatológicas durante el ingreso hospitalario de estos pacientes. Métodos: Durante un periodo de 36 meses consecutivos, se incluyeron de forma retrospectiva las consultas realizadas al servicio de dermatología en pacientes RTR ingresados en un hospital de referencia en trasplantes renales de Brasil. Resultados: Se incluyeron 176 interconsultas. Las dermatosis infecciosas fueron las más prevalentes (52,3%), seguidas de las enfermedades inflamatorias (14,2%), neoplasias (12,5%) y reacciones medicamentosas (8,5%). La concordancia diagnóstica entre el diagnóstico de derivación y el diagnóstico final fue del 38,1%. La mayoría de las interconsultas se debieron a condiciones dermatológicas comunes que no guardaban relación con el motivo de ingreso. Se evidenciaron algunas diferencias con estudios previos en pacientes ingresados en hopitales generales; por ejemplo, en los pacientes RTR hubo una mayor proporción de dermatosis infecciosas y neoplasias y una menor proporción de enfermedades inflamatorias. Así mismo un mayor porcentaje de biopsias cutáneas fueron realizadas, una mayor proporción de interconsultas requirieron más de una visita y hubo la necesidad de pautar tratamiento sistémico en un mayor número de pacientes. Conclusión: Los pacientes RTR ingresados presentaron características epidemiológicas diferentes, así como un mayor nivel de complejidad clínica en comparación con con estudios realizados en hospitales generales. Concluimos que la colaboración del servicio de dermatología durante el ingreso será beneficiosa en el manejo multidisciplinario de estos pacientes, ya que ayudará en el estudio de las enfermedades sistémicas, así como a tratar comorbilidades cutáneas

Background: Renal transplant recipients (RTR), which are an increasing population, frequently suffer from post-transplant dermatological complications. Despite the well-established role of dermatologists in the outpatient care of these patients, no previous studies were found concerning dermatology consultations for hospitalized RTR. Objectives: To investigate the epidemiology of dermatological conditions presented by RTR during hospitalization and assess the impact of dermatology consultations performed in the hospital setting. Methods: Dermatology consultations requested for RTR admitted at a kidney transplantation referral hospital in Brazil over 36 consecutive months were retrospectively included. Results: 176 consultations were included. Infectious dermatoses prevailed (52.3%), followed by inflammatory diseases (14.2%), neoplasms (12.5%) and drug reactions (8.5%). Diagnostic agreement between requesting and consulting teams was 38.1%. Most consultations were motivated by common dermatological conditions, unrelated to admission diagnosis. There were some differences in comparison to previous studies including general inpatients, such as: larger proportion of infectious dermatoses and neoplasms, smaller proportion of inflammatory diseases, higher percentage of patients submitted to skin biopsy, smaller proportion of consultations managed with a single visit and higher probability of a systemic treatment being recommended in this population. Conclusion: Hospitalized RTR present distinct dermatological epidemiology and higher level of complexity, when compared to studies including general inpatients. Dermatology interventions during hospitalization may be beneficial in the multidisciplinary care of these patients, either contributing to the investigation of systemic conditions or providing relief for cutaneous comorbidities

Inpatient Dermatology Consultations in Renal Transplant Recipients. / Interconsulta hospitalaria en dermatología en una unidad de transplante renal.

BACKGROUND: Renal transplant recipients (RTR), which are an increasing population, frequently suffer from post-transplant dermatological complications. Despite the well-established role of dermatologists in the outpatient care of these patients, no previous studies were found concerning dermatology consultations for hospitalized RTR. OBJECTIVES: To investigate the epidemiology of dermatological conditions presented by RTR during hospitalization and assess the impact of dermatology consultations performed in the hospital setting. METHODS: Dermatology consultations requested for RTR admitted at a kidney transplantation referral hospital in Brazil over 36 consecutive months were retrospectively included. RESULTS: 176 consultations were included. Infectious dermatoses prevailed (52.3%), followed by inflammatory diseases (14.2%), neoplasms (12.5%) and drug reactions (8.5%). Diagnostic agreement between requesting and consulting teams was 38.1%. Most consultations were motivated by common dermatological conditions, unrelated to admission diagnosis. There were some differences in comparison to previous studies including general inpatients, such as: larger proportion of infectious dermatoses and neoplasms, smaller proportion of inflammatory diseases, higher percentage of patients submitted to skin biopsy, smaller proportion of consultations managed with a single visit and higher probability of a systemic treatment being recommended in this population. CONCLUSION: Hospitalized RTR present distinct dermatological epidemiology and higher level of complexity, when compared to studies including general inpatients. Dermatology interventions during hospitalization may be beneficial in the multidisciplinary care of these patients, either contributing to the investigation of systemic conditions or providing relief for cutaneous comorbidities.

Melanized fungal infections in kidney transplant recipients: contributions to optimize clinical management.

OBJECTIVES: This is a retrospective and observational study addressing clinical and therapeutic aspects of melanized fungal infections in kidney transplant recipients. METHODS: We retrospectively reviewed medical records of all patients admitted between January 1996 and December 2013 in a single institution who developed infections by melanized fungi. RESULTS: We reported on 56 patients aged between 30 and 74 years with phaeohyphomycosis or chromoblastomycosis (0.54 cases per 100 kidney transplants). The median time to diagnosis post-transplant was 31.2 months. Thirty-four (60.8%) infections were reported in deceased donor recipients. Fifty-one cases of phaeohyphomycosis were restricted to subcutaneous tissues, followed by two cases with pneumonia and one with brain involvement. Most dermatological lesions were represented by cysts (23/51; 45.1%) or nodules (9/51; 17.9%). Exophiala spp. (34.2%) followed by Alternaria spp. (7.9%) were the most frequent pathogens. Graft loss and death occurred in two patients and one patient, respectively. Regarding episodes of subcutaneous phaeohyphomycosis, a complete surgical excision without antifungal therapy was possible in 21 of 51 (41.2%) patients. Long periods of itraconazole were required to treat the other 30 (58.8%) episodes of subcutaneous disease. All four cases of chromoblastomycosis were treated only with antifungal therapy. CONCLUSIONS: Melanized fungal infections should be considered in the differential diagnosis of all chronic skin lesions in transplant recipients. It is suggested that the impact of these infections on graft function and mortality is low. The reduction in immunosuppression should be limited to severely ill patients.

Human papillomavirus detected in viral warts of renal transplant recipients.

OBJECTIVES: Few studies have been conducted in South America regarding the detection and genotyping of human papillomavirus (HPV) in viral warts of renal transplant recipients (RTRs). The characterization of the population most susceptible to the development of warts and the knowledge of the main HPV types in this environment prompted this study, which focuses on the detection and typing of HPV in RTRs in Brazil. METHODS: Fifty-eight patients with viral warts from the Hospital São Paulo/Federal University of São Paulo were included in this study. HPV was detected by polymerase chain reaction (PCR) using combinations of the following primers: PGMY 09/11, RK 91, CP 65/70, and CP 66/69. Restriction fragment length polymorphism and automated sequencing techniques were used for HPV typing. RESULTS: HPV was detected by PCR in 89.7% of viral wart samples. The most frequently detected HPV types included 57, 27, 1a, 2a, and 20. Other types of HPV-epidermodysplasia verruciformis were also detected, including 14, 15, 19, 20, 21, 23, 36, and 38. Rare HPV types were also detected in our environment, including RTR X1, RTR X7, and 100. The time after transplant was correlated with an increased number of lesions and beta papillomavirus genus infection. CONCLUSIONS: The HPV types detected in the RTR population were similar to those described in immunocompetent populations. However, the diversity of the HPV types identified and the number of lesions were increased in the RTR population.

Environmental factors in benign migratory glossitis and psoriasis: retrospective study of the association of emotional stress and alcohol and tobacco consumption with benign migratory glossitis and cutaneous psoriasis.

BACKGROUND: The association between benign migratory glossitis (BMG) and psoriasis (PS) has been reported in the literature. OBJECTIVE: This study aimed to determinate the environmental factors related to BMG and PS and to investigate their interactions. METHODS: The study population included 129 patients with PS, 399 patients with BMG and a control group (CG) of 5472 individuals with neither PS nor BMG. The environmental factors evaluated in this study included alcohol and tobacco consumption and emotional stress. The Pearson's chi-squared test was used for analysing the association of the environmental factors with PS and BMG. RESULTS: The prevalence of alcohol consumption in the PS group was significantly higher than that in the CG. Tobacco consumption had a weak negative association with the BMG group. With respect to the PS group, no statistically significant association was observed. Emotional stress was the most important factor in the two study groups. Emotional stress and alcohol use together presented a higher incidence in the study groups than in the CG. Emotional stress and tobacco consumption together had a three times higher incidence in the PS group than in the BMG group. The association of emotional stress, alcohol and tobacco consumption in the PS group was four times higher than that in the CG. LIMITATIONS: This study was limited by the lack of the information about frequency, type and length time of use of tobacco and alcohol, and by difficult to measure stress thought self-report questionnaire. CONCLUSION: The interactions between PS and environmental factors differ from those between BMG and environmental factors. These differences among interactions may be responsible for different forms of manifestations of these diseases, considering being both the same disease.

Is lack of sleep capable of inducing DNA damage in aged skin?

Skin naturally changes with age, becoming more fragile. Various stimuli can alter skin integrity. The aim of this study was to evaluate whether sleep deprivation affects the integrity of DNA in skin and exacerbates the effects of aging. Fifteen-month old female Hairless mice underwent 72 h of paradoxical sleep deprivation or 15 days of chronic sleep restriction. Punch biopsies of the skin were taken to evaluate DNA damage by single cell gel (comet) assay. Neither paradoxical sleep deprivation nor sleep restriction increased genetic damage, measured by tail movement and tail intensity values. Taken together, the findings are consistent with the notion that aging overrides the effect of sleep loss on the genetic damage in elderly mice.

Clinical and histological features of leprosy and human immunodeficiency virus co-infection in Brazil.

BACKGROUND: Both leprosy and human immunodeficiency virus (HIV) are infectious diseases, and are an important global health problem. Patients with leprosy who are co-infected with HIV seem to be at higher risk of developing leprosy reactions. AIM: To examine the histological features of leprosy in patients with HIV and leprosy co-infection, particularly to determine whether the typical leprosy histopathology is present in skin biopsies, and to assess the histological features of leprosy reactions in co-infected patients. METHODS: This was a matched cohort study with 11 co-infected patients and 31 HIV-negative patients with leprosy. A structured protocol for skin-biopsy evaluation was followed, focusing on inflammation of the skin and dermal nerves. RESULTS: Of the 11 HIV-positive patients, 7 (63%) had borderline tuberculoid (BT) leprosy and 5 (70%) of these 7 patients had developed a type 1 reaction. The lesions in these patients were immunologically active, with 100% of biopsies having evidence of compact granulomas, 90% evidence of oedema and 30% evidence of necrosis. CONCLUSIONS: In this study, patients co-infected with HIV and M. leprae had the typical histological lesions of leprosy. There was evidence of immune activation in patients who received combination antiretroviral therapy, and these patients had BT leprosy and leprosy-upgrading reactions.

HLA alleles in Brazilian patients with fissured tongue.

BACKGROUND: Fissured tongue (FT) is a clinical condition manifested by numerous little furrows on the tongue's surface. Previously, the authors observed an association with HLA-C×06 in psoriasis (PS) and benign migratory glossitis (BMG); however, HLA-C was not surveyed in FT. OBJECTIVE: This study investigated the association between HLA alleles and FT. METHODS: Thirty-three FT bearers were studied, after evaluation of criteria for inclusion. These patients did not present PS, BMG or any other conditions associated with FT. The control group (CG) was composed of 561 individuals with HLA-A, 560 individuals with HLA-B, 168 individuals with HLA-C, 564 individuals with HLA-DRB1 and 390 individuals with HLA-DQB1. Samples from these individuals were processed to extract DNA. The HLA classes I and II were determined using the reverse line blot technique. The frequencies of HLA antigens found in patients were compared with the CG using Fisher's exact test. RESULTS: The comparison of the frequencies of HLA antigens found in the patient groups and in CG revealed no association with any of the alleles studied, except for HLA-A*01, which exhibited a decreased frequency in patient groups. HLA-C*06 was detected in 7.57% of FT patients and 10.42% of the CG (not significant). CONCLUSION: The lack of association of FT with HLA-C*06 reinforces the proposal that this disease does not have a common genetic factor in the triad of BMG, FT and PS.

Can morphine interfere in the healing process during chronic stress?

Technological advances, constant pressure, increased qualified demand, and other daily activities present in modern society result in increasingly stressful living conditions for the population. In the short term, the release of stress-related hormones can play a key role in the survival of an organism. However, it is well known that chronic exposure to cortisol can lead to many adverse effects. Several findings show immunological changes in response to chronic exposure to cortisol, in particular in skin integrity, which may interfere with the healing process. Morphine is an immunosuppressive drug, and when it is used chronically, it can lead to an increased incidence of infections and a delay in the healing process. The importance of opiates as analgesics in the medical setting is indisputable. However, there are a limited number of studies in this field. These investigations can provide further understanding of the mechanisms involved in the healing process in morphine-dependent individuals under chronic stress, which is a common condition in modern society. Furthermore, medical prescriptions of opiates are common among terminal patients, who frequently develop decubitus ulcers and bacterial infections. This review is aimed to provide a concise analysis of effects of morphine and stress on the healing process.

Does sleep deprivation and morphine influence wound healing?

The contrast between present-day sleep habits and those of the pre-industrial era are quite evident. One study recent has shown that the amount of sleep has decreased 2 h per night over the past 50 years. Such sleep curtailment, ubiquitous in the modern lifestyle, inflicts adverse repercussions upon health and well being. Investigations examining the relationship between stress and the skin have shown that different types of stress affect the healing process. Morphine is an immunosuppressive drug, and when it is used chronically, it can lead to an increased incidence of infections and a delay in the healing process. Therefore, our hypothesis is that the lack of sleep associated with chronic treatment with morphine is detrimental to the healing of the skin in the animal model we have adopted. Thus, it is important that future studies consider the paradigm of sleep curtailment when investigating the mechanisms involved in the process of skin healing in individuals who are dependent on morphine.

Can poor sleep affect skin integrity?

Modern society has reported a decline in sleep time in the recent decades. This reduction can increase the morbidity and mortality of several diseases and leads to an immunosuppressive state. The skin is the largest organ in the human body and collagen, its main component, has a key role in the structure and integrity of the organism. The entire sequence of events necessary during collagen formation can be affected by endogenous and exogenous factors. A variety of studies in the literature have shown that sleep plays a role in restoring immune system function and that changes in the immune response may affect collagen production. Several studies of prolonged sleep deprivation suggest a break in skin barrier function and mucous membranes. In fact, the reduction of sleep time affects the composition and integrity of various systems. Thus, we hypothesized that lack of sleep as well as other types of stress can impair skin integrity.

Stress, immunity and skin collagen integrity: evidence from animal models and clinical conditions.

The skin is the largest organ of the human body and plays a major role in maintaining homeostasis and protection. As the main component of skin, collagen has a key role in providing integrity and elasticity to this organ. Several factors, including autoimmune disease, aging, and stress, can change the quantity and integrity of skin collagen. These factors impair collagen quality and consequently affect skin function. Stress seems to affect the integrity of skin collagen through glucocorticoid-mediated processes that alter its synthesis and degradation. Glucocorticoids also affect skin quality through modulation of the immune system. This review will briefly present comprehensive data from both animal and human studies delineating processes that modulate alterations in collagen in general, and will treat in more detail the consequences of stress on skin collagen.