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Flavia de Freire Cassia,1 Juliana Fernandes Cardoso,2 Luiz Cristovao Porto,3 Marcia Ramos-e-Silva,1 Sueli Carneiro4 1Sector of Dermatology, Post-Graduation Course in Dermatology, University Hospital and School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; 2Histocompatibility Section, Special Techniques Laboratory, Albert Einstein Israelite Hospital- HIAE, São Paulo, Brazil; 3Histocompatibility and Cryopreservation Laboratory, Rio de Janeiro State University, Rio de Janeiro, Brazil; 4Sector of Dermatology, University Hospital and School of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, BrazilCorrespondence: Flavia de Freire CassiaSector of Dermatology, Post-Graduation Course in Dermatology, University Hospital and School of Medicine, Federal University of Rio de Janeiro, Rua Jardim Botanico, 700 /416, Rio de Janeiro, 22461-000, BrazilTel +55 21999640406Email flaviafcassia@gmail.comBackground: The study of HLA classes I and II in Brazilian psoriasis patients may contribute to a better understanding of their association with the disease.Objective: To describe HLA classes I and II of Brazilian patients with psoriasis, with or without arthritis, compare them to controls and correlate HLA markers with epidemiological and evolutional aspects of psoriasis.Methods: A total of 55 patients with more than 5 years of psoriasis, with or without arthritis, answered a questionnaire on ethnic background and disease severity. A total of 134 bone marrow donors were controls. HLA class I and II genotyping was determined by PCR-SSP.Results: Mean age was 42.4 years; 23 women and 32 men. HLA-B*57 was present in 23.6% patients and in 7.5% controls (p=0.00200, OR= 3.8381), and HLA-C*06 in 29.1% patients and in 16.4% controls (p= 0.04832, OR=2.0886). HLA-B*57 and HLA-C*18 were significantly present in patients with arthritis (p=0.00104, OR=6.6769 and p=0.00269, OR=16.50, respectively). HLA-B*57 was significantly present in patients with history of erythroderma (p=0.00548, OR= 5.1059), as was HLA-C*06 (p=0.02158, OR=3.0545). HLA-B*57 was also frequent in patients with history of hospital internment due to psoriasis (p= 0.00094, OR=7.8909) and in the ones with history of systemic treatment for psoriasis (p= 0.00011, OR= 5.3733). Haplotype HLA-A*02 B*57 C*06 DRB1*07DQB1*03 was the most common among the patients (p= 0.00069, OR= 3.528).Conclusion: HLA-B*57 and HLA-C*06 were significantly increased in the patients indicating risk for psoriasis. HLA-B*57 remained high in patients with history of erythroderma, hospital internment, systemic treatment, and psoriatic arthritis, showing association with disease severity. HLA-C*18 was significantly high only in patients with psoriatic arthritis. HLA-B*57 and HLA-C*06 and haplotype HLA-A*02B*57Cw*06DRB1*07 DQB1*03 seen in this study were already described before, associated with psoriasis. HLA-Cw*18 was not described in other populations in association with psoriasis.Keywords: psoriasis, psoriatic arthritis, HLA, population study

Hugo Guimarães Scotelaro-Alves,1 Nurimar Conceição Fernandes,2 Marcia Ramos-e-Silva3 1Sector of Dermatology, Post-Graduation Program in Medical Clinics, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; 2Sector of Dermatology and Institute of Pediatrics, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; 3Sector of Dermatology, School of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Background: Previously known as dyshidrosis, recurrent vesicular palmoplantar dermatitis (RVPD) is presented as severe eruption of nonerythematous, symmetrical vesicles or bullae located along the lateral sides of fingers, on the palmar or plantar areas, and developing into a chronic and recurrent condition. Although very frequently observed on the hands, there are no specific studies about such eczema in children and adolescents. Objectives: To report on the RVPD clinical profile in children and adolescents, and monitor the association of RVPD with seasonal variations, hyperhidrosis, atopy and nickel sulfate. Materials and methods: Eighteen patients affected by RVPD were submitted to clinical and laboratory assessment through anamnesis, physical exam, mycological exam, patch test, complete blood count and serum IgE levels. Results: Seven patients (38.9%) reported increased frequency of eruptions during the summer months; 12 patients (66.7%) presented hyperhidrosis; in 14 cases (77.8%), atopic factors were determined; reaction to nickel sulfate was positive in three patients (16.7%). Conclusion: RVPD onset may occur at an early age, developing into a chronic and recurrent infection. Hyperhidrosis and atopic status was established in the clinical profile and no connection between nickel sulfate and RVPD was observed. Keywords: dyshidrosis, hand eczema, vesicular hand dermatitis, pompholyx, children, hyperhidrosis, nickel allergy, atopic dermatitis

Claudio Carneiro,1,2 Mario Chaves,2 Gustavo Verardino,2 Ana Paula Frade,3 Pedro Guimaraes Coscarelli,4 Washington Alves Bianchi,5,6 Marcia Ramos-e-Silva,3 Sueli Carneiro2,3 1Health Ministry, 2Sector of Dermatology, School of Medical Sciences and University Hospital, State University of Rio de Janeiro, 3Sector of Dermatology, University Hospital and School of Medicine, Federal University of Rio de Janeiro, 4General Medicine Department, University Hospital and School of Medical Sciences, State University of Rio de Janeiro, 5Sector of Rheumatology, Santa Casa da Misericórdia, 6University Hospital and School of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Brazil Background: Psoriatic arthritis is associated with psychosocial morbidity and decrease in quality of life. Psychiatric comorbidity also plays an important role in the impairment of quality of life and onset of fatigue.Objectives: This study aimed to assess the prevalence of fatigue in psoriatic arthritis patients and to correlate it to quality of life indexes, functional capacity, anxiety, depression and disease activity.Patients and methods: This cross-sectional study was performed on outpatients with psoriatic arthritis. Functional Assessment of Chronic Illness Therapy – Fatigue (FACIT-F; version 4) was used to measure fatigue; 36-Item Short Form Health Survey (SF-36) and Psoriasis Disability Index (PDI) to measure quality of life; Health Assessment Questionnaire (HAQ) to assess functional capacity; Hospital Anxiety and Depression (HAD) scale to measure anxiety and depression symptoms; Psoriasis Area and Severity Index (PASI), Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Clinical Disease Activity Index (CDAI) to evaluate clinical activity.Results: In all, 101 patients with mean age of 50.77 years were included. The mean PDI score was 8.01; PASI score, 9.88; BASDAI score, 3.59; HAQ score, 0.85; HAD – Anxiety (HAD A) score, 7.39; HAD Depression (HAD D) score, 5.93; FACIT–Fatigue Scale (FACIT-FS) score, 38.3 and CDAI score, 2.65. FACIT-FS was statistically associated with PASI (rs –0.345, p

Carolina Pereira Gonçalves, Beatriz Moritz Trope, Marcia Ramos-e-Silva Sector of Dermatology, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil Background: Non-melanoma skin cancer (NMSC) after kidney transplantation is common and can result in significant morbidity and mortality. Their incidence and risk factors in renal transplant recipients (RTRs) vary depending on geographic location and there is a scarcity of literature describing the features of NMSC in Brazil. Methods: NMSC data were retrospectively reviewed in charts of RTRs at the Clementino Fraga Filho University Hospital from January 2004 to December 2005, with the objectives of: 1) evaluating the occurrence of NMSC in RTRs transplanted between 2004 and 2005 at a reference center in Brazil; 2) verifying the frequency of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) in these patients according to sex, race, age, and tumor site; and 3) determining the time between transplantation and neoplasia. Results: We found 202 RTRs, with 165 suitable for the study. There were 19 NMSC in eleven patients (6.67%), at a mean time of 37.7 months after transplantation. The mean follow-up time was 72.7 months. The ratio of SCC:BCC was 1.1:1. White race and age ≥40 years were associated with a higher incidence of NMSC and they appeared predominantly in sun-exposed sites. Conclusion: Regular dermatological follow-up of RTRs can help to make earlier diagnoses, resulting in better quality of life and lower morbidity and mortality. Keywords: squamous cell carcinoma, basal cell carcinoma, Brazil

Monkeypox, an endemic disease in some African countries, has provoked public health activeness on a global scale that even the World Health Organization (WHO), invoking international health regulations, declared it a public health emergency of international concern (PHEIC). The WHO called attention of member states to exert maximum surveillance over the disease, its patients, and contact persons in order to standardize control measures. A need was directed to provide complete knowledge about the disease, allowing the administration of prior diagnoses as well as isolation and more effective epidemiologic control measures. An updated review on monkeypox emphasized upon having the fundamental aspects of the lesions caused by the disease, and appropriate management of patients upon clinical and epidemiologic evaluation.

The use of enzyme hyaluronidase to treat the complications of different brands of hyaluronic acid (HA) dermal fillers is increasing in the same proportion as the number of nonsurgical cosmetic procedures. Guidelines for diagnosing and treating complications remain controversial and are primarily based on anecdotal reports and small case series. We proposed approaching HA-related complications based on our clinical research and observations of treating more than 200 patients and providing a practical guide for the thoughtful use of hyaluronidase according to adverse events. Standardization of hyaluronidase dose and concentration is beneficial for better outcomes and future comparative analyses of the results of this treatment worldwide. The use of hyaluronidase is increasing for the reversal of the clinical manifestations of complications caused by HA fillers, although a consensus is lacking. We propose using different doses and concentrations of hyaluronidase to focus on selected anatomic areas considering properties of the product and pathogenesis of each complication.

The number of patients developing sterile abscesses because of hyaluronic acid (HA) filler procedures has increased for unknown reasons. We described this adverse reaction after filling with Juvederm Volux ® , the latest innovative product in the Vycross range of technology. We presented five patients with recalcitrant sterile abscesses after filling with Juvederm Volux ® who did not respond to the traditional therapy but whose lesions were resolved with the "Munhoz-Cavallieri lavage protocol" developed and recently published by the present authors. ( SKINmed . 2023;21:27-33).

A 60-year-old black man, working in construction sector, was referred to dermatology clinic for having multiple hardened and asymptomatic tumors on the scalp, face, and trunk for more than 40 years. There was a progressive increase in the number and size of lesions, causing significant aesthetic and functional impairment. In his family history, a son had numerous normochromic papules on the centrofacial region with a diagnosis of multiple trichoepithelioma. The deceased mother of our patient presented lesions similar to those of her grandson but without a confirmatory diagnosis. ( SKINmed . 2023;21:47-50).

Keloids and hypertrophic scars are abnormal responses to wound-healing. While hypertrophic scars remain limited to the areas of trauma, keloids most often develop over several years, growing out from the limits of the initial wound area. Both lesions may cause itching, burning, and pain, and they may lead to significant impairment of self-esteem, socialization, and quality of life. Although they might be observed in all races, they are far more common in Africans and African descendants than in Caucasians.We extensively reviewed their treatment, including compression with pressure garments, occlusion with siliconized and non-siliconized gel sheets, gels, corticosteroid and antineoplastic injections, and the use of lasers and intense pulsed light (IPL) therapy. We also reviewed new therapies, including botulinum toxin injection, and addressed outcomes of various studies. ( SKINmed . 2022;20:432-443).

Background: Melasma is a common hypermelanosis characterized by symmetrical brownish macules, especially on the face. Histologic analysis demonstrates increased epidermal and dermal melanin. Dermoscopy is useful to estimate the depth of the melanin and may help in the diagnosis and classification of melasma, with therapeutic importance., Objectives: To evaluate the diagnostic concordance of dermoscopic classification of epidermal or mixed subtypes of melasma and the correlation between dermoscopic and histopathological findings., Methods: Twenty-eight women with facial melasma, phototypes III to V, ages between 30 and 61 years were selected. Based on the evaluation of clinical and dermoscopic images, two independent observers classified melasma into epidermal or mixed subtypes. The intra and interobserver concordances were calculated. Histopathological analysis of epidermal melanin extension and maximum number of melanophages per high-power field (400×; HPF) have been assessed. Association between the melanophages count and the dermoscopic classification was evaluated., Results: Intraobserver agreement was 82.1%, and between observers, from 78.6% to 89.3%, according to the Kappa index. Histopathology revealed increased intraepidermal melanin and the presence of dermal melanophages in all the samples. Ten or more melanophages/HPF was significantly associated with mixed melasma., Conclusions: Moderate to substantial concordance in the dermoscopic classification of melasma was found, and the correlation between this classification and the dermal melanophages count have been suggested. Intradermal component of every case of melasma should be considered for therapeutic and prognostic purposes., (© 2022 Wiley Periodicals LLC.)

Background: In recent years, fillers procedures with hyaluronic acid (HA) have grown significantly. Despite HA relative safety, the number of cases of complications after injections has grown, and in many of which, we are not aware of or have little control over., Aims: In this article, the authors describe a new adverse reaction after filling with HA injection, the sterile abscess., Patients/methods: We present eight patients with similar clinical, laboratory, and ultrasound characteristics for sterile abscess and report a new therapeutic modality for it., Results: All cases were treated with "Munhoz-Cavallieri Lavage Protocol" procedure with complete resolution., Conclusions: "Munhoz-Cavallieri Lavage Protocol" serves as a guideline in diagnosis and management of sterile abscess., (© 2022 Wiley Periodicals LLC.)

Introduction: The use of hyaluronic acid (HA) as a dermal filler is considered safe. However, as new brands come to the market, reports of adverse events are becoming more and more common., Objective: To describe a particular type of adverse effect that, unlike the erythematous, indurated, and painful nodules described in the literature as "angry red bumps," is characterized by noninflammatory, stony-like nodules that appear in sites previously treated with HA., Methods: The report of four patients who presented this complication, and the occurrence of two HA syringes from the same batch that had hardened the product inside at the time of filling., Conclusion: The authors propose the nomenclature "happy bump" to group adverse reactions to HA that translate into noninflammatory nodules, with a stony consistency, appearing up to 4 weeks (recent) or after one month (late) in sites previously treated with AH., (© 2022 Wiley Periodicals LLC.)

A 47-year-old woman who lived in the metropolitan area of Rio de Janeiro and had abandoned her Acquired Immune Deficiency Syndrome (AIDS) therapy 3 years prior, was admitted to our hospital due to weight loss, cough, and fever for 2 weeks. The dermatologic examination established normochromic papules with molluscum-like central umbilication on the face (Figure 1) and hands, erythema and infiltration in the oral cavity (Figure 2), desquamative patches on the legs, and ulceration on right calcaneus (Figure 3). Her CD4 (T-cells) count was 47 cells/ mm. 3 Direct mycology examination and cultures for several agents were performed. The mycology culture done from her skin and sputum grew Sporothrix 1 week after admission (Figure 4).

Background: Acute Generalised Exanthematous Pustulosis (AGEP) is a rash with multiple sterile intraepidermal or subcorneal non-follicular pustules on edematous papules, with a sudden development and rapid evolution, triggered by drugs, vaccination, insect bites, exposure to mercury, and allergens., Objectives and Methods: We describe a female patient who developed extensive and abnormally prolonged AGEP following exposure to terbinafine and SARS-CoV vaccine. A detailed review of terbinafine-induced-AGEP cases was performed, with the aim of evaluating if the AGEP criteria would follow a different pattern when the disease is triggered by this drug. A PubMed search helped retrieve all terbinafine-induced AGEP case reports. AGEP-specific Sideroff criteria were analysed in terbinafine-induced cases and compared to other trigger causes., Conclusions: When the AGEP causative drug was terbinafine, a delay in recovery was observed, compared to the existing AGEP criteria when other causes are considered. Terbinafine frequently leads to delayed resolution AGEP probably due to the presence of the drug in the skin for several weeks after exposure, even after discontinuation, and the disease severity may be potentialised by additional factors such as concomitant viral infections or vaccination., (© 2022 Wiley-VCH GmbH.)

Background: Psoriatic disease (PD) is a chronic inflammatory disorder often associated with cardiovascular risk (CVR) factors such as obesity, hypertension, diabetes, dyslipidaemia and smoking. It is estimated that 2%-4% of the population worldwide has PD. Cutaneous lesions of psoriasis (PsO) may be associated with psoriatic arthritis (PsA) in up to 40% of patients. Studies have been carried out around the world with the aim of evaluating CVR in such patients., Aim: To determine CVR in a multiracial population with PsA or PsO from southeastern Brazil, which has a predominantly tropical climate, compared with controls., Methods: A cross-sectional study was carried out in outpatients with PsO or PsA followed up at a quaternary referral hospital in Rio de Janeiro. The Framingham Risk Score (FRS) was used to predict cardiovascular events (CVEs) over 10 years in patients with PsO and PsA compared with controls., Results: FRS was significantly higher at 10 years in patients with PsO (mean ± SD 16.3 ± 14) and PsA (18.0 ± 15) compared with controls (10.6 ± 9.5) (P = 0.01) and also increased with age. The chance of having a high FRS in the PsO and PsA groups increased by 0.30 and 0.23 times per year, respectively, compared with controls (PsO vs. controls 95% CI 0.090-1.00; PsA vs. controls 95% CI 0.08-0.75)., Conclusion: In this multiethnic Brazilian population, both PsO and PsA were associated with higher CVR compared with controls. The frequency of high FRS was highest in the sixth decade of life for all three groups of participants. Annual assessment of patients with PD is necessary in order to prevent CVEs., (© 2022 British Association of Dermatologists.)

Background: Epidemiological studies indicate that onychomycosis may affect up to 79% of psoriatic patients. Onychomycosis in psoriatic patients is more commonly caused by yeasts comparing with non-psoriatic., Objectives: Evaluate the prevalence of fungi in nail psoriasis. Evaluate the association between direct mycological examination (DME) and mycological culture, Nail Psoriasis Severity Index (NAPSI) and systemic treatment for psoriasis., Methods: Of 133 nails from 20 patients with nail psoriasis were evaluated as follows: 9 patients were using topical treatment and 11 were on systemic treatment. The assessment of psoriasis severity using NAPSI was performed in all psoriatic nails. The presence of fungi was confirmed in DME and culture., Results: DME showed the presence of fungal elements in 45 nails (33.83%) with a predominance of blastoconidia (95.5%) No septate hyphae were seen. Mycological culture was positive in 36 (27.06%) samples. Among them, Candida grew in 31 (86.1%): Candida parapsilosis in 15 (48.38%), Candida spp in 14 (45.16%). No growth of dermatophytes was observed. Patients with systemic treatment showed a higher frequency of positive test (DME and culture) for fungi when compared to topic treatment (p:.006). There was a positive correlation between NAPSI, mycological culture and systemic treatment (p:.0063); the risk was four times higher (OR:4.0)., Limitation of the Study: Sample size., Conclusion: These results are consistent with some previous reports, Candida was the fungus with higher frequency on the psoriatic nails, however, the role of these fungi is controversial (contamination x colonisation x infection). The fact that the immunosuppressive treatment increases the chance of fungal infection leads us to a greater attention to this patient profile, to prevent the intensification of nail psoriasis (Köbner phenomenon)., (© 2021 Wiley-VCH GmbH.)

Our patient was a 43-year-old, single black woman, born and living in Paracambi, State of Rio de Janeiro, who worked as a surgical instrumentalist. She was sent to our sector of dermatology due to hypochromia and diffuse skin roughness that had first appeared 8 years previously. She had been diagnosed 6 months before admission with ductal infiltrating metastatic carcinoma in the right breast, with therapeutic failure of chemotherapy and radiotherapy. Her menarche had occurred at age 13 years, she reported normal menstrual cycles from there on, and she had never been pregnant. She denied neoplasias and other comorbidities in her family history.

Tuberous sclerosis is a rare autosomal dominant genetic disorder. It is characterized by the appearance of benign tumors, known as hamartomas, which can affect multiple organs, including the skin. Cutaneous manifestations are present in almost all patients; therefore, the dermatologist has a fundamental role in the history and evolution of the disease in spite of being a multisystemic disorder. Two tumor suppressor genes, CET1 and CET2 , involved in tissue growth and cell proliferation, show mutation in this disease, which leads to the appearance of various benign tumors, hamartomas. Clinical characteristics are more than three hypomelanotic macules, more than three angiofibromas or face or scalp cephalic fibrotic plaque, more than two ungual fibromas, shagreen plaque, multiple retinal hamartomas, etc. Treatment is basically symptomatic, and genetic counseling is very important. This is an autosomal dominant disorder, although there is spontaneous mutation and no familial history in 65% of patients. When one of the parents is affected, genetic study is useful for prenatal diagnosis.

Background: Facial filling based on hyaluronic acid (HA) is an esthetic procedure that is widely performed worldwide., Methodology: Fifty patients underwent facial filling based on HA, and 10 board-certified dermatologists evaluated clinical photographs before and after the procedure and completed a questionnaire to provide information about the procedure., Results: All doctors and 96% of patients were agreed about the pre- and postprocedural photographs. Physicians were more aware of the possibility of frequent pain and erythema. Both groups showed agreement in their responses on the following topics: the possibility of hematoma and edema, a lack of secretion, improvement in patients' self-confidence, recognition of the procedure by third parties, and knowledge of the procedure by the dermatologists themselves. However, physicians tend to overestimate the possibility of erythema, pain, and edema; they also tend to minimize the duration and discomfort of postprocedural edema and the risk of third parties noticing patients' HA filling and how much it bothers patients when third parties do notice., Conclusion: Doctors and patients disagree on some questions about what actually happens and what is supposed to happen in facial filling procedures based on HA., (© 2021 Wiley Periodicals LLC.)

Background: Spiny keratoderma shows "music box spine" keratotic papules limited to the palms and soles and these lesions do not cause any trouble besides the cosmetic impairment and the sensation of roughness of hands and soles., Aim: To present cases and review the literature on spiny keratoderma., Patients/methods, Results: Three cases of spiny keratoderma are presented. The first case is a 52-year-old man with protein S deficiency presented with multiple spiny keratotic papules on palms and soles for more than 30 years, referring to remove them with a razor blade. The second case is an 84-year-old man who was hospitalized due to a rectal adenocarcinoma diagnosed 2 months before and presented multiples papules on palms and soles that were present for more than 50 years, with worsening after being bedridden. The third case is a 59-year-old woman who had since birth together with relatives the same type of spiny keratotic papules on palms and soles., Conclusion: The authors discuss the epidemiologic data and differential diagnosis of spiny keratoderma, as well as the related literature. Associations with systemic disease or malignancy occur in some acquired cases. It is important to distinguish from other palmoplantar keratodermas as some of that can be linked to cutaneous and internal malignancies. To date, no cases of spiny keratoderma in patients with protein S deficiency and only one case of association with rectal carcinoma have been reported., (© 2019 Wiley Periodicals, Inc.)

Background: Diagnosis of mycosis fungoides is challenging due to the non-specificity of clinical and histopathological findings. The literature indicates an average delay of 4-6 years for a conclusive diagnosis. Refinement of the histopathological criteria for the diagnosis of patients in early stages of the disease is considered of interest., Objectives: To study the histopathological aspects of early-stage mycosis fungoides and the applicability, in a retrospective form, of the diagnostic algorithm proposed by Pimpinelli et al. METHODS: Observational, retrospective, transversal study based on revision of histopathological exams of patients with suspected mycosis fungoides. Medical records were reviewed, and complementary immunohistochemistry performed., Results: Sixty-seven patients were included. The most frequent histopathological features were superficial perivascular lymphoid infiltrate (71.6%), epidermotropism (68.7%), lymphocytic atypia (63.8%), hyperkeratosis (62.7%) and acanthosis (62.7%). Forty-three patients scored 4 points at the algorithm, by clinical and histological evaluation. Immunohistochemistry was performed on 23 of the 24 patients with less than 4 points. Of those 23, 22 scored 1 point, allowing a total of 61 patients (91%) with the diagnosis of early-stage mycosis fungoides., Study Limitations: Its retrospective character, reduced sample size and incomplete application of the algorithm., Conclusions: Application of the Pimpinelli et al. algorithm, even in an incomplete form, increased the percentage of cases diagnosed as mycosis fungoides. Routine application of the algorithm may contribute to earlier and specific management and improvement of the patients' outcome., (Copyright © 2020 Sociedade Brasileira de Dermatologia. Published by Elsevier España, S.L.U. All rights reserved.)

Nocardiosis is caused by Gram-positive aerobic bacilli of the Nocardia genus, which are saprophytes living in the soil. It is a rare and opportunist disease with a localized or disseminated infection. When occurring in patients who are immunocompromised, involvement is usually systemic, most commonly represented by pulmonary disease. It can also be acquired through direct inoculation, entailing primary skin and subcutaneous tissue infections, frequently presenting as a localized nodular process. Cutaneous nocardiosis can manifest as a lymphocutaneous infection, actinomycetoma, superficial skin infection, or secondary infection from hematogenic dissemination. Diagnosis is made by identification of the organism in the culture of a clinical sample. Staining for acid-alcohol-resistant bacteria and, especially, Gram staining, is particularly relevant to obtain a rapid and presumptive diagnosis, while awaiting culture results. First-line medication is sulfamethoxazole-trimethoprim, which may be used with other antimicrobials, if necessary. Nocardiosis may be considered a major mimicker of several cutaneous diseases that present difficult, and often, delayed diagnoses., (Copyright © 2019. Published by Elsevier Inc.)

Skin rashes have exanthema as a synonym, a term derived from the Greek words exanthem, meaning "to appear," and anthos, which denotes "flourishing." The relevant factors for characterization of a rash include distribution, configuration, and organization of the lesions, in addition to evidence of systemic involvement through toxemia, adenopathy, and conjunctive lesions, hepatosplenomegaly, excoriations or phlogosis, neck rigidity, or neurologic dysfunction. A rash may evolve to cutaneous ulceration in many instances, which is relevant for the diagnosis, the followup, and the therapeutic management of the patient. Systemic diseases with exanthemas that result in ulcerations prevail over diseases that are restricted to signs and/or merely cutaneous clinical manifestations. A variety of etiologies can present cutaneous rashes with ulcers, subject or not to systemic involvement by the underlying disease, among which stand out the bullous diseases, infectious and parasitic diseases, noninfectious granulomatous diseases, vasculitis, paraneoplastic syndromes, autoimmune diseases of the connective tissue, neutrophilic diseases, lichen planus, and drug hypersensitivity syndrome. The authors present a detailed review of some diseases corresponding to each one of the mentioned etiologies, updating the clinical manifestations and therapeutic proposals., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Immunosuppressed patients frequently have skin diseases of mild to moderate intensity. Diagnosis as well as treatment should be performed early to avoid important complications for these patients. Skin eruptions are among these problems. Life-threatening eruptions in HIV and other types of immunosuppression range from acute retroviral syndrome to drug eruptions; immune reconstitution inflammatory syndrome; infection by virus, protozoan, bacteria, or fungi; inflammatory and immune dermatoses; and neoplasia. All of these are discussed in this group of patients., (Copyright © 2019 Elsevier Inc. All rights reserved.)

A rash is a disseminated eruption of cutaneous lesions with great variation in appearance, cause, and severity. When the physician is facing a rash, the history and physical examination of the patient are extremely important for the identification of the disease and its causal agent. There are various causes for a rash, which may be infectious, allergic, or rheumatologic, besides many others. Rashes associated with mucosal ulcers may have causes related to viral and bacterial infections or drug reactions. They may be associated with measles; erythema infectiosum; roseola infantum; rubella; hand, foot, and mouth disease; pityriasis rosea; dengue fever; chikungunya; zika; scarlet fever; meningococcal diseases; syphilis; and exanthematous drug eruptions., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The occurrence of keratoses in patients with psoriasis under treatment with psoralens and ultraviolet A (PUVA) has been described as an entity called PUVA keratosis. Similar lesions were seen later in patients with vitiligo under the same treatment. We describe the presence of distinct keratoses in the vitiligo lesions of three women patients from Rio de Janeiro, Brazil. The lesions started after PUVA treatment with total body irradiation, cabin or topical, and persisted long after the therapy was finished. All patients presented small rounded keratotic papules on achromic areas of the feet. Biopsies showed mild acanthosis, compact orthokeratotic hyperkeratosis, and hypergranulosis with increase of stratum granulosum layers or size increase of keratohyaline granules. Inflammatory infiltrate was sparse or absent. Cytologic atypia was not observed. Histologic features were compatible with reactive keratosis. None of the patients had a history of previous actinic keratosis or non-melanoma skin cancer and had been treated before with PUVA therapy either orally or topically; however, lesions occurred only in areas exposed to sunlight and persisted for long periods, even without treatment with PUVA or narrowband ultraviolet B (NB-UVB). The authors discuss whether these lesions can be considered as PUVA keratosis or if the sun exposure may have played an important role in the reported cases.

Background: One of the most used resources for the treatment of psoriasis is ultraviolet radiation (UV) with psoralens (PUVA) and narrow-band UV (UVB-NB 311-312 nm). Although many researchers have assessed the histopathological effects of this therapy modality, none used a morphological classification system specific to psoriasis., Purpose: To assess the clinical and histopathological response in the phototherapy treatment of plaque psoriasis with PUVA and UVB-NB with use of PASI and TROZAK., Methods: Histopathological changes of plaque psoriasis were quantified with help of the grading system for psoriasis-Trozak in 20 patients of both sexes, before and after 32 PUVA phototherapy sessions (10 patients-GPUVA) and UVB-NB (10 patients-GUVB-NB). The severity and extension of psoriasis was evaluated through PASI. The slides stained with hematoxylin and eosin were scanned in an Aperio CS2 scanner (Leica Biosystems) and evaluated through the software ImageScopeTM (Aperio Technologies). Statistical analysis was performed with the use of the program SPSS 22.0, with application of the Wilcoxon and Mann-Whitney tests., Results: All patients presented improvement in psoriatic plaques with decrease in PASI after treatment (P < 0.01) and significant reduction in histopathological changes in psoriasis from 15.4 ± 1.7 to 3.7 ± 3.2 (P < 0.01) in group GPUVA and from 13.2 ± 1.7 to 4.9 ± 5.2 (P < 0,01) in group GUVB-NB., Conclusions: Phototherapy, regardless of type, is an effective treatment for moderate and severe psoriasis, with possibility of being quantified clinically by PASI and histopathologically by Trozak., (© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

In Type II lepromatous reaction, there is exacerbation of humoral immunity, classified as Gell & Coombs Type III hypersensitivity reaction. It is more common in lepromatous borderline (LB) and lepromatous lepromatous (LL) patients. Our objective was to study the clinical and laboratorial expressions of lepromatous Type II reactions, establishing concordances between them, and for this the medical records of leprosy patients observed at the Clementino Fraga Filho University Hospital of the Federal University of Rio de Janeiro (HUCFF/UFRJ) were reviewed. There were a total of 358 leprosy cases over a period of 12 years. Demographic, clinical, and laboratory data of 133 patients with Type II reaction were collected. Among the 133 patients, 19 were classified as borderline borderline (BB), 15 (11.3%) as LB, and 97 (72.9%) as LL. Mitsuda intradermal reaction was negative in all the 49 patients who underwent this test. Histopathologic study confirmed the diagnosis. Lepromatous patients (LP) presented positive bacilloscopy more frequently (73.91% of 68 patients) than borderline patients (BP) (26.9% of 24 patients). Among BP, 44% presented erythema nodosum leprosum (ENL), which was seen in 71% of LP. Erythema multiforme (EM) occurred in 32% of BP and 13% of LP. Lucio phenomenon (LPh) was observed in 8 of 34 BP (23.6%), and 15 of 97 LP (15.4%). The understanding of the laboratorial and clinical presentations of reactional episodes are relevant to the development of preventive and therapeutic strategies, in order to avoid potential complications and comorbidities that cause disability, paralysis, deformities, and stigma of leprosy.

Strongyloidiasis is a parasitic infestation caused by the helminth Strongyloides stercoralis. It is essentially gastrointestinal and in general asymptomatic but can sometimes present with skin signs. Immunocompromised patients can develop the disseminated form of the disease due to the parasite's opportunistic behavior, as in cases of coinfection by the human T-lymphotropic type 1 virus (HTLV-1). This article presents a case of a patient infected with HTLV-I and Strongyloides stercoralis who developed the disseminated form. There were purpuric reticulated periumbilical lesions as well as vibices on the patient's flanks. Histopathologic exam of a skin lesion revealed the presence of larvae in the deep reticular dermis. We emphasize the relevance of awareness regarding interaction between HTLV-1 and strongyloidiasis, besides identification of the cutaneous manifestations of the disease to reach an appropriate therapeutic diagnosis.

Glomeruloid hemangiomas were first described by Chan in 1990 as a cutaneous marker of POEMS syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, Monoclonal proteinemia, and Skin changes). POEMS syndrome is a multisystem disease with a significant cutaneous involvement. Among its manifestations, hemangiomas are common, observed in up to one third of the patients, and, although specific, the glomeruloid subtype is very rare. The vascular endothelium growth factor (VEGF) is an angiogenic stimulation factor, which also induces increased systemic vascular permeability. Thus, a scenario of overexpression of VEGF can credibly lead to the assumption of an association between cutaneous hemangiomas and systemic manifestations, implying prognostic and therapeutic considerations and reinforcing the importance of dermatological periodical consultations for these patients. We report the case of a patient in whom glomeruloid hemangiomas marked the recurrence of POEMS syndrome, occurring before the systemic symptoms.

Background: Histiocytoid Sweet syndrome is characterized by a predominant neutrophilic dermal infiltrate. Usual clinical differential diagnosis includes erythema multiforme, drug eruption, and erythema nodosum. Histiocytoid Sweet syndrome is considered an uncommon histopathological variant of the disease., Methods: We evaluated clinical, histopathological, and immunohistochemical findings of a case categorized as idiopathic histiocytoid Sweet syndrome in which clinical-epidemiological data raised the possibilities of Sweet syndrome, leprosy, and drug reaction., Results: Positive reaction to myeloperoxidase (MPO) in histiocytoid cells of the dermal infiltrate, response to oral corticosteroids, clinical and laboratory investigation, and absence of cutaneous lesions or clinical complaints within 1 year of follow-up are consistent with the diagnosis of idiopathic histiocytoid Sweet syndrome. CD68 (PG-M1) and CD15 positive cells were also present among dermal cells., Conclusions: Epidemiological data are relevant while considering a clinical differential diagnosis of Sweet syndrome that can be further expanded, from a histopathological point of view, when dealing with the histiocytoid variant since neutrophils, macrophages, and immature myelomonocytic cells with histiocytoid morphology are present. The significance of the MPO positive mononuclear dermal cells are not completely established., (© 2018 The International Society of Dermatology.)

Background: Mycosis fungoides (MF) is the most common subtype of cutaneous T-cell lymphoma. TNMB system is the staging method used in MF, and it not only guides therapeutic management, but represents the main prognostic factor. In order to improve the prognostic evaluation, the Cutaneous Lymphoma International Prognostic Index (CLIPi) was proposed., Objective: To evaluate the performance of CLIPi score for prognostic analysis in patients with early stage MF., Methods: This is a retrospective cross-sectional observational study, with exploratory analysis. The outcome variables were disease progression and related death., Results: One hundred and two patients were stratified according to CLIPi score, being the majority classified as low risk. Patients with intermediate or high risk presented disease progression more frequently than those with low risk (PR: 1.2 / p = 0.004 / 95%CI: 1.0 - 1.6). The same did not occur with the variable related death. In addition, survival rates were not consistent with risk stratification., Study Limitations: Small sample and its retrospective analysis., Conclusions: Since CLIPi score was proposed, four other studies that we could consult showed conflicting results, similar to the present study. Further studies are necessary for a recommendation of its use.

Background: Mycosis fungoides is the most common form of primary cutaneous lymphoma, with an indolent, slowly progressive course and 88% five-year survival rate. The diagnosis is challenging, especially in the early stages, and usually relies on a good clinical-histopathological correlation., Objective: The aim was to establish the clinical and epidemiological profile of patients with early-stage mycosis fungoides., Methods: This was a retrospective cross-sectional observational study with an exploratory analysis. Outcome variables were disease progression and mycosis fungoides-related death., Results: One hundred and two patients were included. The majority were white males, with a mean age of 55.6 years. Mean time from onset of lesions to diagnosis was 51.08 months. The majority of patients were classified as IB stage according to TNMB. Mean follow-up time was 7.85 years. Disease progression was seen in 29.4% of the patients. Death related to the disease occurred in 7.9% of patients. Plaque lesions, involvement of more than 10% of the body surface, altered lactate dehydrogenase and beta-2-microglobulin, and stage IB were significantly associated with disease progression, and altered lactate dehydrogenase and beta-2-microglobulin also correlated with higher frequency of deaths., Study Limitations: Small sample and retrospective design., Conclusions: The clinical and epidemiological profile of patients with early-stage mycosis fungoides in our sample corroborates reports in the literature. Diagnostic delay in our series is also consistent with previous findings, but the rate of disease progression, despite treatment, was higher than reported in the literature.