Abstract Background American cutaneous leishmaniasis is an infectious dermatosis caused by protozoa of the genus Leishmania, which comprises a broad spectrum of clinical manifestations depending on the parasite species involved in the infections and the immunogenetic response of the host. The use of techniques for amplification of the parasites DNA based on polymerase chain reaction polymerase chain reaction and the recent application of combined techniques, such as high-resolution DNA dissociation, have been described as a viable alternative for the detection and identification of Leishmania spp. in biological samples. Objectives To identify the Leishmania species using the polymerase chain reaction high-resolution DNA dissociation technique in skin biopsies of hospital-treated patients, and compare with results obtained by other molecular identification techniques. Methods A retrospective study assessing patients with suspected American cutaneous leishmaniasis seen at a hospital in São Paulo/Brazil was conducted. The paraffin blocks of 22 patients were analyzed by polymerase chain reaction high-resolution DNA dissociation to confirm the diagnosis and identify the species. Results Of the 22 patients with suspected American cutaneous leishmaniasis, the parasite was identified in 14, comprising five cases (35.6%) of infection by L. amazonensis, four (28.5%) by L. braziliensis, two (14.4%) by L. amazonensis + L. infantum chagasi, two (14.4%) by L. guyanensis, and one (7.1%) by Leishmania infantum chagasi. In one of the samples, in which the presence of amastigotes was confirmed on histopathological examination, the polymerase chain reaction high-resolution DNA dissociation technique failed to detect the DNA of the parasite. Study limitations The retrospective nature of the study and small number of patients. Conclusions The method detected and identified Leishmania species in paraffin-embedded skin biopsies with a sensitivity of 96.4% and could be routinely used in the public health system.

Abstract: Background: Acne in women is often associated with anxiety and depression, and may persist from adolescence as well as manifest for the first time in adulthood. Genetic and hormonal factors contribute to its etiopathogenesis, and maintenance treatment is required, usually for years, due to its clinical evolution. Objective: To develop a guide for the clinical practice of adult female acne. Methods: A team of five experts with extensive experience in acne conducted a literature review of the main scientific evidence and met to discuss the best practices and personal experiences to develop a guide containing recommendations for the clinical practice of adult female acne. Results: The group of specialists reached consensus on the main guidelines for clinical practice, providing detailed recommendations on clinical picture, etiopathogenesis, laboratory investigation and treatment of adult female acne. Conclusion: Different from teenage acne, adult female acne presents some characteristics and multiple etiopathogenic factors that make its management more complex. This guide provides recommendations for best clinical practices and therapeutic decisions. However, the authors consider that additional studies are needed in order to provide more evidence for adult female acne to be better understood.

Inflammatory bowel diseases can commonly present many cutaneous lesions which can contribute to the diagnosis of the disease or its activity. The most frequent cutaneous or mucocutaneous manifestations suggesting ulcerative rectocolitis activity are erythema nodosum (3-10%), pyoderma gangrenosum (5-12%) and aphthous stomatitis (4%). Other reactive skin manifestations related to immunological mechanisms associated with the inflammatory bowel disease are: Sweet's syndrome, arthritis-dermatitis syndrome associated with inflammatory bowel disease and leukocytoclastic vasculitis. We describe the case of a young man with diagnosis of ulcerative rectocolitis, which presented an extensive cutaneous gangrene secondary to microvascular thrombosis. The case represents a dermatologic rarity and should be recognized as a cutaneous manifestation related to the hypercoagulability state observed in the disease's activity.

Pênfigo Vulgar é uma doença bolhosa auto-imune, cuja terapêutica é baseada em corticoesteróides sistêmicos, associados ou não a imunossupressores. Rituximabe é um anticorpo monoclonal quimérico da classe IgG direcionado a um antígeno CD20 de superfície celular específico da célula B, usado em pênfigo vulgar desde 2002, com sucesso em 90% e longos períodos de remissão. Paciente masculino, 33 anos, diagnóstico de pênfigo vulgar, confirmado por histopatologia e imunofluorescência direta. Durante 7 meses, recebeu inúmeros tratamentos com imunossupressores, apresentando resposta insatisfatória e progressão da doença, até que logo após a introdução de rituximabe teve completa remissão. Durante um acompanhamento de 34 meses, apresentou leve recidiva clínica, controlada com prednisona 120mg/dia, rapidamente reduzida e em uso atual de Prednisona 20mg/dia.

Pemphigus vulgaris is an autoimmune bullous disease whose therapy is based on systemic corticosteroids, with or without immunosuppressants. Rituximab is a chimeric monoclonal antibody of the IgG class, directed at a specific CD20 B cell surface antigen, used in pemphigus vulgaris empirically since 2002, with success in 90% of the cases and long periods of remission. Male patient, 33 years old, diagnosed with pemphigus vulgaris, confirmed by histopathology and direct immunofluorescence. He was treated for seven months with numerous treatments, including immunosuppressive drugs, with an unsatisfactory response, until he had complete remission with the use of rituximab. During a 34-month follow-up period, the patient presented a slight clinical relapse, which was successfully controlled with prednisone in a daily dose of 120mg, soon reduced to 20mg.

CONTEXTO: A síndrome DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) é um tipo de reação a drogas comumente confundida com uma infecção viral. Deve ser prontamente reconhecida devido a sua alta morbidade e taxa de mortalidade de 10%. Poucos casos de síndrome DRESS induzida por sulfasalazina foram relatados na literatura. RELATO DE CASO: É relatado o caso de uma mulher branca, brasileira, de 47 anos, que desenvolveu a síndrome DRESS oito semanas após iniciar tratamento com sulfasalazina para artrite soronegativa. A paciente apresentou rash maculopapular, febre, hepatite, linfadenomegalia, eosinofilia e linfocitose atípica. A medicação foi suspensa imediatamente no início dos sintomas, mas só houve melhora clínica após tratamento com prednisona.

CONTEXT: DRESS syndrome (Drug Rash with Eosinophilia and Systemic Symptoms) is a type of drug reaction commonly mistaken for a viral infection. It must be recognized promptly due to its high morbidity and 10% mortality rate. Few cases of DRESS syndrome induced by sulfasalazine have been reported in the literature. CASE REPORT: The case of a 47-year-old white Brazilian woman who developed DRESS syndrome eight weeks after starting a course of sulfasalazine for treatment of seronegative arthritis is reported. She presented a skin rash, fever, hepatitis, lymphadenopathy, eosinophilia and atypical lymphocytes. The causative drug was discontinued immediately, but she only improved after treatment with prednisone.

A osteodistrofia hereditária de Albright é caracterizada por calcificações cutâneas, obesidade, baixa estatura, braquidactilia associada ao pseudo-hipoparatireoidismo do tipo IA entre outras alterações hormonais como hipotireoidismo e hipogonadismo. O diagnóstico é baseado no quadro clínico associado aos achados de hipocalcemia e níveis elevados de hormônio da paratireóide. Os autores relatam caso em que a avaliação dermatológica foi de grande contribuição para o diagnóstico.

Albright hereditary osteodystrophy is characterized by subcutaneous calcification, obesity, short stature, brachydactyly and pseudohypoparathyroidism type IA. Hypothyroidism and hypogonadism may be present. The diagnosis is based on clinical characteristics associated with hypocalcemia and high levels of parathyroid hormone. The authors report a case in which the dermatological evaluation contributed to diagnosis.

Os efeitos benéficos dos corticosteróides sistêmicos no tratamento e/ou controle de inúmeras dermatoses é inquestionável. No entanto, o dermatologista deve conhecer os principais efeitos adversos destas drogas e adotar medidas apropriadas com o intuito de evitar danos maiores à saúde do paciente. Este artigo discorre sobre as medidas pré-corticoterapia e o seguimento clínico do paciente durante o tratamento, de modo que as complicações possam ser diagnosticadas e controladas prontamente.

The beneficial effects of systemic corticosteroids in treatment and/or control of several skin diseases are unquestionable. Nevertheless, dermatologists should be aware of the main adverse effects of these drugs and do what is necessary to avoid any harm to patients. The authors report the measures physicians should take before and during glucocorticoid therapy, so that any complications be immediately diagnosed and treated.

Há quase 60 anos os corticosteróides sistêmicos têm sido amplamente utilizados na área de dermatologia, trazendo benefícios para muitas doenças em decorrência de suas ações antiinflamatórias e imunossupressoras. O desafio de seu uso consiste em contrabalançar os efeitos benéficos e as atividades farmacológicas indesejáveis. Infelizmente, os avanços no conhecimento sobre os mecanismos de ação dos corticosteróides não resultaram no desenvolvimento de regimes com mínima toxicidade. Dessa maneira, este artigo de revisão discorre sobre os aspectos farmacológicos dos corticosteróides sistêmicos, bem como suas principais indicações de uso e efeitos colaterais da administração em altas doses e/ou por longos períodos de tempo.

Systemic corticosteroids have been used in dermatological practice for approximately 60 years due to their anti-inflammatory and immunosuppressive effects. The challenge of corticosteroid therapy is to counterbalance the desirable actions and undesirable pharmacological effects. Unfortunately, advanced understanding of the mechanisms of action of corticosteroids has not resulted in the development of minimal toxicity regimens. In this article, we report the main pharmacological properties of systemic corticosteroids, their major indications in clinical practice and the adverse effects of high doses and/or prolonged administration.

FUNDAMENTOS: O líquen plano é dermatose inflamatória crônica de etiologia desconhecida. Sua associação com doença hepática, particularmente a hepatite C, é tema de diversos trabalhos em todo o mundo, desde 1990, quando a sorologia para detecção do vírus da hepatite C (VHC) se tornou disponível. OBJETIVOS: Este estudo visa avaliar uma possível relação causal entre a infecção pelo vírus C e o líquen plano. MÉTODOS: Tomaram-se por grupo de estudo 66 pacientes com líquen plano matriculados na Clínica de Dermatologia da Santa Casa de Misericórdia de São Paulo, no período de 2000 a 2003. O grupo comparativo foi constituído pelos doadores de sangue voluntários do Banco de Sangue da Santa Casa de Misericórdia de São Paulo, durante o período de outubro de 2001 a outubro de 2002. RESULTADOS: Dos 66 pacientes com líquen plano, cinco apresentaram sorologia positiva para VHC, representando 7,5% em comparação com 0,69% dos doadores de sangue. CONCLUSÕES: Esse resultado é compatível com muitos dados contidos na literatura médica mundial. Entretanto, são necessários novos estudos para o melhor conhecimento dessa controversa relação.

BACKGROUND: Lichen planus is a chronic inflammatory dermatosis of unknown etiology. Its association with liver diseases, particularly hepatitis C, has been widely approached since 1990, when serology for the detection of hepatitis C virus became available. OBJECTIVES: The objective of this study was to evaluate a possible causal relation between virus C infection and lichen planus. METHODS: Sixty-six patients with lichen planus seen at the Dermatology Department of Santa Casa de Misericórida de Sao Paulo from 2000 to 2003 were included in the study group. The control group comprised volunteer blood donors of the Blood Bank of Santa Casa de Misericórida de Sao Paulo, from October 2001 to October 2002. RESULTS: Five out of the 66 patients with lichen planus had a positive serology for HCV, representing 7.5% in comparison with 0.69% of the blood donors. CONCLUSIONS: Our findings are consistent with those reported in the medical literature. However, further studies are necessary to improve our knowledge on such a controversial relation.

O mieloma múltiplo é neoplasia de células plasmáticas que infiltram a medula óssea; as lesões cutâneas no mieloma múltiplo são raras, inespecíficas ou específicas, sendo estas últimas primárias ou secundárias. Lesões específicas secundárias de pele em pacientes com mieloma ocorrem por extensão direta para a pele, a partir de lesões ósseas subjacentes, ou como plasmocitomas extramedulares metastáticos. Os autores relatam caso de paciente de 59 anos, que apresentou diagnóstico de mieloma múltiplo e, após sete meses de evolução, desenvolveu plasmocitomas cutâneos, caracterizados por nódulos eritêmato-violáceos nas extremidades.

Multiple myeloma is a malignant proliferation of plasma cells which infiltrate bone marrow; cutaneous involvement with plasma cell neoplasms is uncommon, and may be nonspecific or specific. The specific dermatologic lesions arise either as a direct extension from the underlying bone lesions or by metastatic accumulation in the form of nodules and plaques. The authors report the case of a 59-year-old male patient with multiple myeloma, who developed cutaneous plasmacytomas (violaceous nodules on the limbs) seven months after the disease diagnosis.

FUNDAMENTOS: Erisipela e celulite são infecções cutâneas freqüentes. OBJETIVOS: Com o objetivo de avaliar incidência, fatores de risco, principais complicações, esquemas terapêuticos utilizados e evolução. MÉTODOS: Foram estudados 35 pacientes com diagnóstico de erisipela internados nas enfermarias do Hospital Central da Irmandade da Santa Casa de Misericórdia de São Paulo no período de abril a agosto de 2002. RESULTADOS: A incidência de pacientes com diagnóstico de erisipela no período estudado foi de 0,87%. O fator de risco local mais encontrado foi o linfedema, seguido por episódios prévios de erisipela. Dos fatores de risco gerais, aqueles que comprometem a imunidade, como diabetes mellitus, etilismo e neoplasias, foram os mais observados em associação ao quadro de infecção dermatológica. Sinais inflamatórios locais foram encontrados em 97,8% dos casos. Verificaram-se quatro casos com complicações: necrose, abscesso, trombose venosa profunda e septicemia. A evolução dos pacientes foi satisfatória em mais de 97% dos casos. CONCLUSÕES: O tratamento com penicilina cristalina foi associado ao menor número de complicações (p<0,05) e ao menor custo (p<0,05), e a associação de anticoagulantes à terapia evidenciou menor incidência de complicações (p<0,05).

BACKGROUND: Erysipelas and cellulitis are common skin infections. OBJECTIVES: The aim of this paper is to investigate the frequency, risk factors, clinical features, complications, principal drugs used for treatment and the disease course. METHODS: The authors studied 35 ward patients who had been diagnosed with erysipelas, and were admitted to the Central Hospital of Irmandade da Santa Casa de Misericórdia de São Paulo between April and August 2002. RESULTS: Among the patients in the ward during the study 0.87% had been diagnosed with erysipelas. The most common local risk factor was lymphedema, followed by previous episodes of erysipelas. Among the general risk factors, diabetes mellitus, alcohol abuse and cancer were most frequently observed. Local inflammatory signs were found in 97.8% of the patients. Four cases were observed to have complications, which were: necrosis, abscess, deep thrombophlebitis and septicemia. The course was satisfactory in more than 97% of patients. CONCLUSIONS: Therapy with penicillin was associated with a decrease of complications (p<0.05) and at a lower cost compared to other antibiotic therapies (p<0.05). When anticoagulants were combined to the therapy, there was a lower incidence of complications (p<0.05).

FUNDAMENTO: Lúpus eritematoso cutâneo crônico é uma doença inflamatória crônica relativamente freqüente, mas pouco estudada entre nós. OBJETIVO: Caracterizar epidemiologia e clínica de pacientes com lúpus eritematoso cutâneo crônico, visando comparar dados obtidos com literatura mundial. PACIENTES E MÉTODOS: Foram estudados retrospectivamente 290 pacientes com lúpus eritematoso cutâneo crônico no período de 1982 a 1996, na Clínica de Dermatologia da Santa Casa de São Paulo. RESULTADOS: A média de idade da instalação da doença foi de 32,3 anos, houve predomínio do sexo feminino em relação ao masculino (3,4:1), a maior parte dos pacientes teve lesões localizadas no segmento cefálico (58,3%). Quanto às variedades clínicas, houve predomínio da placa discóide típica em 90,4% dos casos, seguida das variantes verrucosa ou hipertrófica (7,9%), lúpus eritematso pérnio (1,4%), e túmida (0,3%). Lesões em mucosas ou epitélios de transição ocorreram em 27,2% dos pacientes. CONCLUSÕES: Lúpus eritematoso cutâneo crônico é doença mais comum em mulher adulta, sendo a placa discóide típica a lesão mais comum. Lesões mucosas ocorreram em aproximadamente em um quarto dos casos.

BACKGROUND: Chronic cutaneous lupus erythematosus is a chronic inflammatory disease, which albeit relatively frequent, has been the object of few studies. OBJECTIVE: To characterize the epidemiological and clinical aspects of patients with chronic cutaneous lupus erythematosus, with a view to comparing the data obtained with the world literature. PATIENTS AND METHODS: A retrospective study was done on 290 patients with chronic cutaneous lupus erythematosus from 1982 to 1996, attended at the Dermatology Clinic of Hospital Santa Casa de Sao Paulo. RESULTS: The mean age at onset of the disease was 32.3 years, there was a female prevalence in relation to males (3.4:1), most of the patients had lesions located in the cephalic segment (58.3%). Regarding the clinical types, there was a prevalence of the typical discoid plaque in 90.4% of cases, followed by the verrucous or hypertrophic forms (7.9%), erythematous lupus pernio (1.4%) and tumid (0.3%). Lesions in the mucous membranes or transition epithelia occurred in 27.2% of the patients. CONCLUSIONS: Chronic cutaneous lupus erythematosus is a disease more frequent in adult women and the most common lesion is the typical discoid plaque. Mucous lesions occurred in approximately one fourth of the cases.