Marilda Aparecida Milanez Morgado de Abreu

Leprosy: review of the epidemiological, clinical, and etiopathogenic aspects - part 1.

Leprosy is caused by Mycobacterium leprae and has been known since biblical times. It is still endemic in many regions of the world and a public health problem in Brazil. The prevalence rate in 2011 reached 1.54 cases per 10,000 inhabitants in Brazil. The mechanism of transmission of leprosy consists of prolonged close contact between susceptible and genetically predisposed individuals and untreated multibacillary patients. Transmission occurs through inhalation of bacilli present in upper airway secretion. The nasal mucosa is the main entry or exit route of M. leprae. The deeper understanding of the structural and biological characteristics of M. leprae, the sequencing of its genome, along with the advances in understanding the mechanisms of host immune response against the bacilli, dependent on genetic susceptibility, have contributed to the understanding of the pathogenesis, variations in the clinical characteristics, and progression of the disease. This article aims to update dermatologist on epidemiological, clinical, and etiopathogenic leprosy aspects.

Actinic cheilitis: histopathology and p53

Background:  Chronic actinic cheilitis (AC) is a precursor of squamous cell carcinoma (SCC) of the lip.

Immune-expression of HSP27 and IL-10 in recurrent aphthous ulceration

BACKGROUND Recently, abnormal cellular immune response has been considered responsible for the oral lesion in the recurrent aphthous ulceration (RAU). For reasons not yet defined, antigens of the oral microbiota would trigger abnormal Th1 immune response against epithelial cells. On the other hand, studies have demonstrated that heat shock proteins (HSP) can block the production of proinflammatory cytokine through inhibition of NF-kappaB and mitogen-activated protein kinase pathways or activate anti-inflammatory cytokines and therefore control the magnitude of the immune response. HSP27 has been considered a powerful inductor of IL-10, a major inhibitor of Th1 response. METHODS Using immunohistochemistry, we studied the expression and location of HSP27 and IL-10 in ulcerated lesions clinically diagnosed as RAU (n = 27) and to compare it with that of oral clinically normal mucosa (CT; n = 6) and of other inflammatory chronic diseases such as oral fibrous inflammatory hyperplasia (FIH; n = 18), Crohns disease (CD; n = 10) and ulcerative colitis (UC; n = 9). RESULTS A lower proportion of HSP27-positive epithelial cells in RAU and CD were observed when compared with CT and FIH (P < 0.001**; P = 0.013**). A lower proportion of IL-10-positive interstitial cells in RAU was observed when compared with FIH, UC, CT and CD (P < 0.001**; P < 0.001**; P < 0.001**; P = 0.034*). CONCLUSION Altogether the data suggest that a reduced cellular expression of HSP27 and IL-10 in RAU might be related with the aetiopathogenesis of the ulcerated oral lesions.

Treatment of recurrent aphthous stomatitis with clofazimine

OBJECTIVE The aim was to investigate the safety and efficacy of clofazimine for the treatment of recurrent aphthous stomatitis. STUDY DESIGN In this randomized controlled partially blind study, 23 patients received clofazimine 100 mg daily for 30 days and then 100 mg every other day. Twenty-three patients received colchicine 0.5 mg 3 times daily. Twenty patients received 1 placebo pill 2 times daily. All subjects received medications for 6 months. The chi-squared or Fisher exact tests were used to assess drug efficacy with respect to objective findings and symptoms. RESULTS A greater percentage of individuals in the clofazimine group had no further aphthous episodes (17%-44% compared with <or=6% in the other groups). A significantly greater percentage of treatment interruption occurred in the colchicine group because of gastrointestinal effects (23%-45%). Individuals in the clofazimine group who continued to suffer from aphthous stomatitis presented with better results for the evaluated variables. CONCLUSION Clofazimine should be considered for the treatment of recurrent aphthous stomatitis.

The oral mucosa in leprosy: a clinical and histopathological study

INTRODUCTION Multibacillary leprosy may involve the oral mucosa, with or without apparent lesions. There are few studies that deal with this issue in the era of multidrug therapy. AIM To assess the frequency of oral mucosa involvement in multibacillary leprosy patients. PATIENTS AND METHODS A transversal study with twenty non-treated multibacillary leprosy patients. The patients were treated in Dracena, São Paulo, between 2000 and 2002. Clinical examination of the oral mucosa was carried out. All patients were submitted to jugal mucosa, soft palate and tongue biopsies, in altered or in pre-established sites. The cross-sections were stained by techniques of hematoxilin-eosin and Ziehl-Neelsen. Granuloma and alcohol-acid-resistant bacilli findings determined the specific histopathological involvement. RESULTS The study involved 19 patients with an average of 2.5 years of disease progression. Specific histopathological involvement occurred in the tongue and soft palate of one lepromatous patient with an apparently normal oral mucosa. CONCLUSIONS (1) Clinical alterations in the oral mucosa does not imply disease involvement, it is necessary to have histopathological confirmation. (2) Apparent specific clinical alterations are rare. (3) The clinically normal oral mucosa can show specific histopathological involvement.

Review: dermatitis herpetiformis

Dermatitis herpetiformis (DH) or Duhring-Brocq disease is a chronic bullous disease characterized by intense itching and burning sensation in the erythematous papules and urticarial plaques, grouped vesicles with centrifuge growth, and tense blisters. There is an association with the genotypes HLA DR3, HLA DQw2, found in 80-90% of cases. It is an IgA-mediated cutaneous disease, with immunoglobulin A deposits appearing in a granular pattern at the top of the dermal papilla in the sublamina densa area of the basement membrane, which is present both in affected skin and healthy skin. The same protein IgA1 with J chain is found in the small intestinal mucosa in patients with adult celiac disease, suggesting a strong association with DH. Specific antibodies such as antiendomysium, antireticulina, antigliadin and, recently identified, the epidermal and tissue transglutaminase subtypes, as well as increased zonulin production, are common to both conditions, along with gluten-sensitive enteropathy and DH. Autoimmune diseases present higher levels of prevalence, such as thyroid (5-11%), pernicious anemia (1-3%), type 1 diabetes (1-2%) and collagen tissue disease. The chosen treatment is dapsone and a gluten-free diet.

Actinic cheilitis adjacent to squamous carcinoma of the lips as an indicator of prognosis

UNLABELLED Many studies have shown an association between actinic cheilitis and squamous carcinoma of the lips. AIM The aim of the study was to observe the relation between actinic cheilitis and the prognosis of squamous carcinoma of the lips. MATERIALS AND METHODS This is a retrospective cross-sectional cohort study of squamous carcinoma of the lips. Histological sections of squamous carcinoma tumors done at the the Department of Pathology of the Sao Paulo Federal University between 1993 and 2000 were reviewed for evidence of actinic cheilitis in the lip vermillion adjacent to the tumor. Patient reports were reviewed to find information about exposure to sun, metastases and relapses. The occurrence or absence of relapses and metastases was correlated with the presence or absence of actinic cheilitis in the lip vermillion. Data was analyzed by Fishers Exact test. RESULTS Of the 31 selected patients, most were caucasian, males and with lower lip involvement. Statistical analysis demonstrated independence between the occurrence of metastases and relapse and gender, skin color and site (lower or upper lips). There was dependence between actinic cheilitis and solar elastosis, and between the absence of actinic cheilitis and the occurrence of metastases. There was no dependence between the absence of actinic cheilitis and the occurrence of relapses. CONCLUSION It may be concluded that tumors originating from actinic cheilitis have a better prognosis.

Granular parakeratosis in children: case report and review of the literature.

Abstract: Granular parakeratosis is a cutaneous eruption with erythematous and/or brownish hyperkeratotic papules and plaques which are exclusively localized to intertriginous areas and show histopathologic features of an unusual form of parakeratosis. The etiology is unknown, but the excessive use of various topical preparations (e.g., ointments and deodorants) has been associated with this disease. It has heretofore been reported only in adults. We report two children, ages 3 and 5 months, with characteristic lesions in the groin associated with topical pomades used to prevent diaper rash. This is the first report associating the clinical presentation and the histopathologic diagnosis of granular parakeratosis in children. The literature on this entity is also reviewed and all case reports are summarized.

Levamisol não previne lesões de estomatite aftosa recorrente: um ensaio clínico randomizado, duplo-cego e controlado por placebo

OBJECTIVE: to utilize a double-blind protocol to provide clarification about the safety and effectiveness of levamisole in the treatment of recurrent aphthous stomatitis. METHODS: Fourteen patients took a decreasing dose of oral levamisole for six months (initial dose 150mg three times a week) and ten others were placebo control patients. All were evaluated monthly. RESULTS: The number of crises had a tendency to decrease in both groups, but without a difference between groups. The number of lesions diminished significantly in the two groups, but upon comparison the difference was not significant. Duration of the lesions diminished significantly in the placebo, however when compared to the levamisole group, difference was not significant during treatment. The intensity of pain was significantly lower in the two groups, but upon comparison, pain was significantly lower in the placebo group. The final global evaluation showed improvement in 50% of patients of the levamisole group and in 70% of the placebo, without a significant difference between treatments. No difference in the frequency of collateral effects was observed between groups. CONCLUSIONS: Levamisole, as used in this protocol, is a safe drug. When compared with the placebo, levamisole is not effective in the prophylactic treatment of recurrent aphthous stomatitis. The placebo effect is important in diseases where emotional factors affect recurrence or expression of symptoms.

Dermatologia na pele negra

This study approaches dermatology in dark skinned individuals. First, it discusses the concepts of race and ethnicity, as well as the classification criteria of the Brazilian population, indicating areas where the dark skinned people are concentrated. Next, it makes one brief explanation on skin color classification systems and describes structural, biological and functional characteristics of the epidermis, dermis and cutaneous attachments that differentiate dark from fair skin. It also approaches some physiological alterations that usually are observed in the skin, nails and in the mucosa of dark skinned people. Also discussed are some patterns of reactions and alterations of lesion color, due to cutaneous hyperpigmentation, which lend unexpected aspects to the dermatosis, making its recognition difficult. Finally, the study highlights some diseases in particular, emphasizing inherent characteristics associated to lesion patterns and the frequency of some dermatoses in the black skin. The aim of this study was to bring data to help the dermatologist be familiar with the different nuances that lesions may present in a more pigmented skin.