Ana Fidalgo

Allergic contact dermatitis due to amorolfine nail lacquer.

of neutrophilic dermatosis of the hands are associated with tumors (mostly hematological in origin), and 15% of cases are associated with inflammatory bowel disease.2 The disorder has also sporadically been associated with hepatitis C and streptococcal infection.6 Its occurrence in patients with rheumatoid arthritis is more infrequent, and in this context, it is important to distinguish it from other neutrophilic dermatoses related with this disease, such as rheumatoid neutrophilic dermatitis, erythema elevatum et diutinum, and pyoderma gangrenosum.7 Given the clinical similarities, a differential diagnosis with rheumatoid neutrophilic dermatitis becomes particularly relevant.8 There are no more than 30 cases of rheumatoid neutrophilic dermatitis—first described in 1978 by Ackerman—reported in the literature. This nonparaneoplastic sudden-onset dermatosis mostly affects women with seropositive rheumatoid arthritis. It is characterized by the formation of tender erythematous nodules and papules on the hands and extensor surfaces of the limbs, mainly around the joints and adjacent areas. The histopathology study reveals an intense neutrophilic infiltrate in the dermis with a variable degree of leukocytoclasia. Rheumatoid neutrophilic dermatitis is distinguished from neutrophilic dermatosis of the hands by the absence of vasculitis. The finding of vasculitis in the latter becomes more evident as time passes after the onset of symptoms.1,9 It is not unusual for rheumatoid neutrophilic dermatitis to resolve spontaneously or secondary to an improvement in the underlying rheumatoid disease. Other cases tend to resolve in response to treatment with dapsone.8 The treatment of choice for neutrophilic dermatosis of the hands is systemic corticosteroid therapy using oral prednisone at doses of up to 1 mg/kg/d. Contrasting with rheumatoid neutrophilic dermatitis, there is a response rate of up to 71%. Cases that fail to respond to systemic corticosteroid therapy should be treated with dapsone or potassium iodide.10 In conclusion, in cases of neutrophilic dermatosis of the hands, we believe that extensive screening should be performed to exclude the possibility of neoplastic or other diseases, given that there is a rare association—as occurred with our patient— between neutrophilic dermatosis of the hands and rheumatoid arthritis-like rheumatological disorders. References

Porokeratosis ptychotropica of the scrotum: dermoscopic evaluation of an atypical presentation

Porokeratosis ptychotropica is a rare variant of porokeratosis that is classically located on the gluteal and perianal regions, seldom extending to the genitalia. The authors report an atypical presentation of porokeratosis ptychotropica and discuss the use of dermoscopy in evaluating this dermatosis. Dermoscopic findings, although not specific to this variant of porokeratosis, are helpful in the differential diagnosis of other genital disorders. Histopathology, through the visualization of multiple cornoid lamellae, prevails as the gold standard for the definite diagnosis of porokeratosis ptychotropica.

Postradiation Cutaneous Angiosarcoma of the Breast: A Diagnosis to Keep in Mind

presents in a similar pattern as nodal uptake as in our case. Moreover, hibernomas demonstrate uptake values similar to those described for liposarcomas, and thus biopsy is required to exclude a malignant etiology. Accurate assessment is crucial because misinterpretation could lead to inappropriate therapeutic approaches like unnecessary invasive staging and diagnostic procedures or follow-up imaging with additional radiation exposure. Although hibernoma would not normally be subject to CT–PET scanning, in the setting of a known malignancy and routine oncologic follow-up, it can lead to a false-positive diagnosis of metastasis. This diagnosis should therefore be taken into consideration in FDG avid masses of the soft tissues during oncologic follow-up.

Cutaneous leukemic infiltration following varicella - a case of Wolf's isotopic response

Wolfs isotopic response designates the appearance of two subsequent unrelated dermatoses in the same anatomic location. We report the case of a 51-year-old man with a medical history of chronic lymphocytic leukemia without known extra-hematopoietic involvement. The patient developed a disseminated papulo-vesiculous eruption, diagnosed as varicella. Few days after recovering, an erythematous and violaceous papular dermatosis with histopathological examination compatible with leukemic infiltration appeared on the scars of previous herpetic lesions. Complete remission was obtained under systemic corticotherapy, without cutaneous recurrence or blastic transformation. Wolfs isotopic response is attributed to a localized immunologic imbalance following a certain stimulus. In this patient, herpetic infection acted as a local spur for inaugural cutaneous leukemic infiltration, with no impact on the prognosis for the underlying disease.

Unusual Presentation of Tinea Corporis Associated With the Use of a Microneedling Device

2017, Vol 37(7) NP69–NP72

UTILIZAÇÃO OFF-LABEL DE TERAPÊUTICA BIOLÓGICA EM DERMATOLOGIA – EXPERIÊNCIA CLÍNICA DE 5 ANOS

Introduction : In recent years, the development of numerous biologic agents extended the therapeutic armamentarium available to dermatologists. Although they are currently approved only for psoriasis, experience is being accumulated with its use in the treatment of different inflammatory skin diseases. Methods : This was a retrospective study of all patients treated in our department with biologic agents for skin disease other than psoriasis. We analyzed the clinical data, previous and concomitant treatments, efficacy and safety profile of these agents in this setting. Results : 15 patients were included with 7 different skin diseases resistant to conventional therapies. Etanercept was used in 4 cases: 3 patients with scleroderma (2 patients developed major side effects and had to interrupt treatment, while the third patient had a good response) and one patient with elastolytic granuloma. Four patients were treated successfully with infliximab (3 cases of Behcet’s disease and 1 case of pytiriasis rubra pilaris). Adalimumab was used to treat a patient with subcorneal pustular dermatosis with excellent results. Efalizumab was ineffective in 2 cases of atopic dermatitis. Rituximab was used in 5 patients: 3 cases of pemphigus (with complete clinical improvement) and 2 patients with atopic dermatitis (1 patient had a good response but had to interrupt treatment because she become pregnant and in the other patient there wasn’t any clinical improvement). Conclusion : Biologic immunomodulators have demonstrated efficacy in the treatment of several dermatologic diseases; however, most of the available information are individual case reports or small case series. Despite our limited experience in this setting, these results seem promising in the treatment of some inflammatory skin diseases resistant to conventional therapies.Introduction : In recent years, the development of numerous biologic agents extended the therapeutic armamentarium available to dermatologists. Although they are currently approved only for psoriasis, experience is being accumulated with its use in the treatment of different inflammatory skin diseases. Methods : This was a retrospective study of all patients treated in our department with biologic agents for skin disease other than psoriasis. We analyzed the clinical data, previous and concomitant treatments, efficacy and safety profile of these agents in this setting. Results : 15 patients were included with 7 different skin diseases resistant to conventional therapies. Etanercept was used in 4 cases: 3 patients with scleroderma (2 patients developed major side effects and had to interrupt treatment, while the third patient had a good response) and one patient with elastolytic granuloma. Four patients were treated successfully with infliximab (3 cases of Behcet’s disease and 1 case of pytiriasis rubra pilaris). Adalimumab was used to treat a patient with subcorneal pustular dermatosis with excellent results. Efalizumab was ineffective in 2 cases of atopic dermatitis. Rituximab was used in 5 patients: 3 cases of pemphigus (with complete clinical improvement) and 2 patients with atopic dermatitis (1 patient had a good response but had to interrupt treatment because she become pregnant and in the other patient there wasn’t any clinical improvement). Conclusion : Biologic immunomodulators have demonstrated efficacy in the treatment of several dermatologic diseases; however, most of the available information are individual case reports or small case series. Despite our limited experience in this setting, these results seem promising in the treatment of some inflammatory skin diseases resistant to conventional therapies.

ONICOMICOSE EM DOENTES COM PSORÍASE – UMA ENTIDADE SUBESTIMADA?

Introduction: Ungueal changes in psoriatic patients might occur or worsen due to mycotic infections, which are more likely to happen in the setting of immunosuppressive therapies and nail plate changes. There is still controversy about the prevalence of onychomycosis in psoriatic patients in the literature. The aim of this observational prospective study is to access the prevalence of ungueal mycotic infection in psoriatic patients with nail changes during one-year period. Materials & Methods: Relevant clinical data and samples of affected nails were collected. The biological material was subject to direct mycological exam and culture. Statistical analysis was performed with Excel and R software. Results: Of the 47 patients included, 33 were male. Mean age was 55 years. Twenty-seven patients (55%) had fingernail changes, with mean NAPSI 3.5. Candida albicans was isolated in 6 cultures (22%). Among the studied nail changes, pitting and longitudinal lines correlated with negative culture (p<0.05). Toenail changes were found in 44 patients (94%), with mean NAPSI 3.7. Culture was positive in 11 exams (25%), in seven of which were found dermatophytes. There was no statistical correlation between toenail changes and culture. Conclusions: In our psoriatic population, onychomycosis was more prevalent than the reported data for non-psoriatic population. Pitting and longitudinal lines were negative predictors of fingernail onychomycosis.

PROVAS EPICUTÂNEAS SOB IMUNOSSUPRESSÃO SISTÉMICA - CONTRA-INDICAÇÃO ABSOLUTA?

Introducao: As provas epicutâneas (PE) sao o exame complementar de diagnostico indicado para avaliacao de suspeita de dermite de contacto alergica. Idealmente, devem ser realizadas sem que o doente se encontre sob imunossupressores. Existem contudo situacoes clinicas em que tal nao e possivel, nao havendo informacao disponivel acerca de como realizar e valorizar os resultados das PE nestes doentes. O objectivo do presente trabalho e rever a literatura no que concerne a realizacao de PE sob imunossupressao iatrogenica. Material e Metodos: Revisao da literatura relevante para o tema publicada ate Janeiro de 2015 e indexada a Medline. Resultados: De acordo com o reportado na literatura, foram realizadas PE em 77 doentes sob corticoide sistemico, 78 doentes sob ciclosporina (CyA), 6 sob azatioprina, 10 sob metotrexato (MTX), 4 sob micofenolato de mofetil (MMF), 11 sob farmacos anti-factor de necrose tumoral e 7 sob farmaco anti-IL-12/23. Foram ainda descritos 15 casos de realizacao de PE sob associacao de imunossupressores. Verificaram-se reaccoes positivas em todos os grupos. Conclusao: O tratamento concomitante com imunossupressores nao deve ser uma contra-indicacao para realizacao de PE, estando descritas reaccoes positivas em doentes sob prednisolona, azatioprina, CyA, MTX, MMF, infliximab, etanercept, adalimumab e ustecinumab. Os resultados negativos ou duvidosos devem, contudo, ser interpretados de forma cautelosa.

Do steroid hormones have an important role on cutaneous lupus physiopathology

Sir, An 80-year-old-Caucasian-woman has been followed during the last 25 years for cutaneous discoid lupus erythematosus (CDLE) without systemic involvement. The lesions, limited to the face, ears and scalp, had been controlled with photoprotection, topical corticosteroids, topical calcineurin inhibitors and hydroxychloroquine, combined intermittently with intralesional and systemic steroids. Her medical history was otherwise not relevant and she had never been a smoker. Four years ago she underwent radical left mastectomy for carcinoma ductal in situ with positive oestrogen receptors, followed by hormonotherapy with letrozole 2,5mg/day. A month later there was pronounced cutaneous worsening and the lesions became refractory to previously effective therapies (Figure 1). There were no other recently started medications or systemic complaints; routine blood laboratory tests and autoimmunity antibodies were within normal range. Acitretin 25mg/day was attempted but