Flávia Trevisan

Efficacy of gabapentin in the improvement of pruritus and quality of life of patients with notalgia paresthetica

BACKGROUND notalgia paresthetica is a subdiagnosed sensory neuropathy presenting as a condition of intense itching and hyperchromic macule on the back that interferes with daily habits. OBJECTIVES To determine the efficacy of treatment of notalgia paresthetica using oral gabapentin, assessing the degree of improvement in itching and influence on quality of life. Moreover, to evaluate the signs and symptoms associated with notalgia paresthetica. METHODS We conducted an experimental, non-randomized, parallel, non-blinded study including 20 patients with clinical and histopathological diagnosis of notalgia paresthetica. After application of the visual analogue scale of pain adapted for pruritus and of the questionnaire of dermatology life quality index (DLQI), ten patients with visual analogue scale > 5 were given treatment with gabapentin at the dose of 300 mg/day for four weeks. The other ten were treated with topical capsaicin 0.025% daily for four weeks. After the treatment period, patients answered again the scale of itching. RESULTS The use of gabapentin was responsible for a significant improvement in pruritus (p=0.0020). Besides itching and hyperchromic stain on the back, patients reported paresthesia and back pain. It was observed that the main factor in the worsening of the rash is heat. CONCLUSION Gabapentin is a good option for the treatment of severe itching caused by nostalgia paresthetica.

Histopathological analysis of the therapeutic response to cryotherapy with liquid nitrogen in patients with multiple actinic keratosis

Actinic keratoses are premalignant lesions of the skin caused by excessive sun exposure. Lesions may become mainly squamous cell carcinoma. Cryotherapy with liquid nitrogen is one of the main treatments. In order to evaluate the response of actinic keratosis to cryotherapy by histopathology, two lesions were selected in each of 14 patients with multiple actinic keratoses. In one lesion a biopsy was performed and in the other lesion a biopsy was performed after cryotherapy. Subsequently, both biopsies were compared histologically. Of the thirteen patients who completed the study, the best results were obtained in lesions undergoing cryotherapy concerning the atypia of keratinocytes, epithelial thickness and corneal layer and lymphocytic infiltrate. Despite the small number of patients, it was concluded that, if performed correctly, cryotherapy has high efficacy in the treatment of actinic keratoses.

Cutaneous neonatal lupus with cutis marmorata telangiectatica congenita-like lesions

Neonatal lupus is a rare disease caused by the transplacental transfer of maternal autoantibodies to the foetus, characterized by transient clinical manifestations such as cutaneous, haematological, and hepatobiliary events or permanent such as congenital heart block. The typical cutaneous manifestations include erythematous, scaly, annular or arched lesions on the face, with slight central atrophy and photosensitivy, clinically and histologically similar to subacute cutaneous lupus. However, in some cases, the lesions may resemble those in cutis marmorata telangiectatica congenita, although this phenomenon is rare and only eight such cases have been reported to date. We report a case of cutaneous neonatal lupus with atypical lesions on the limbs, which had a reddish-purple marbled appearance, resembling the lesions in cutis marmorata telangiectatica congenita.

Case report of cutaneous histiocytic sarcoma: diagnostic and therapeutic dilemmas

Histiocytic sarcoma is a rare hematologic malignant neoplasia originating from histiocytic or dendritic cell clones. The lesions may be in nodal or extranodal sites, most commonly in the gastrointestinal tract. A small number of cases presents as unique cutaneous lesions. The definitive diagnosis is made by positivity for the immunohistochemical markers CD163, CD68, CD4 and lysozyme. The treatment is controversial, often with combined systemic chemotherapy. This is a case of cutaneous histiocytic sarcoma in an 82-year-old patient presenting two nodular lesions in the breast and right arm which were treated with simple excision and multidisciplinary follow-up, avoiding aggressive management and exhaustive investigations. Although most studies report aggressive evolution, the patient had good and stable clinical status during the twelve-month follow-up period.

Clear cell sarcoma: a case report from clinic to cytogenetic studies.

In 1965, Franz M. Enzinger reported a series of 21 cases of a malignant tumor, which was named clear cell sarcoma of tendons and aponeuroses. Since then, a little over 300 cases have been reported, corresponding to 1% of all soft tissue sarcomas. Clear cell sarcoma is an anaplastic rare tumor of soft tissues, originating from neural crest cells derived from melanoblasts. It affects 30to 40-year-old adults, primarily Caucasian, with no sex predilection. Most of the tumors are located close to the tendons and aponeuroses of the extremities: feet, ankles, plantar aponeurosis, hands, and forearms. They present as a swelling or non-fluctuating mass and are typically painless, mobile, and non-pigmented, with sluggish growth and a variable size with average diameter of 4 cm. Histologically, nests and fascicles are located in the deep dermis and subcutis, almost always associated with tendons and aponeurosis. The epidermis and dermal–epidermal junction are generally not involved. Occasionally, organized, uniform neoplastic cells interspersed with connective tissue tendons are seen, as are fascia and aponeuroses, forming lobes with septa of varying thickness. The cells are polygonal or spindle-shaped with pale eosinophilic cytoplasm, a round or oval central nucleus, and a prominent basophilic nucleolus. Few mitoses are found, which is in accordance with the slow growth of the tumor. Some giant cells may also be present. In clear cell sarcoma, immunohistochemical studies are positive for antigens associated with the synthesis of melanin, such as human melanoma black-45 (HMB-45), S-100 protein, Melan-A, and microphthalmia-associated transcription factor. In melanocytic lesions, such as nevi and melanoma, these markers are also positive. S-100 protein is positive in almost 95% of primary cutaneous melanoma, HMB-45 is highly specific for melanocytic differentiation, and microphthalmia-associated transcription factor is a nuclear protein involved with melanocytogenesis and melanogenesis. The positivity of these stains and their patterns are used to diagnose and differentiate melanoma from benign pigmented lesions of the skin. Vimentin and cytoketarins are usually negatives in clear cell sarcoma cases. To confirm the diagnosis, it is often necessary to perform cytogenetic studies and verify the presence of reciprocal chromosomal translocation t(12, 22):(q13, q12). This is also demonstrable via the Ewing’s sarcoma breakpoint region 1 (EWSR1) gene on 22q12 using fluorescent in situ hybridization (FISH). The FISH method uses specific DNA probes and can detect chromosomal aberrations in formalin-fixed, paraffin wax-embedded tissue.

Primary cutaneous follicle center lymphoma simulating basal-cell carcinoma on the nasal ala

Primary cutaneous B-cell lymphomas (PCBCLs) constitute 25% of all primary cutaneous lymphomas. They present in the skin with no evidence of systemic or extracutaneous disease at the time of diagnosis, after adequate staging. Primary cutaneous B-cell lymphomas differ significantly from their nodal counterparts in relation to both clinical behavior and prognosis. The distinction between primary and secondary B-cell lymphomas is essential for defining prognosis/course of action. Such distinction is also very difficult to make, since primary and secondary B-cell lymphomas are clinically and histologically indistinguishable. We report the case of a patient with primary cutaneous follicle center lymphoma who underwent surgical excision.

Osteogenic Melanoma with Desmin Expression

Background: Osteogenic differentiation is rarely seen in melanomas, when it occurs it is mainly in acral lesions. Methods: We report a case of an osteogenic melanoma in a 49-year-old woman who presented with a pigmented lesion in the subungueal region of her left hallux. The lesion was ulcerated and infiltrated until the deep dermis without bone involvement. Results: The tumor was composed of pleomorphic atypical epithelioid and fusiform cells disposed in nests or cords, with vesicular nuclei and prominent central nucleoli. Focal lentiginous proliferation of large atypical melanocytes was present along the dermoepidermal junction. Areas of osteoid matrix focally mineralized were disposed in trabeculae, and there were islands of neoplastic cells. Immunohistochemistry revealed strong expression of S-100 protein and, unexpectedly, of desmin. Focal expression of Melan-A, microphthalmia transcription factor, and HMB-45 is also revealed. Mutations in BRAF and NRAS genes were not present. The patient was submitted to an amputation of the left hallux with negative sentinel lymph node. Conclusion: The importance of recognizing osteogenic melanoma is based on difficulties for histologic recognition and its differentials diagnosis.

Classic Kaposi's sarcoma treated with elastic stockings and outpatient follow-up of a 90-year-old patient

Kaposis sarcoma is a multifactorial angioproliferative disorder. The herpes virus 8 human contributes to its pathogenesis, but it is uncertain whether these lesions are only reactive hyperplasia to the virus or neoplasia. Four clinical types are described: classic, endemic, iatrogenic and HIV-associated. Classic Kaposis sarcoma has no standard staging or treatment protocols. Some studies have shown the use of compression stockings in the treatment of lymphedema associated with Kaposis sarcoma. We report the case of a 90 year-old patient with classic Kaposis sarcoma treated with compression stockings who showed a satisfactory response.