Cacilda da Silva Souza

Long-term follow-up of topical 5-aminolaevulinic acid photodynamic therapy diode laser single session for non-melanoma skin cancer

Photodynamic therapy (PDT) is based on the association of a light source and light sensitive agents in order to cause the selective death of tumor cells. To evaluate topical 5-aminolaevulinic acid (5-ALA) and diode laser photodynamic single session therapy single session for non-melanoma skin cancer (NMSC), a long-term follow-up was performed. Nineteen Bowens disease (BD) and 15 basal cell carcinoma (BCC) lesions were submitted to 6-h topical and occlusive 20% 5-ALA plus DMSO and EDTA, and later were exposed to 630 nm diode laser, 100 or 300 J cm(-2) dose. At 3 months tumor-free rate was 91.2% (31/34) whereas at 60 months, 57.7% (15/26), slightly higher in BCC (63.6%; 7/11). The relation between the reduction of the clinical response and the increase of tumor dimension observed at 18 months was lost at 60 months. The sBCC recurrence was earlier compared to the nBCC one. ALA-PDT offered important advantages: it is minimally invasive, an option for patients under risk of surgical complications; clinical feasibility; treatment of multiple lesions in only one session or lesions in poor healing sites and superior esthetical results. However, the recurrence rate increase after ALA-PDT diode laser single session can be observed at long-term follow-up, and the repetitive sessions, an additional advantage of the method, is strongly recommended. The clinical response and recurrence time seem to be related to the laser light dose and NMSC types/sub-types, thickness and dimension, which must be considered for the choice of the ALA-PDT.

Topical photodynamic therapy for Bowen's disease of the digit in epidermolysis bullosa

nails. She had no prior manicure treatments to the nails or cuticles. After 3 months of daily isotretinoin her rosacea had cleared but the appearance of her nails caused her significant psychological distress and she elected to discontinue isotretinoin. Trimethoprim 200 mg twice daily was commenced but was discontinued due to nausea. She was recommenced on doxycycline 100 mg daily with 0Æ75% metronidazole gel. Three months after discontinuing isotretinoin the nail dystrophy had grown out 3 mm from the proximal nail fold (Fig. 1b). At 6 months her nails had completely returned to normal (Fig. 1c). The patient’s rosacea remains well controlled 9 months after discontinuing isotretinoin. Review of the images suggested that the patient had elkonyxis rather than median nail dystrophy. A diagnosis of isotretinoin-induced elkonyxis was made. Elkonyxis is an unusual nail dystrophy where the nail develops a pinched-out appearance which begins at the lunula and progressively grows out. This rare nail dystrophy has only previously been reported to occur in association with etretinate treatment. Our patient was initially thought to have isotretinoin-induced median nail dystrophy, a rare complication of isotretinoin treatment. However, median nail dystrophy tends to be a symmetrical nail dystrophy with a longitudinal defect in the nail in the centre or just off-centre of the nail with numerous transverse feathery cracks. There may be an associated enlarged lunula present. If the longitudinal defect is prominent and there are prominent multiple transverse nail defects in a ‘fir tree’ or ‘herring bone’ like appearance, the condition is often termed ‘median canaliform (Heller’s) dystrophy’. Median nail dystrophy is thought most commonly to be due to repeated inadvertent or selfinflicted trauma to the proximal nail fold. The cause for retinoid elkonyxis is unknown. Possible mechanisms would include alteration in the formation of keratins within the nail matrix or altered keratinization of the proximal nail fold and ⁄or cuticle (or alternatively the nail bed) which impairs or impinges on the uninterrupted formation of the nail plate. Close inspection of our sequential images demonstrates loss of cuticle early on (Fig. 1a) but re-establishment of a normal cuticle 3 months after discontinuing isotretinoin (Figs 1b,c). This suggests that abnormalities of the cuticle and proximal nail fold may contribute to the formation of elkonyxis. In our case, the temporal onset of elkonyxis after commencing isotretinoin, resolution following discontinuation of isotretinoin and the absence of trauma or other skin disease affecting the proximal nail fold is suggestive of a causal relationship. It is interesting that isotretinoin 20 mg daily (but not at doses of 20 mg twice and thrice weekly) elicited the development of elkonyxis. This suggests that the development of elkonyxis may in part be dose related in susceptible individuals. Elkonyxis is a rare and unusual type of nail dystrophy previously reported with etretinate treatment. Elkonyxis appears to be an idiosyncratic and possibly dosedependent nail dystrophy rarely associated with retinoid therapy.

Disseminated mucocutaneous leishmaniasis resulting from chronic use of corticosteroid

Mucocutaneous leishmaniasis is a granulomatous disease clinically characterized by ulcerated skin and mucosal lesions whose clinical manifestations can regress spontaneously, but with possible long subclinical evolution. The course of the disease is often related to the host immune response. The purpose of this article is to describe the clinical and microscopic findings of cutaneous and mucosal lesions of mucocutaneous leishmaniasis in a patient who presented an unusual form of the disease associated with an immunosuppressive state.

Generalized cutaneous leishmaniasis in acquired immunodeficiency syndrome

BACKGROUND Leishmaniasis associated with HIV/AIDS has been reported in the last decade. CASE REPORT A case of generalized cutaneous leishmaniasis in a patient with AIDS is described. The case is paradoxical in that the cutaneous lesions resemble anergic leishmaniasis caused by Leishmania (L.) amazonensis and Jorge Lobos disease, but the positive Montenegro test and the clinical improvement with antimonial are more commonly observed in leishmaniasis caused by L.(V.) braziliensis. COMMENT The immunosuppression due to HIV/AIDS seen in this patient may explain the dissemination of the lesions, but the positive specific response to leishmanial antigen may explain the good response to the antimonial treatment.

Dermatomyositis and acquired ichthyosis as paraneoplastic manifestations of ovarian tumor

Case 1 A 37‐year‐old white woman was seen at the Dermatology Clinic presenting muscle weakness of the pelvic and scapular girdles, as well as a violaceous erythema and periorbital infiltration (heliotropium) and erythematous‐violaceous lesions on the dorsum of the finger joints, with periungual telangiectasia. A diagnosis of dermatomyositis was confirmed and treatment with prednisone, 1 mg/kg per day, was started, with improvement.

Double-blind, crossover, placebo-controlled clinical trial with clobetasol propionate in desquamative gingivitis

The aim of this study was to evaluate the efficacy of a 0.05% clobetasol propionate ointment administered in trays to 22 patients with desquamative gingivitis in a double-blind, crossover, placebo-controlled trial. Patients received container number 1 and were instructed to apply the ointment 3 times a day for 2 weeks, and to reduce the application to once a day in the third week. Next, the patients were then instructed to discontinue the treatment for 2 weeks, and were then given container 2, used in the same way and for the same length of time as container 1. Regarding signs, 17 patients presented some improvement, while 5 experienced worsening with clobetasol propionate. With the placebo, 14 patients presented some improvement, and 8 patients presented worsening. For symptoms, there was complete improvement in 2 patients, partial improvement in 12, no response in 7, and worsening in 1 with clobetasol propionate. With the placebo, there was partial improvement in 8 patients, no response in 12 and worsening in 2. No statistically significant difference was found between clobetasol and placebo (p>0.05). Within the period designed to treat the gingival lesions of the patients, clobetasol propionate did not significantly outperform the placebo.

Adrenocortical hormones and interleukin patterns in leprosy.

The functional status of adrenocortical hormones and their relationship to the pattern of inflammatory cytokines in the lepromatous and tuberculoid poles of leprosy were investigated. Interleukin (IL)‐1β, IL‐6 and tumour necrosis factor (TNF)‐α plasma levels, C‐reactive protein (CRP) concentrations and erythrocyte sedimentation rates (ESR) were significantly higher in LL/BL (lepromatous) leprosy patients than in control subjects. There was a significant positive correlation between IL‐6 and TNF‐α plasma levels and ESR and CRP concentrations. IL‐1β was positively correlated with ESR but not with CRP. Both baseline and stimulated adrenocorticotropic hormone and cortisol plasma levels were not different between patients and control subjects. In contrast, adrenal androgen dehydroepiandrosterone sulphate (DHEA‐S) plasma levels were significantly lower in leprosy patients than in sex‐matched control subjects. There was a significant inverse correlation between DHEA‐S and IL‐6, TNF‐α, and CRP concentrations. This finding may be of pathogenetic significance in this disease and in other inflammatory states.

Cryptococcosis in cirrhotic patients

The objective of the present study was to report on three distinct forms of presentation of Cryptococcus neoformans infection in three cirrhotic patients. One patient had disseminated cryptococcosis with detection of the fungus in ascitic fluid, cerebrospinal fluid and blood; the second patient had pleural involvement and the third had cutaneous infection caused by C. neoformans.

Terapia fotodinâmica com ftalocianina de zinco tópica: avaliação da intensidade de fluorescência, absorção cutânea, alterações histológicas e imuno-histoquímicas na pele do modelo animal

BACKGROUND - Phthalocyanines are promising photosensitizers used in photodynamic therapy (PDT). OBJECTIVES - To evaluate the following parameters: intervals, vehicles and enhancer using topical zinc-phthalocyanine (Zn-PC) formulation. To examine macro and micromorphological changes and Fas expression induced by topical Zn-PC-PDT on murine skin. MATERIAL AND METHODS - Using fluorescence spectrometry, different intervals of topical occlusion employing Zn-PC gel or emulsion, with or without monolein 5% were studied. After an 8-hour occlusion of different formulations, the mice were exposed to 670 nm laser, at a 50 J.cm-2 dose. RESULTS - Fluorescence was slightly higher after 8 hours, and also with emulsion formulation at one-, two- and four-hour occlusion periods. The intensity of edema and erosion were correlated to epidermal necrosis and to Fas immunoexpression in skin histological specimens. CONCLUSIONS - The results show the effects of photodynamic action promoted by the interaction between Zn-PC formulation and a 670-nm light source. Macro and micromorphological alterations were correlated and more substantial with monolein and Zn-PC emulsion, suggesting more marked effects with this formulation. The Fas immunoexpression and histological changes suggested that apoptosis plays a role in the mechanism of cell death caused by PDT based in Zn-PC.

Pituitary-gonadal hormones and interleukin patterns in leprosy.

The functional status of pituitary–gonadal hormones and their relationship to the pattern of inflammatory cytokines in the lepromatous (LL/BL) and tuberculoid (TT/BT) poles of leprosy were investigated. Gonadotropins [luteinizing hormone (LH) and follicle‐stimulating hormone (FSH)], interleukin (IL)‐1β, IL‐6, tumour necrosis factor (TNF)‐α and C‐reactive protein (CRP) concentrations and erythrocyte sedimentation rate (ESR) were significantly higher in LL/BL leprosy patients than in controls and were not different from controls in TT/BT patients. LH and FSH were positively correlated with IL‐1β, IL‐6 and TNF‐α, and CRP concentrations and ESR. Testosterone plasma levels were significantly decreased in LL/BL patients and not different in TT/BT patients compared with controls. In addition, testosterone levels were inversely correlated with IL‐6 and TNF‐α. Prolactin plasma levels of both LL/BL and TT/BT patients were not different when compared with those of controls. There was a significant positive correlation between IL‐6 and TNF‐α plasma levels and ESR and CRP concentrations. IL‐1β was positively correlated with ESR but not with CRP. The significant correlations between gonadotropins and testosterone and cytokines in leprosy patients suggest that cytokines may have a direct influence at testicular level and may be of pathogenetic significance in leprosy and in other inflammatory states involving reproductive dysfunction.