[Cutaneous Manifestations during Pregnancy]. / Manifestações Dermatológicas na Gravidez.

Pregnancy is a period characterized by complex and significant skin changes, which can have a major impact on a woman's life. The cutaneous manifestations associated with this period are usually divided into physiological changes related with pregnancy, pre-existing dermatoses modified by pregnancy, and pregnancy-specific dermatoses, with the latter being potentially associated with significant fetal morbidity. The diagnosis of dermatoses of pregnancy can be challenging due to the variability in its clinical presentation; therefore, a complete and detailed clinical history and a thorough physical examination are essential. Primary care clinicians should be able to recognize these entities and provide some therapeutic strategies, as well as to refer patients whenever there is a risk to the mother and/ or to the fetus. A multidisciplinary team is essential in the evaluation of the most complex entities, and should include dermatologists, pediatricians, obstetricians and family physicians, so that both the mother's symptomatic relief and the minimization of fetal risk can be achieved quick and concurrently.

A gravidez é um período caracterizado por alterações cutâneas significativas e complexas, as quais podem ter um grande impacto na vida da mulher. As manifestações cutâneas associadas a este período dividem-se habitualmente em alterações fisiológicas relacionadas com a gravidez, dermatoses pré-existentes modificadas pela gravidez e dermatoses específicas da gravidez, podendo estas últimas estar associadas a morbidade fetal significativa. O diagnóstico das alterações cutâneas associadas à gravidez pode constituir um desafio devido à variabilidade na sua apresentação clínica, sendo fundamental uma história clínica completa e detalhada e um exame físico minucioso. Os clínicos dedicados aos cuidados de saúde primários devem saber reconhecer estas entidades e providenciar algumas estratégias terapêuticas, bem como referenciar as utentes sempre que exista risco para a mãe e/ou para o feto. Na abordagem das entidades mais complexas é fundamental uma equipa multidisciplinar, envolvendo dermatologistas, pediatras, obstetras e médicos de família, de forma a que se consiga simultânea e rapidamente o alívio sintomático da mãe e a minimização do risco fetal.

Reasons for inpatient dermatological consultation requested by other specialities: a five-year data analysis of 1,052 patients from a Portuguese tertiary teaching hospital

Background: The involvement of a dermatologist in inpatient care can result in accurate diagnosis and prescription of appropriate treatment more promptly. Objectives: We aimed to analyse the main reasons for dermatological inpatient consultation in a tertiary centre. Materials & Methods: A retrospective analysis was performed based on clinical registries that included inpatients observed in emergency dermatology consultation between January 1st 2016 to December 31st 2020 at the Hospital de Santa Maria, a tertiary teaching hospital in Lisbon, Portugal. Results: In our dermatology emergency department, we performed 1,052 inpatient consultations during this five-year period. The most frequent diagnostic groups were infections and parasitic diseases (31.1%), inflammatory skin disorders (18.1%) and reactive erythemas (17.7%). Requests were most commonly (85.1%) made by medical specialities. Conclusion: Inpatient dermatological consultations grant access to expert management of drug-induced dermatoses, flares of chronic skin diseases, skin manifestations of systemic diseases and cutaneous infections. Prompt dermatological evaluation is essential for early diagnosis, thus enabling a better prognosis.

Cutaneous Markers of Cardiovascular Diseases.

Cardiovascular diseases are one of the most important global medical challenges because of their high rates of morbidity and mortality. In this narrative review, the authors address the most important dermatologic signs that can be present in patients with cardiovascular disease. The early recognition of these underestimated entities is very important as it may lead to an early diagnosis and timely treatment, thus lessening the effects of long-term disease and possibly improving the prognosis.

As doenças cardiovasculares são um dos desafios médicos mais importantes a nível mundial devido às suas elevadas taxas de morbilidade e mortalidade. Neste artigo, é feita uma revisão das manifestações cutâneas mais importantes que poderão estar presentes em doentes com doenças cardiovasculares. O reconhecimento atempado destas entidades clínicas é fulcral, uma vez que permite um diagnóstico e tratamento precoces, minimizando os efeitos destas doenças a longo prazo e possivelmente melhorando o prognóstico destes doentes.

Emerging treatments for bullous pemphigoid.

Bullous pemphigoid (BP) is the most common autoimmune blistering disease. It is characterized by an immune response against the hemidesmosomal anchoring proteins BP180 and BP230. BP mainly affects elderly patients, with an increasing incidence over the past two decades. High potency topical and/or systemic corticosteroids as well as immunosuppressants are the current mainstay of treatment. However, long-term systemic immunosuppression may result in significant morbidity and mortality. Recent advances in the understanding of the pathogenesis of BP have enabled the investigation of newer therapies that specifically work against a variety of pro-inflammatory mediators associated with BP. These new treatments hold promise to be highly efficient and safer alternatives and are expected to be shortly available for the treatment of BP. This review discusses current evidence on the use of novel targeted therapeutic approaches in the treatment of BP.

Nail Surgery: General Principles, Fundamental Techniques, and Practical Applications.

Despite being an integral part of dermatologic surgery, nail surgery is infrequently performed in daily practice. Indeed, it is frequently considered difficult, time-consuming, and the results take a long time to be observed. Nonetheless, nail pathology is a frequent cause of dermatology consultation, so dermatologists should be familiar with its diagnosis and therapeutic approach, which often involves surgical procedures. This article provides a review of nail surgery, focusing on the anatomy of this region, anesthesia of the ungual apparatus, common surgical techniques, reconstruction of defects in these locations, and a general approach to the most frequently encountered conditions in clinical practice.

Cutaneous leiomyosarcoma: a 20-year retrospective study and review of the literature

Abstract Background: Cutaneous leiomyosarcoma is a rare malignant neoplasm with muscular origin, representing 2%-3% of all cutaneous soft tissue sarcomas. Objectives: The aim of this study was to characterize clinicopathological features of patients diagnosed with cutaneous leiomyosarcoma in our center over the last 20-years. Methods: A retrospective study of patients with a histopathological diagnosis of leiomyosarcoma between 1999 and 2018 was conducted. Results: Eleven patients were diagnosed with cutaneous leiomyosarcoma during this period. Most cases occurred in men (n = 7). Age at presentation ranged from 47 to 92 years (mean 64.9 years). Head and neck were the most frequently involved locations (n = 5). Ten leiomyosarcoma were dermal, with one cutaneous metastasis. Immunohistochemical staining was available for 7 patients, demonstrating positivity for smooth muscle actin in all of them. All neoplasms were treated surgically. Mean survival was 32.2-months. Study limitations: This was a retrospective study based on medical and pathological records. Conclusions: Histopathology is essential for the diagnosis of leiomyosarcoma, usually revealing a dermal or subcutaneous lesion composed of intertwined fascicles of smooth muscle fibers. Immunohistochemistry is then used to adequately differentiate leiomyosarcoma from other spindle cell tumors. When dealing with cutaneous leiomyosarcoma, it is advisable to carefully evaluate the depth of subcutaneous extension, since even minimal subcutaneous involvement may be associated with a poorer prognosis.

Cutaneous leiomyosarcoma: a 20-year retrospective study and review of the literature.

BACKGROUND: Cutaneous leiomyosarcoma is a rare malignant neoplasm with muscular origin, representing 2%-3% of all cutaneous soft tissue sarcomas. OBJECTIVES: The aim of this study was to characterize clinicopathological features of patients diagnosed with cutaneous leiomyosarcoma in our center over the last 20-years. METHODS: A retrospective study of patients with a histopathological diagnosis of leiomyosarcoma between 1999 and 2018 was conducted. RESULTS: Eleven patients were diagnosed with cutaneous leiomyosarcoma during this period. Most cases occurred in men (n = 7). Age at presentation ranged from 47 to 92 years (mean 64.9 years). Head and neck were the most frequently involved locations (n = 5). Ten leiomyosarcoma were dermal, with one cutaneous metastasis. Immunohistochemical staining was available for 7 patients, demonstrating positivity for smooth muscle actin in all of them. All neoplasms were treated surgically. Mean survival was 32.2-months. STUDY LIMITATIONS: This was a retrospective study based on medical and pathological records. CONCLUSIONS: Histopathology is essential for the diagnosis of leiomyosarcoma, usually revealing a dermal or subcutaneous lesion composed of intertwined fascicles of smooth muscle fibers. Immunohistochemistry is then used to adequately differentiate leiomyosarcoma from other spindle cell tumors. When dealing with cutaneous leiomyosarcoma, it is advisable to carefully evaluate the depth of subcutaneous extension, since even minimal subcutaneous involvement may be associated with a poorer prognosis.

Spitz nevus and infliximab: association or coincidence?

Abstract Biological therapies, including anti-TNF agents, are important in the treatment of various chronic inflammatory diseases, including psoriasis, rheumatoid arthritis or inflammatory bowel disease. The increased use of these drugs translates into an increasing awareness of its adverse effects, which include malignancy. In this paper, we describe the case of a 28-year-old woman who developed a spitzoid melanocytic tumor after starting infliximab therapy for ulcerative colitis. The evidence for causality between anti-TNF and melanocytic proliferations is still sparse; nonetheless, treatment-associated immunosuppression seems to play a key role in this phenomenon. Therefore, a regular follow-up with a rigorous skin examination is essential in these patients. Noninvasive techniques such as dermoscopy or reflectance confocal microscopy are particularly useful diagnostic tools in these circumstances.

Spitz nevus and infliximab: association or coincidence?

Biological therapies, including anti-TNF agents, are important in the treatment of various chronic inflammatory diseases, including psoriasis, rheumatoid arthritis or inflammatory bowel disease. The increased use of these drugs translates into an increasing awareness of its adverse effects, which include malignancy. In this paper, we describe the case of a 28-year-old woman who developed a spitzoid melanocytic tumor after starting infliximab therapy for ulcerative colitis. The evidence for causality between anti-TNF and melanocytic proliferations is still sparse; nonetheless, treatment-associated immunosuppression seems to play a key role in this phenomenon. Therefore, a regular follow-up with a rigorous skin examination is essential in these patients. Noninvasive techniques such as dermoscopy or reflectance confocal microscopy are particularly useful diagnostic tools in these circumstances.

Photodynamic therapy in dermatology: Beyond current indications.

Photodynamic therapy (PDT) has long been used in dermatology as a therapeutic strategy for several malignant and premalignant conditions. Currently, it is approved in Europe for the treatment of actinic keratosis, squamous cell carcinoma in situ, and some forms of basal cell carcinoma, with favorable clearance rates associated with satisfying aesthetic results. Nonetheless, in the past few years, PDT has also demonstrated efficacy in many other conditions, including inflammatory and infectious dermatoses. These results, probably explained by its immunomodulatory, anti-inflammatory, and bactericidal effects, may lead to an expansion of PDT indications in the upcoming years. In this article, conditions where PDT may be useful are reviewed, thus highlighting the potential of this therapeutic modality for the dermatologist.

Granulomatous Skin Diseases in a Tertiary Care Portuguese Hospital: A 10-Year Retrospective Study.

Granulomatous skin diseases comprise an extensive group of pathologies whose diagnosis usually requires a histopathological examination. At this level, various types of granulomas can be distinguished, namely tuberculoid, sarcoid, necrobiotic, suppurative, xanthogranuloma, and foreign-body granulomas. This study aimed to determine the frequency and pattern of different granulomatous skin lesions in the Dermatopathology Department of Hospital de Santa Maria (Lisboa, Portugal). A retrospective study of all skin biopsies with granulomatous lesions received during a period of 10 years (2008-2017) was performed. Clinical and histopathological characteristics of the selected cases were analyzed, and the lesions were categorized according to histological type of granuloma and etiology. Foreign-body granulomas secondary to ruptured cyst, folliculitis, or suture material were excluded. From a total of 48,253 cutaneous biopsies performed in this period, 461 (1%) granulomatous lesions were included in our study. In the analysis according to type of granuloma, necrobiotic granulomas were the most frequent (N = 111; 27.0%), followed by sarcoidal (N = 72; 17.5%), tuberculoid (N = 51; 12.4%), suppurative (N = 45; 10.9%), foreign body (N = 40; 9.7%), and xanthogranulomas (N = 26; 6.3%). The remaining 20% corresponded to granulomas of other types. During these 10 years, the most frequent etiology was granuloma annulare (N = 98; 88.3%), followed by sarcoidosis (N = 47; 65.3%). Histopathology is a fundamental tool in the diagnosis of granulomatous skin diseases, allowing for the categorization of various types of granulomas and often guiding further investigation of these patients. The geographical area has an influence on the types of granulomas observed, as evidenced by comparing this study with others previously published.

Acquired perforating dermatosis: clinicopathologic study of a 10-year period at a tertiary teaching hospital.

BACKGROUND: Acquired perforating dermatosis (APD) comprises an uncommon group of skin disorders that develop in adulthood in association with systemic diseases. The aim of this study was to characterize clinicopathologic features and treatment outcomes in a series of patients diagnosed with APD. METHODS: Retrospective study of all patients diagnosed with an APD over a 10-year period (2009-2018) at a tertiary teaching hospital in Lisbon, Portugal. RESULTS: Fifty-seven patients with APD were identified. Thirty-five patients presented lesions in multiple anatomic areas (61.4%), and the lower limbs were the most common location. Forty-six patients reported pruritus (80.7%), which was classified as severe in 21 of them (36.8%). An underlying systemic disease was identified in 53 patients (93.0%). Diabetes mellitus (DM) and chronic kidney disease (CKD) were the most common associated systemic diseases, but psychiatric disorders, malignancies, and chronic infections were present in a significant number of patients. The combination of topical steroids with antihistamines was the most prescribed initial treatment, but only 37.8% of the patients had a complete response. Acitretin, systemic steroids, and phototherapy were the treatments associated with the best outcome. CONCLUSION: Acquired perforating dermatosis can be associated with many systemic disorders that have pruritus as a common factor. Chronic viral infections and an occult malignancy should be sought, particularly in the absence of DM and CKD. The management of APD is challenging and is best achieved with the control of the underlying systemic diseases.

Oral Transmission of Sexually Transmissable Infections: A Narrative Review.

Over the last few decades, behavioral changes in sexual practices have made oral transmission of traditional sexually transmissible infections increasingly recognized. Patients harboring a sexually transmissible infection may first present lesions on the oral cavity, as these may be visible and interfere with basic functions such as speech or swallowing. Moreover, the oral cavity may function as a reservoir for future spread of these infections. In order to successfully control this problem, a greater focus on oral sex should be persued, along with promotion of the use of condom and education on safe oral sex practices. Furthermore, examination of the oral cavity should is essential when evaluating any patient suspected of harboring a sexually transmissible infection. In this article, oral transmission of several viral and bacterial infections is reviewed, including human papillomavirus infection, genital herpes, syphilis and gonorrhea, among others.

Com as alterações comportamentais nas práticas sexuais verificadas nas últimas décadas, a transmissão oral de infeções sexualmente transmissíveis tem vindo a ser progressivamente mais reconhecida. As lesões na cavidade oral podem ser visíveis ou interferir com funções básicas como a fala ou deglutição, sendo por isso o motivo de apresentação de muitos destes doentes. Além disso, a cavidade oral pode funcionar como um reservatório para a disseminação futura dessas infecções. Para um controlo adequado deste problema, deve ser prestada uma maior atenção às práticas de sexo oral, à promoção do uso do preservativo e à educação relativamente a práticas sexuais seguras. Por outro lado, o exame da cavidade oral deve ser parte integrante da avaliação de qualquer indivíduo com suspeita de uma infecção sexualmente transmissível. Neste artigo, a transmissão oral de várias infeções virais e bacterianas é revista, nomeadamente a infeção pelo vírus do papiloma humano, herpes genital, sífilis e gonorreia, entre outras.

Sun Exposure: Beyond the Risks.

Excessive solar exposure presents well-recognized risks and side effects, solar radiation being the most important environmental factor concerning skin cancer. In the last few years, several connections between solar exposure and prevention and/or treatment of several diseases have been discussed, with studies suggesting that regular solar exposure may be beneficial for conditions such as colorectal, breast, prostate, and pancreatic cancer; non-Hodgkin lymphoma; arterial hypertension; obesity; type 2 diabetes mellitus and metabolic syndrome; nonalcoholic hepatic steatosis; multiple sclerosis; Alzheimer disease; and several psychiatric disturbances. In most cases, UV radiation's beneficial effects are mediated through vitamin D; however, studies show that in other instances other mediators are responsible for these associations, specifically nitric oxide. Moderation is therefore essential, as a strict strategy of total sun avoidance may be inadequate.

Multiple eruptive dermatofibromas associated with pregnancy- a case and literature review.

Dermatofibromas are common and asymptomatic benign histiocytic tumors. The occurrence in a small number (up to 5 lesions) is frequent. However, the expression "multiple eruptive dermatofibromas" is reserved for the appearance of more than 5 lesions in less than four months. Multiple eruptive dermatofibromas are rare and usually associated with an underlying systemic condition, the most common being autoimmune diseases or HIV infection. Herein we report multiple eruptive dermatofibromas developing in an otherwise healthy pregnant woman. Although the pathogenesis of this condition remains unknown, it is believed to be related to immunological alterations, given the strong association with states of immunosuppression or, in the case of pregnancy, with a state of immunotolerance.

Methemoglobinemia After Paracetamol Ingestion: A Case Report.

Methemoglobinemia is a potentially fatal condition, mainly acquired after intoxication by certain drugs. To this date, only three cases associated with paracetamol have been reported. This case report describes a patient with autosomal dominant polycystic kidney disease undergoing hemodialysis who was self-medicated with acetaminophen for seven days (at a daily dose of 3 g); the patient went to the hospital after noticing the appearance of a diffuse brownish skin tone, without other symptoms. Arterial blood analysis revealed an increase in methemoglobin levels, with biochemistry showing an increase in total bilirubin and alanine aminotransferase. Paracetamol was discontinued and on reassessment nine days after the onset of symptoms the patient had a clear improvement in her skin color, with normalization of methemoglobin levels.

A metemoglobinemia é uma condição potencialmente fatal, maioritariamente adquirida após intoxicação por determinados fármacos; até à data estão relatados apenas três casos associados à toma de paracetamol. Este caso clínico descreve uma doente com doença renal poliquística autossómica dominante, sob hemodiálise, que se automedicou com paracetamol durante sete dias (numa dose diária de 3 g); a doente recorreu ao hospital após ter notado o aparecimento de uma tonalidade cutânea difusamente acastanhada, sem outros sintomas. A análise de sangue arterial revelou aumento da metemoglobina, tendo a bioquímica apresentado um aumento da bilirrubina total e da aminotransferase da alanina. A toma de paracetamol foi suspensa, e na reavaliação nove dias após o início dos sintomas a doente apresentava uma clara melhoria da cor da pele, com normalização dos valores de metemoglobina.

Platypnea-Orthodeoxia Syndrome After Complicated Cholecystectomy: An Unsuspected Diagnosis.

A 65-year-old woman with no significant prior medical history presented, in the postoperative course of a complicated cholecystectomy, several episodes of arterial desaturation. Pulmonary embolism was repeatedly suspected, but there was no evidence of pulmonary thrombus on the chest computed tomography angiographies obtained. As these episodes were mainly induced by postural changes, a platypnea-orthodeoxia syndrome was suspected. A transthoracic echocardiogram was performed and revealed a patent foramen ovale. A transesophageal echocardiography confirmed the presence of a significant right-to-left shunt exacerbated by the Valsalva manouver. The defect was repaired using a percutaneous transcatheter technique with complete resolution of the condition.

Doente do sexo feminino, 65 anos de idade, sem antecedentes pessoais relevantes, apresentou no pós-operatório de uma colecistectomia complicada diversos episódios de dessaturação arterial. Suspeitou-se repetidamente de tromboembolismo pulmonar, no entanto as diversas angio-tomografias computorizadas obtidas nunca revelaram a presença de trombos no leito vascular pulmonar. Atendendo a que os episódios de dessaturação eram maioritariamente despoletados por alterações posturais, foi levantada a hipótese de se tratar de uma síndrome de platipneia-ortodeoxia. Foi realizado ecocardiograma transtorácico, que revelou um foramen oval patente; o ecocardiograma transesofágico confirmou a presença de um shunt direito-esquerdo significativo, exacerbado pela manobra de Valsalva. O defeito foi reparado através de uma técnica transcatéter, com resolução completa do quadro clínico.