André Pinho

Patch testing - a valuable tool for investigating non-immediate cutaneous adverse drug reactions to antibiotics.

Antibiotics are among the most frequent causes of cutaneous adverse drug reactions (CADR); patch testing may be an important tool in their evaluation and management. We assessed the role of patch testing as a diagnostic tool in non‐immediate CADR to antibiotics, and evaluated cross‐reactivity among them.

Long-term reproducibility of positive patch test reactions in patients with non-immediate cutaneous adverse drug reactions to antibiotics

As in contact allergy, T cell‐mediated hypersensitivity in non‐immediate (NI) cutaneous adverse drug reactions (CADRs) to antibiotics is considered to be lifelong, but, in this setting, patch tests have rarely been repeated after long time intervals.

Non-melanoma skin cancer in Portuguese kidney transplant recipients - incidence and risk factors.

Background Cancer is currently among the three leading causes of death after solid organ transplantation and its incidence is increasing. Non-melanoma skin cancer - squamous cell carcinoma and basal cell carcinoma - is the most common malignancy found in kidney transplant recipients (KTRs). The incidence of non-melanoma skin cancer in KTRs has not been extensively studied in Portugal. Objectives To determine the incidence of non-melanoma skin cancer in KTRs from the largest Portuguese kidney transplant unit; and to study risk factors for non-melanoma skin cancer. Methods Retrospective analysis of clinical records of KTRs referred for the first time for a dermatology consultation between 2004 and 2013. A case-control study was performed on KTRs with and without non-melanoma skin cancer. Results We included 288 KTRs with a median age at transplantation of 47 years, a male gender predominance (66%) and a median transplant duration of 3.67 years. One fourth (n=71) of KTRs developed 131 non-melanoma skin cancers, including 69 (53%) squamous cell carcinomas and 62 (47%) basal cell carcinomas (ratio squamous cell carcinoma: basal cell carcinoma 1.11), with a mean of 1.85 neoplasms per patient. Forty percent of invasive squamous cell carcinomas involved at least two clinical or histological high-risk features. The following factors were associated with a higher risk of non-melanoma skin cancer: an older age at transplantation and at the first consultation, a longer transplant duration and the presence of actinic keratosis. KTRs treated with azathioprine were 2.85 times more likely to develop non-melanoma skin cancer (p=0.01). Conclusion Non-melanoma skin cancer was a common reason for dermatology consultation in Portuguese KTRs. It is imperative for KTRs to have access to specialized dermatology consultation for early referral and treatment of skin malignancies.

Advanced Merkel cell carcinoma: a new case of spontaneous regression

Merkel cell carcinoma is an aggressive skin neoplasm affecting predominantly older or immunosuppressed patients. The progression to metastatic disease is frequent while spontaneous regression is quite uncommon. Chronic sun exposure and infection by Merkel cell polyomavirus are known etiopathogenic factors.A 89-year-old female was observed with a locally advanced Merkel cell carcinoma of the left nasal ala. Lymph node metastases in left submandibular region were clinically apparent and confirmed by fine-needle aspiration. A solitary metastasis in the liver was identified by positron-emission tomography/computed tomography with (68)Ga-DOTATOC.While she was waiting for palliative radiation therapy, the patient experienced a complete clinical remission of the primary tumor and regional lymph nodes metastases occurring after 6 weeks. A liver ultrasonography disclosed remission of the liver metastasis as well.The spontaneous remission is rarely reported in medical literature. As far as we know, this is the first report in Portugal. The underlying mechanism of the spontaneous remission remains unknown, although theoretically it can be explained by the development of an efficient immune response against the tumor.

Patch testing in the investigation of non‐immediate cutaneous adverse drug reactions to metamizole

Metamizole [INN; dipyrone (BAN, USAN)] is a pyrazolone derivative and one of the most commonly prescribed analgesics worldwide (1). Along with non-steroidal anti-inflammatory drugs (NSAIDs), metamizole is very frequently involved in hypersensitivity reactions (2). Immunologically mediated hypersensitivity reactions to metamizole can be immediate (IgE-mediated) or non-immediate (T cell-mediated) (2, 3). Although immediate cutaneous adverse drug reactions (CADRs) are frequent and well known, non-immediate CADRs to metamizole, other than fixed drug eruptions, are less common and have been poorly described in the literature (3, 4). The usefulness of patch testing in the investigation of non-immediate CADRs to metamizole has not been extensively studied. The following study was performed to evaluate the value of patch testing in the setting of non-immediate CADRs imputable to metamizole.

Sirolimus e Prevenção Primária de Cancro Cutâneo Não-melanoma em Transplantados Renais – Um Estudo Retrospetivo

Introducao: A imunossupressao desempenha um papel central na patogenese do cancro cutâneo, em transplantados renais. Recentemente tem sido estudado o potencial do sirolimus na reducao da incidencia de cancro cutâneo nao-melanoma nesta populacao.Objetivo: Analisar a relacao entre os esquemas imunossupressores de manutencao iniciais e o desenvolvimento de cancro cutâneo nao-melanoma – carcinoma espinhocelular e carcinoma basocelular – em transplantados renais.Metodos: Analise retrospetiva dos registos clinicos de doentes submetidos a transplante renal entre os anos 2002 e 2012 e que vieram posteriormente a ser observados no nosso Servico de Dermatologia. Os transplantados renais foram divididos em tres grupos, de acordo com o esquema imunossupressor de manutencao inicial: grupo A (a base de sirolimus), grupo B (a base de tacrolimus), grupo C (a base de ciclosporina).Resultados: Dos 188 transplantados renais estudados, 24,5% (n=46) foram diagnosticados com 83 cancro cutâneo nao-melanoma (42 carcinoma basocelular e 41 carcinoma espinhocelular). Nao houve diferencas na sobrevivencia livre do primeiro cancro cutâneo nao-melanoma ou do primeiro carcinoma basocelular entre os grupos. A sobrevivencia livre de primeiro carcinoma espinhocelular foi significativamente maior no grupo A (media 10,7 anos), quando comparado com os grupos B (media 7,48 anos) e C (media 8,29 anos). O hazard ratio bruto de carcinoma espinhocelular foi significativamente superior nos grupos C (7,74, p = 0,05) e B (9,02, p = 0,03), em comparacao com o grupo A. Contudo, apos ajuste para a idade a data de transplante, estes valores perderam significado estatistico.Conclusao: Ainda que o switch para sirolimus esteja descrito como benefico na prevencao secundaria de carcinoma espinhocelular em transplantados renais, a sua utilizacao ab initio nao pareceu apresentar o mesmo efeito protetor.

New onset of few atrophic white papules of the trunk and limbs

A 26-year-old Caucasian man presented with a 1-year history of scattered asymptomatic skin lesions, initially appearing on the dorsa of his hands, then spreading over his trunk and legs. He had no fever, weight loss, or digestive, neurological, respiratory or urinary symptoms. His medical history was unremarkable and no first-degree relatives shared similar lesions. On physical examination, around 15 circular papules were seen distributed over the patient’s hands (Fig. 1a), flanks (Fig. 1b) and thighs. The lesions ranged in size from 4 to 8 mm, with an atrophic porcelain-white centre and an erythematous telangiectatic rim. The face, palms and soles were not affected. No other relevant changes were detected. Dermoscopy (Fig. 1c) showed a central whitish structureless area surrounded by a rim of short, thin, slightly curved vessels over an erythematous background. Results of further investigations, including complete blood count, erythrocyte sedimentation rate, renal and liver function tests, proteinogram, and tests for coagulation, autoimmunity, cryoglobulins and immunoglobulins were normal, as were digestive endoscopic study, faecal occult blood test and brain magnetic resonance imaging.

Elastosis Perforans Serpiginosa and Wilson Disease: A Rare but Predictable Consequence of Long-term Therapy with D-Penicillamine

Elastosis perfurans serpiginosa is a rare perforating dermatosis found primarily in adolescents and young adults, characterized by transepidermal elimination of abnormal elastic fibers. The only drug known capable of inducing elastosis perfurans serpiginosa is D-penicillamine. We report the case of a 52 year-old woman with keratotic papules arranged in an annular pattern with central clearing and centrifugal growth, located in the anterior cervical region. The patient was chronically treated with D-penicillamine for Wilson disease. Lesion biopsy showed transepidermal elimination of thickened, eosinophilic, branched, sawtooth-like elastic fibers. The clinical and pathological findings were consistent with elastosis perfurans serpiginosa secondary to D-penicillamine. It is estimated that elastosis perfurans serpiginosa occurs in 1% of patients treated with D-penicillamine. By blocking directly or indirectly the desmosine cross-links between elastin molecules, D-penicillamine leads to the synthesis of abnormal dermal and extracutaneous elastic fibers. Elastosis perfurans serpiginosa may be the first manifestation of a multisystemic degenerative process of elastic connective tissue.

Bier spots and unilateral nevoid telangiectasia: more than just a coincidence.

Dear editors: Twin spotting (didymosis) means the coexistence of discrete areas of skin in close spatial and temporal proximity, differing clinically and genetically from each other, and from the background skin. This is a type of mosaicism caused by somatic recombination. A growing list of previously unexplained skin conditions has been attributed to this phenomenon.1 We describe the case of a 12-year-old Caucasian female with numerous macular, ovoid, hypochromic lesions of about 5mm on the dorsum of the left hand and arm. Some of the lesions were confluent, surrounded by erythematous, blanching skin. (Figures 1-3). These lesions were asymptomatic, began at birth and were induced by pendent position of the arm, disappearing a few seconds after its elevation.