Inpatient dermatological consultations in a university hospital

INTRODUCTION: Dermatology is primarily an outpatient specialty, but it also plays an important role in the care of inpatients. METHODS: We conducted a prospective study that recorded data from inpatient dermatology consultation request forms over a period of four months. The study evaluated 313 requests that led to 566 visits, 86 biopsies, 35 laboratory exams, 41 direct microscopic studies, 18 direct immunofluorescence analyses, 14 skin cultures and a few other exams. RESULTS: The most frequent requesting service was internal medicine (24%), followed by neurology (12%), cardiology (11%), infectious diseases and pediatrics (8% each) and psychiatry and general surgery (6% each). The most frequent diagnostic groups were infectious diseases (25%, divided into fungal infections (13%), bacterial infections (7%) and viral infections (5%)), eczemas (15%) and drug reactions (14%). To our knowledge, this is the first study to attempt to evaluate the impact of the consultations by asking multiple-choice questions that were analyzed by the authors. In 31% of the cases, the consultation was considered extremely relevant because it aided in managing the disease that led to admission or treated a potentially severe dermatological disease. In 58% of the cases, the consultation was considered important because it facilitated diagnosis and/or treatment of a dermatological disease that was unrelated to the reason for admission

Photodynamic therapy in dermatology: basic principles

A terapia fotodinâmica envolve a administração de uma droga fotossensibilizante e sua ativação subsequente pela luz de comprimento de onda correspondente ao espectro de absorção do fotossensibilizador. Atualmente, a terapia fotodinâmica tópica é aprovada para o tratamento de condições oncológicas cutâneas como queratoses actínicas, doença de Bowen e carcinoma basocelular superficial em diversos países do mundo. Estudos multicêntricos controlados e randomizados demonstram a alta eficácia e resultado cosmético final superior dessa modalidade terapêutica em relação aos tratamentos convencionais. Para condições cutâneas não oncológicas, como acne vulgar, verrugas virais e esclerodermia localizada, há também relatos e série de casos confirmando o potencial terapêutico da terapia fotodinâmica. O desenvolvimento de fotossensibilizantes tópicos, ácido 5-aminolevulínico (ALA) ou seu metiléster (MAL), frente aos derivados da hematoporfirina de aplicação sistêmica, permitiu um grande avanço na popularidade da TFD na dermatologia, uma vez que tanto ALA quanto MAL tópicos não induzem mais fotossensibilidade generalizada prolongada. A produção de intermediários reativos de oxigênio, como oxigênio singlet, depende da concentração, da localização do fotossensibilizante no tecido alvo, assim como da dose de luz utilizada. Tanto as lâmpadas de amplo espectro quanto os LEDs (do inglês light emitting diodes) constituem fontes de luz adequadas para que os efeitos citotóxicos da terapia fotodinâmica resultem na destruição do tumor ou seus efeitos imunomodulatórios atuem melhorando as condições inflamatórias cutâneas.Photodynamic therapy involves the administration of a photosensitizing drug and its subsequent activation by light at wavelengths matching the absorption spectrum of the photosensitizer. Currently, topical photodynamic therapy has received approval for the treatment of cutaneous oncologic conditions such as actinic keratoses, Bowen’s disease and superficial basal cell carcinoma in many countries in the world. Multicenter randomized controlled studies have demonstrated high efficacy and superior cosmetic outcome over standard therapies. For many non-oncologic dermatological diseases such as acne vulgaris, viral warts and localized scleroderma, case reports and small series have confirmed the potential of photodynamic therapy. After the development of topical photosensitizers 5-aminolevulinic acid (ALA) or its methyl ester (MAL), photodynamic therapy has gained worldwide popularity in dermatology, as these drugs do not induce prolonged phototoxicity as the systemic photosensitizing hematoporphyrin derivatives do. The production of reactive oxygen intermediates such as singlet oxygen depends on the concentration and localization of the photosensitizer in the diseased tissue as well as the applied light dose. Either incoherent lamps or LED arrays are suitable for the cytotoxic effects resulting in tumor destruction or immunomodulatory effects improving inflammatory condition

Predictors of higher number of stages in Mohs micrographic surgery for the treatment of squamous cell carcinoma of the head

FUNDAMENTOS: Os carcinomas espinocelulares da pele da cabeça têm como opção terapêutica mais segura a cirurgia micrográfica de Mohs, que apresenta os menores índices de recidiva e a máxima preservação tecidual. Características dos carcinomas espinocelulares podem estar relacionadas a maior número de estádios cirúrgicos. OBJETIVO: Definir características dos carcinomas espinocelulares que sejam preditoras de maior número de estádios na cirurgia de Mohs. MÉTODOS: Análise retrospectiva de 51 carcinomas espinocelulares da cabeça tratados pela cirurgia de Mohs para determinar fatores de risco de maior número de estádios. Foram analisados limites clínicos, morfologia, recidiva, histologia e tamanho, relacionando-os ao número de estádios cirúrgicos. A análise estatística foi realizada pelo teste exato de Fisher e regressão logística multivariada. RESULTADOS: Os carcinomas recidivados tiveram tendência a maior número de estádios (p=0,081). Os tumores com limites imprecisos apresentaram três vezes mais possibilidades de maior número de fases na análise da razão de chances. Esse achado foi compatível com dados da literatura, apesar de não ter sido estatisticamente significante. CONCLUSÃO: Características pré-operatórias dos carcinomas espinocelulares, como recidiva e limites imprecisos, apesar de não preditivas, indicaram tendência a maior número de estádios na cirurgia micrográfica de Mohs.BACKGROUND: Squamous cell carcinomas of the skin of the head are better treated with Mohs micrographic surgery which has the lowest recurrence rates and allows spare normal tissue. There are some characteristics of squamous cell carcinoma that can be related to a higher number of surgical stages. OBJECTIVE: To study characteristic of head squamous cell carcinoma that predicts a higher number of Mohs surgical stages. METHODS: A retrospective analysis of 51 squamous cell carcinomas of the head treated with Mohs surgery was performed to determine risk factors for a higher number of surgical stages. The characteristics analyzed were clinical limits, morphology, recurrence, histological differentiation and size and compared to the number of surgical stages. The analysis was performed by Fisher's exact test and multivariate logistic regression. RESULTS: The recurrent squamous cell carcinomas showed a tendency for a higher number of stages (p=0,081). The Odds Ratio for a higher number of Mohs stages was three for inaccurate limits; although not statistically significant,it corroborates clinical and previous publication. CONCLUSION: Clinical characteristics of squamous cell carcinoma as recurrence and inaccurate limits would not predict, but could indicate tendency of a higher number of Mohs micrographic surgery stages

Genomic instability in human actinic keratosis and squamous cell carcinoma

OBJECTIVE: To compare the repetitive DNA patterns of human actinic keratoses and squamous cell carcinomas to determine the genetic alterations that are associated with malignant transformation. INTRODUCTION: Cancer cells are prone to genomic instability, which is often due to DNA polymerase slippage during the replication of repetitive DNA and to mutations in the DNA repair genes. The progression of benign actinic keratoses to malignant squamous cell carcinomas has been proposed by several authors. MATERIAL AND METHODS: Eight actinic keratoses and 24 squamous cell carcinomas (SCC), which were pair-matched to adjacent skin tissues and/or leucocytes, were studied. The presence of microsatellite instability (MSI) and the loss of heterozygosity (LOH) in chromosomes 6 and 9 were investigated using nine PCR primer pairs. Random Amplified Polymorphic DNA patterns were also evaluated using eight primers. RESULTS: MSI was detected in two (D6S251, D9S50) of the eight actinic keratosis patients. Among the 8 patients who had squamous cell carcinoma-I and provided informative results, a single patient exhibited two LOH (D6S251, D9S287) and two instances of MSI (D9S180, D9S280). Two LOH and one example of MSI (D6S251) were detected in three out of the 10 patients with squamous cell carcinoma-II. Among the four patients with squamous cell carcinoma-III, one patient displayed three MSIs (D6S251, D6S252, and D9S180) and another patient exhibited an MSI (D9S280). The altered random amplified polymorphic DNA ranged from 70% actinic keratoses, 76% squamous cell carcinoma-I, and 90% squamous cell carcinoma-II, to 100% squamous cell carcinoma-III. DISCUSSION: The increased levels of alterations in the microsatellites, particularly in D6S251, and the random amplified polymorphic DNA fingerprints were statistically significant in squamous cell carcinomas, compared with actinic keratoses. CONCLUSION: The overall alterations that were observed in the repetitive DNA of actinic keratoses and squamous cell carcinomas indicate the presence of a spectrum of malignant progression

Data on inflammasome gene polymorphisms of patients with sporadic malignant melanoma in a Brazilian cohort

AbstractThis article presents data related to our another article entitled, Genotyping and differential expression analysis of inflammasome genes in sporadic malignant melanoma reveal novel contribution of CARD8, IL1B and IL18 in melanoma susceptibility and progression (W.C. Silva, T.M. Oshiro, D.C. Sá, D.D.G.S. Franco, C. Festa Neto, A. Pontillo, 2016) [2]. Data presented here refers to the distribution of selected inflammasome SNPs in a Brazilian case/control cohort. We have identified 4 inflammasome related Single Nucleotide Polymorphisms (SNPs) for CARD8 (rs6509365); IL1B (rs1143643) and IL18 (rs5744256 and rs1834481) related to melanoma susceptibility/protection. This data can serve as a potential prognostic marker in sporadic malignant melanoma

Treatment of Cutaneous Tumors with Topical 5% Imiquimod Cream

INTRODUCTION: There are various approaches to the treatment of cutaneous tumors; one of them is treatment with imiquimod, a synthetic toll-like receptor agonist with a low molecular weight that offers a topical, noninvasive, and non-surgical therapeutic option. The main objective of our study was to provide data on 89 patients who used a 5% imiquimod cream for the treatment of cutaneous tumors at the Cutaneous Oncology Group of the Dermatology Department of Hospital das Clinicas from 2003 to 2008. MATERIALS AND METHODS: Here, we present our experience in the treatment of 123 cutaneous tumors of various types, including basal cell carcinoma (BCC), squamous cell carcinoma (SCC), Bowen's disease, erythroplasia of Queyrat, Paget's disease, and trichoepithelioma, with 5% imiquimod cream from 2003 to 2008 in the Cutaneous Oncology Group of the Dermatology Department of Hospital das Clinicas. Patients were divided into two separate groups according to their diagnosis and comorbidities; these comorbidities included epidermodysplasia verruciformis, xeroderma pigmentosum, albinism, basal cell nevus syndrome, Brooke-Spiegler syndrome, HIV, chronic lymphocytic leukemia, B-cell lymphoma, and kidney transplantation. Treatment duration, response to imiquimod, follow-up, recurrence, and local and systemic reactions associated with use of the drug were analyzed. Epidemiological data were obtained and cure rates were calculated. RESULTS: The ratio of women to men was 1.28:1, and the mean age was 63.1 years. Tumors were located mainly on the face, back, trunk, and legs. For patients with comorbidities, the overall cure rate was 38%. These specific patients demonstrated cure rates of 83.5% for superficial BCC and 50% for Bowen's disease. Aggressive BCC and superficial and nodular BCC did not present a good response to treatment. Trichoepitheliomas and nodular BCC showed a partial response, and erythroplasia of Queyrat showed a complete response. For patients without comorbidities, the overall cure rate was 73%. For these patients, the cure rates were 85.7% for superficial and nodular BCC, 88% for superficial BCC, 57% for Bowen's disease, 50% for nodular BCC, and 50% for aggressive BCC. One SCC lesion demonstrated a complete response, and tumors caused by Paget's disease and erythroplasia of Queyrat presented a partial response. None of the tumors considered as clinically cured recurred. Thirty-seven lesions demonstrated no response to imiquimod. Having a cutaneous comorbidity, high-risk tumors such as mixed aggressive BCC (sclerodermiform or micronodular), nodular BCC, or Bowen's disease, and presenting no local reaction to imiquimod were considered as risk factors for a worse prognosis. We demonstrate that patients with no response to imiquimod, even when they demonstrated no local reaction, can undergo another cycle of six weeks of imiquimod treatment and show a complete response. The healing pattern led to good cosmetic outcomes, and the side effects were tolerable. CONCLUSIONS: Our experience confirms imiquimod as an effective treatment option for several types of cutaneous tumors, especially in patients without the cutaneous comorbidities cited above and with low-risk tumors. Imiquimod has a relatively low cost compared to other therapeutic options and can be delivered via ambulatory care to patients with surgery contraindications, and its side effects are tolerable

Eritema necrolítico migratório associado à síndrome glucagonoma: descrição de um caso

Necrolytic migratory erythema is a rare skin condition that consists of migrating areas of erythema with blisters that heal with hyperpigmentation. It usually occurs in patients with an alpha islet cell tumor of the pancreas-or glucagonoma-and when associated with glucose intolerance, anemia, hyperglucagonemia, and weight loss defines the glucagonoma syndrome. We describe a 52-year-old female patient with necrolytic migratory erythema associated with glucagonoma syndrome who had metastatic disease at presentation and passed away one week after her admission. The autopsy showed a tumor in the body of the pancreas, which was diagnosed as a neuroendocrine tumor and confirmed by immunohistochemistry. The diagnosis of necrolytic migratory erythema is a matter of great importance, since it might be an auxiliary tool for the early detection of glucagonoma.O eritema necrolítico migratório é uma rara condição cutânea que se apresenta como lesões eritematosas, migratórias, com vesículas e bolhas na superfície, evoluindo para cura com hiperpigmentação. É freqüentemente observado em doentes com tumor de células alfa do pâncreas, ou glucagonoma, e quando associado com intolerância a glicose, anemia, hiperglucagonemia, e perda de peso definem a síndrome do glucagonoma. É descrito o caso de uma paciente do sexo feminino, 52 anos, branca, com eritema necrolítico migratório associado à síndrome do glucagonoma com doença metastática na apresentação, vindo a falecer uma semana após sua admissão. A autópsia mostrou um tumor no corpo do pâncreas diagnosticado como tumor neuroendócrino e confirmado pela imuno-histoquímica. O reconhecimento do eritema necrolítico migratório é de grande importância para a possibilidade de diagnóstico precoce do glucagonoma