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A plethora of prolonged COVID-19 symptoms, or late manifestations has been reported after acute disease and labeled “post-COVID”. The aim of this study was to identify the prevalence of and risk factors for post-COVID up to 12 weeks after the onset of acute COVID-19. An electronic survey was conducted to evaluate post-COVID-19 symptoms, disease severity, demographics, and pre-existing diseases. The participants were recruited through 88,648 SMS messages, and post on social media. The associations between variables were explored through multivariate models. From 6,958 respondents with confirmed COVID-19, 753 (10.8%) required hospitalization, and 5,791 (83.2%) exhibited at least one post-COVID manifestation. Hair loss (49.4%), memory loss (40.7%), low attention (37.0%), fatigue (34.2%), anxiety (31.2%), and headache (29.6%) were the most reported post-COVID manifestations. Female sex, myalgia, anosmia, and severe disease were associated with most post-COVID manifestations. Pre-existing depression was associated with the development of neuropsychiatric manifestations. Post-COVID manifestations were identified in most patients following COVID-19 infection, placing a supplementary burden on the healthcare system. Hair loss, fatigue, and neuropsychiatric symptoms were the most prevalent post-COVID manifestations. Female sex, myalgia, anosmia, and more severe disease are risk factors for multiple post-COVID manifestations.

Introduction: the COVID-19 pandemic dramatically disrupts health care around the globe. The impact of the pandemic on chronic urticaria (CU) and its management are largely unknown. Aim: to understand how CU patients are affected by the COVID-19 pandemic; how specialists alter CU patient management; and the course of CU in patients with COVID-19. Materials and methods: our cross-sectional, international, questionnaire-based, multicenter UCARE COVID-CU study assessed the impact of the pandemic on patient consultations, remote treatment, changes in medications, and clinical consequences. Results: the COVID-19 pandemic severely impairs CU patient care, with less than 50% of the weekly numbers of patients treated as compared to before the pandemic. Reduced patient referrals and clinic hours were the major reasons. Almost half of responding UCARE physicians were involved in COVID-19 patient care, which negatively impacted on the care of urticaria patients. The rate of face-to-face consultations decreased by 62%, from 90% to less than half, whereas the rate of remote consultations increased by more than 600%, from one in 10 to more than two thirds. Cyclosporine and systemic corticosteroids, but not antihistamines or omalizumab, are used less during the pandemic. CU does not affect the course of COVID-19, but COVID-19 results in CU exacerbation in one of three patients, with higher rates in patients with severe COVID-19. Conclusions: the COVID-19 pandemic brings major changes and challenges for CU patients and their physicians. The long-term consequences of these changes, especially the increased use of remote consultations, require careful evaluation., Novartis; Sanofi; Menarini Universidad Espiritu Santo; Takeda; Allakos; AstraZeneca; CSL Behring; Genentech; Pharming; GSK; Shire/Takada; BioCryst; ResTORbio; Pearl Therapeutics, CVS Health; Law offices of Levin; Riback; Adelman; Flangel; Vedder Price; Fresenius; Taiho; Kyowa Kirin; Tanabe; Korin; Uriach Pharma; Instituto Carlos III FEDER; Menarini; Amgen; Thermo Fisher; Avene; ALK‐Abello; Bencard/Allergy Therapeutics; Celgene; Allergopharma; Faes Farma; AbbVie; Janssen; Leo Pharma; Lilly; Roche; Genesis; Menlo Therapeutics; UCB; Pfizer; Almirall; Galderma; Allergika; Beiersdorf; Biocryst; Biogen Idec; BMS; Boehringer‐Ingelheim; Eli‐Lilly; Galderma; Hexal; Klosterfrau; LEO‐Pharma; LETI‐Pharma; L´Oreal; Medice; Octapharma; Pflüger; Pharming; Regeneron; Shire; ALK‐Abello; Fraunhofer‐IZI Leipzig; Hautnetz Leipzig/Westsachsen; MSD; HAL‐Allergy; Bencard; Nestle; Nutricia; Bayer Health Care; FAES; Henkel; Allakos; Argenx; Genentech Menarini; Moxie; Aralez; Celldex

Publisher Copyright: © 2021 GA²LEN. Allergy published by European Academy of Allergy and Clinical Immunology and John Wiley & Sons Ltd. This update and revision of the international guideline for urticaria was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA(2)LEN) and its Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs), the European Dermatology Forum (EDF; EuroGuiDerm), and the Asia Pacific Association of Allergy, Asthma and Clinical Immunology with the participation of 64 delegates of 50 national and international societies and from 31 countries. The consensus conference was held on 3 December 2020. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease that presents with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous or inducible urticaria is disabling, impairs quality of life, and affects performance at work and school. This updated version of the international guideline for urticaria covers the definition and classification of urticaria and outlines expert-guided and evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria.

The technological advancement of the pharmaceutical industry, resulting from the techniques of molecular biology and expansion of the knowledge of immunopathogenesis, has modified the therapeutic arsenal used in dermatology. Scientific research and regulatory standards cause drug costs to rise, thus making their use impossible in most public policies. In order to make high-cost drugs viable in the public health network, the Specialized Pharmaceutical Assistance Component was created. However, despite the frequent incorporation of medications, the constant requirement of drugs through lawsuits leads to exorbitant costs to the state budget. The present work analyzed through a descriptive observational study, the current situation of the Specialized Component and the involvement of medicines used in dermatology, through legal reviews, financial analyses, and medical articles, aiming at future incorporations for the specialty. When assessing the legal demands for dermatological drugs in the state of São Paulo, the specialty still has a low participation and psoriasis is the main disease involved in requiring drugs through the judicial system in the state. New methods of access to raw materials must be created to reduce legal issues. Cost-effectiveness and public planning studies are mandatory for incorporating new dermatological therapies.

Tuberculosis verrucosa cutis is a rare medical condition that is caused by the inoculation of Mycobacterium tuberculosis into the skin of a previously sensitized individual. This clinical form of tuberculosis corresponds to 1–2% of all cases of tuberculosis and due to the paucibacillary characteristic of the lesions, patients can be misdiagnosed, accounting for the chronification of the skin infection. Herein, we report the case of a 26-year-old male farmer, presenting plaques with verrucosa and hyperkeratosis features in the left thigh and buttocks during 15 years. M. tuberculosis was identified by PCR and the patient was treated with standard anti-tuberculosis drugs, with subsequent improvement of the skin lesions.

Multinucleate cell angiohistiocytoma is a rare, benign vascular proliferation of unknown etiology. It occurs mainly in middle-aged women and usually affects the acral regions; the lesions appear as discrete, grouped, and asymptomatic violaceous papules. Histopathology shows proliferation and dilated small vessels in the papillary dermis, fibrous stroma with thickened collagen bundles, and multinucleated giant cells. To date, there are approximately 140 cases described in the indexed literature. This report presents the case of a 62-year-old woman with a typical clinical condition, who chose not undergo treatment, considering the benign character of her illness. The clinical and immunohistological aspects of this unusual dermatological entity are emphasized.

Resumo Paciente do sexo feminino, 46 anos de idade, procurou o pronto socorro do Hospital Municipal Universitário apresentando lesões necróticas em membros inferiores associadas à síndrome consumptiva. Após anamnese e exame físico, obteve-se o diagnóstico de vasculite leucocitoclástica de modo imediato e econômico por meio da utilização de algoritmo específico de vasculites primárias, permitindo início precoce da terapêutica adequada. A boa evolução do quadro clínico ratificou a necessidade de se obter diagnóstico definitivo e início rápido da terapêutica. Abstract A 46-year-old female patient presented at the emergency department of a Municipal University Hospital with necrotic lesions in lower limbs associated with wasting syndrome. She was diagnosed with leukocytoclastic vasculitis after physical examination and history-taking in a fast and cost-effective manner, using an algorithm specifically for primary vasculitis, enabling early and appropriate treatment. The good clinical outcome demonstrates the need to quickly make a definitive diagnosis and start treatment.

A 46-year-old female patient presented at the emergency department of a Municipal University Hospital with necrotic lesions in lower limbs associated with wasting syndrome. She was diagnosed with leukocytoclastic vasculitis after physical examination and history-taking in a fast and cost-effective manner, using an algorithm specifically for primary vasculitis, enabling early and appropriate treatment. The good clinical outcome demonstrates the need to quickly make a definitive diagnosis and start treatment.

Livedoid Vasculopathy is a disease characterized by occlusion of the capillaries of the dermis, without inflammatory signs. It begins with purpuric papules or macules that develop into painful ulcers, mainly involving the ankles and feet. In this case report, we describe diagnosis and treatment in a young pregnant patient, with excellent clinical response. Resumo A vasculopatia livedoide é uma doença caracterizada pela oclusão dos capilares da derme, sem sinais inflamatórios. Tem início com pápulas ou máculas purpúricas que evoluem para úlceras dolorosas, com predominância na topografia de tornozelos e pés. Neste relato de caso, descrevemos o diagnóstico e a terapêutica em uma paciente jovem gestante, com excelente evolução clínica.

Adverse events and adverse drug reactions are common in clinical practice. Side effects range from the common to the rare and may be confused with other mucocutaneous manifestations resulting from several medications to treat infections, other medical conditions, and in the clinical setting of oncologic treatment. The objective of this chapter to review current data on adverse drug reactions, here classified as (i) severe adverse drug reactions, (ii) uncomplicated cutaneous adverse drug reactions, and (iii) adverse drug reactions caused by chemotherapy drugs, particularly those cases whereby the dermatologist is requested to issue a report and asked to comment on the safety and viability of readministration of a specific drug. We describe aspects associated with these events, presenting a detailed analysis of each of them.

Chromoblastomycosis is a subcutaneous mycosis that remains a therapeutic challenge, with no standard treatment and high rates of relapse. On the basis of our recent discoveries in mouse models, we tested the efficacy of topical applications of imiquimod to treat patients afflicted with this chronic fungal infection. We report results of treatment for the first 4 recipients of topical imiquimod, all of whom displayed a marked improvement of their lesions, both with and without concurrent oral antifungal therapy.

A literatura sobre o papel da resposta imune inata em dermatofitose é escassa. Este estudo se propôs a investigar a participação dos receptores do tipo Toll 2 e 4 (TLRs) 2 e 4 em pacientes com dermatofitose localizada (LD) e disseminada (DD, definida como lesões em pelo menos três segmentos corpóreos distintos), causadas por Trichophyton rubrum. Foram analisados cortes histológicos de 15 pacientes recém-diagnosticados, oito com LD e sete com DD. O grupo controle foi composto por 20 amostras de pele de indivíduos saudáveis submetidos a cirurgia plástica. TLR-2 e TLR-4 foram quantificados em lesões cutâneas por imunohistoquímica. Encontramos uma expressão reduzida de TLR-4 na epiderme superior e inferior nos dois grupos, LD e DD, quando comparados com o grupo controle; a expressão de TLR-2 foi preservada na epiderme superior e inferior de todos os três grupos. Como a sinalização por TLR-4 induz produção de citocinas inflamatórias e recrutamento de neutrófilos, a menor expressão desta molécula provavelmente contribui para a não resolução da infecção e conseqüente natureza persistente da dermatofitose. Como a sinalização via TLR-2 tem sido descrita como fator de regulação do processo inflamatório e de preservação da estrutura epidérmica, a sua expressão inalterada nas lesões dos pacientes com DD e DL pode contribuir também para a persistência da infecção e do reduzido processo inflamatório que são característicos das infecções por dermatófitos. There are few studies on the role of innate immune response in dermatophytosis. An investigation was conducted to define the involvement of Toll-Like Receptors (TLRs) 2 and 4 in localized (LD) and disseminated (DD) dermatophytosis due to T. rubrum. Fifteen newly diagnosed patients, eight patients with LD and seven with DD, defined by involvement of at least three body segments were used in this study. Controls comprised twenty skin samples from healthy individuals undergoing plastic surgery. TLR2 and TLR4 were quantified in skin lesions by immunohistochemistry. A reduced expression of TLR4 in the lower and upper epidermis of both LD and DD patients was found compared to controls; TLR2 expression was preserved in the upper and lower epidermis of all three groups. As TLR4 signaling induces the production of inflammatory cytokines and neutrophils recruitment, its reduced expression likely contributed to the lack of resolution of the infection and the consequent chronic nature of the dermatophytosis. As TLR2 expression acts to limit the inflammatory process and preserves the epidermal structure, its preserved expression may also contribute to the persistent infection and limited inflammation that are characteristic of dermatophytic infections.

An uncommon skin manifestation of Dermatitis Herpetiformis is palmar and plantar purpura. Dermoscopic examination is useful for any skin condition since it allows recognition of structures that are not discernible to the naked eye. A 22 year-old Caucasian man was admitted with excoriated lesions and pruritus. Petechial lesions could be seen on volar aspect of the digits on the hands and feet. Dermoscopy examination revealed erythematous and violaceous dots and erythematous and brown dots. Púrpura palmar e plantar é uma manifestação cutânea incomum da Dermatite Herpetiforme. A dermatoscopia é útil para o exame dermatológico por permitir o reconhecimento de estruturas que ao olho nu não são perceptíveis. Doente caucasiano masculino de 22 anos que queixava-se de lesões escoriadas e prurido. Observouse na face volar dos dedos dos pés e das mãos lesões petequiais. O exame dermatoscópico revelou pontos eritematosos e violáceos, além de pontos eritematosos e marrons.

BACKGROUND: It has been demonstrated that neutrophils, eosinophils and monocytes, under appropriated stimulus, may express tissue factor and therefore, activate the extrinsic pathway of coagulation. We performed a transversal and case-control study of patients with chronic urticaria and patients with psoriasis, in our outpatient clinic to evaluate the production of D-dimer. OBJECTIVE: To evaluate D-dimer serum levels in patients with chronic urticaria and its possible correlation with disease activity. PATIENTS AND METHODS: The study was conducted from October 2010 until March 2011. We selected 37 consecutive patients from our Allergy Unit and Psoriasis Unit, and divided them into three groups for statistical analysis: (i) 12 patients with active chronic urticaria (CU); (ii) 10 patients with chronic urticaria under remission and (iii) 15 patients with psoriasis (a disease with skin inflammatory infiltrate constituted by neutrophils, lymphocytes and monocytes). Another five patients with urticarial vasculitis were allocated in our study, but not included in statistical analysis. The serum levels of D-dimer were measured by Enzyme Linked Fluorescent Assay (ELFA), and the result units were given in ng/ml FEU. RESULTS: Patients with active chronic urticaria had the highest serum levels of D-dimer (p

Nós descrevemos uma mulher de 41 anos em tratamento de câncer colorretal avançado que, após a segunda dose de cetuximabe, desenvolveu intensa blefarite e tricomegalia bilateral. A toxicidade ocular decorrente do cetuximabe tem sido relatada, porém ainda tem mecanismos fisiopatogênicos incertos. This report describes the case of a 41-year old woman in treatment for advanced colorectal cancer who developed severe bilateral blepharitis and trichomegaly after the second dose of cetuximab. Cetuximab-related eyelid toxicity has been described previously; however, its pathogenesis has not yet been clearly established.

O nevo de Meyerson ocorre quando uma rara erupção eczematosa focal e transitória surge ao redor de lesões melanocíticas. O mesmo fenômeno também foi observado em lesões não melanocíticas. O caso relatado é o de um doente masculino, 25 anos, que há dois meses notara surgimento de eritema e prurido, circundando dois nevos, localizados no abdome. As lesões eram atípicas à dermatoscopia e procedeu-se à excisão cirúrgica dos dois nevos. O exame histopatológico revelou nevos melanocíticos compostos displásicos, envolvidos por espongiose e vesículas intraepidérmicas. O presente relato sugere que o fenômeno de Meyerson não modifica as características dermatoscópicas dos nevos. Meyerson nevi occur whenever a rare focal and transitory eczematous eruption arises around melanocytic lesions. The same phenomenon has also been observed in non-melanocytic lesions as well. Herein we report the case of a 25 year old, male patient, who had noticed, two months before, the arising of a pruriginous and erithematous halo around two nevi localized on his abdomen. The lesions were found to be atypical on dermoscopic examination and he was submitted to surgical excision of both nevi. Histopathological examination revealed displastic compound melanocytic nevi, surrounded by intraepidermical vesicles and spongiosis. Present report suggests that Meyerson phenomenon does not seem to alter dermoscopic features of nevi.

O nevo de Meyerson ocorre quando uma rara erupção eczematosa focal e transitória surge ao redor de lesões melanocíticas. O mesmo fenômeno também foi observado em lesões não melanocíticas. O caso relatado é o de um doente masculino, 25 anos, que há dois meses notara surgimento de eritema e prurido, circundando dois nevos, localizados no abdome. As lesões eram atípicas à dermatoscopia e procedeu-se à excisão cirúrgica dos dois nevos. O exame histopatológico revelou nevos melanocíticos compostos displásicos, envolvidos por espongiose e vesículas intraepidérmicas. O presente relato sugere que o fenômeno de Meyerson não modifica as características dermatoscópicas dos nevos.

Lesões decorrentes da infecção pelo papilomavírus humano na infância, em especial as verrugas anogenitais, são um importante problema epidemiológico e terapêutico. O tratamento das verrugas anogenitais na infância é um desafio terapêutico. Os tratamentos convencionais geralmente são dolorosos e necessitam de anestesia geral. O imiquimode, um imunomodulador tópico, constitui uma alternativa terapêutica. Serão descritos quatro casos tratados com sucesso utilizando creme de imiquimode a 5% aplicado topicamente. In children, lesions caused by the human papillomavirus (HPV) constitute a significant epidemiological issue and a therapeutic dilemma, particularly in the case of anogenital warts. The treatment of anogenital warts in children is a challenge, since standard treatments are generally painful and require the patient to be anesthetized. Imiquimod, a topical immune response modifier, constitutes an alternative therapeutic agent for the treatment of HPV. The present report describes four cases in which treatment with topically applied imiquimod 5% cream was implemented with successful results.

O tratamento local e sistêmico das neoplasias pode causar alterações na pele, membranas mucosas, cabelos e unhas. O diagnóstico preciso e o tratamento adequado destes efeitos colaterais requerem conhecimento dos padrões das reações adversas mais comuns para as medicações que o paciente está utilizando. O dermatologista deve estar familiarizado com as manifestações tegumentares das neoplasias, bem como com os efeitos adversos mucocutâneos dos tratamentos antineoplásicos. The local and systemic treatment of tumors can cause changes in the skin, mucous membranes, hair and nails. Accurate diagnosis and appropriate treatment of side effects require knowledge about the patterns of the most common adverse reactions to drugs the patient may be using. The dermatologist must be familiar with the manifestations of certain soft tissue neoplasms, as well as with the adverse mucocutaneous forms of cancer treatment.

FUNDAMENTOS: A cromoblastomicose é uma micose subcutânea que acomete principalmente homens trabalhadores rurais, sendo cada vez mais observada em outras atividades profissionais. O fungo penetra na pele após inoculação, e o agente mais frequentemente isolado é a Fonsecaea pedrosoi. OBJETIVOS: Este estudo visa a avaliar os pacientes com cromoblastomicose admitidos no departamento de dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no período de 1997 a 2007. MÉTODOS: É um estudo retrospectivo, utilizando a revisão de prontuários, e inclui 27 pacientes. Analisaram-se os tratamentos prévios e os atuais instituídos, o tempo entre o aparecimento das lesões e o diagnóstico, a idade, o gênero, a profissão, a procedência, a localização das lesões e os agentes isolados em cultivo. RESULTADOS: Vinte e dois pacientes eram procedentes do estado de São Paulo. Os demais eram procedentes da Bahia e Rondônia. A maioria dos pacientes estudados eram trabalhadores rurais (37%). Os homens foram os mais acometidos (85%). A maior parte dos pacientes apresentava lesões nos membros inferiores (59,2%). Em 52% dos casos foi isolado o fungo F. pedrosoi. O exame anatomopatológico mostrou corpos escleróticos em 92,5% dos casos. CONCLUSÃO: Os dados encontrados estão concordantes com os da literatura, sendo este o segundo estudo retrospectivo sobre as características dos doentes portadores de cromoblastomicose no âmbito do estado de São Paulo publicado na literatura indexada. BACKGROUND: Chromoblastomycosis is a subcutaneous mycosis that occurs mainly in rural workers although is being more commonly found among people working in other sectors. The fungus penetrates the skin after its inoculation and the most frequently isolated agent is the Fonsecaea pedrosoi. OBJECTIVES: This study aims at evaluating patients suffering from chromoblastomycosis admitted into the Department of Dermatology of the University Hospital of the Faculty of Medicine of São Paulo State during the ten-year period from 1997 to 2007. METHODS: It is a retrospective study and the medical report cards of 27 Brazilian patients diagnosed as suffering from Chromoblastomycosis from 1997 to 2007 at the Dermatology Department of the Medical School, University of Sao Paulo were reviewed. The following items were analyzed: previous therapeutic approaches; treatment implemented by the group; length of time between the appearing of the lesion and diagnosis; age; gender; profession; origin; site of lesions; isolated agents found in culture and histopathology. RESULTS: Twenty two patients were from the state of Sao Paulo whereas the others came from the states of Bahia and Rondonia. 37% of them were rural workers. Men were more frequently infected (85%). Lesions were more commonly found on the lower limbs (59.2%). In 52% of the cases the isolated agent was the dematiaceous fungus Fonsecaea. pedrosoi. Biopsies showed sclerotic bodies in 92.5% of the cases. CONCLUSION: Data found are in accordance with medical literature on the subject. The disease had been previously studied in our institution in 1983 by Cucé et al. This present study is the second retrospective one about the characteristics of patients suffering from chromoblastmycosis which has been published in indexed medical literature in the state of Sao Paulo.

Os autores relatam o caso clínico de uma doente que procurou atendimento dermatológico em decorrência da presença de lesão em placa papulosa de superfície verrucosa no cotovelo esquerdo. In this report, the authors describe the clinical case of a woman seeking care at this dermatology outpatient clinic with a verrucous plaque on her left elbow.

FUNDAMENTOS: O termo telemedicina faz referência ao uso de tecnologias de comunicação para a transmissão a distância de informações relacionadas à saúde. Esse recurso é utilizado em várias especialidades médicas, principalmente naquelas em que a interpretação de imagens representa uma etapa fundamental na formulação diagnóstica. OBJETIVO: Avaliar a concordância entre o diagnóstico presencial e o diagnóstico a distância de lesões cutâneas, utilizando a teledermatologia, em pacientes atendidos em uma unidade básica de saúde. MÉTODOS: Foi realizado um estudo prospectivo envolvendo pacientes atendidos no serviço de dermatologia da clínica FTC em Salvador - BA. Participaram do estudo um dermatologista responsável pela consulta presencial e dois dermatologistas responsáveis pela consulta a distância. Os diagnósticos obtidos através da teleconsulta foram avaliados quanto à concordância e comparados com os diagnósticos da consulta presencial. RESULTADOS: Foram incluídos neste estudo 60 pacientes. Observou-se um grau de concordância total variando de 86,6% a 91,6% com índice Kappa de 0,62. CONCLUSÃO: A teledermatologia é uma forma de assistência com um grande potencial de uso na dermatologia, podendo representar uma ferramenta útil principalmente em casos clínicos de baixa complexidade, oriundos de unidades básicas de saúde. BACKGROUND: Telemedicine can be defined as the use of telecommunication technologies for the transmission of health data. It has been described in different medical specialties, especially those in which interpretation of images represents a fundamental key in formulating diagnosis. OBJECTIVE: To evaluate the role of teledermatology in primary care system. METHODS: A prospective analysis included 60 patients seen in a primary care unit. All patients were seen by a dermatologist as regular outpatient dermatology consultation. A medical student obtained digital images and a brief clinical history of all patients. Using a Telemedicine system these data were reviewed by two dermatologists for distance diagnosis. Agreement between the diagnoses was assessed. RESULTS: Good agreement, ranging from 86.6% to 91.6%, was achieved between direct observation and teleconsultation. Good agreement was also achieved between two telemedicine diagnosis (Kappa = 0.62). CONCLUSION: Teledermatology is a form of care with great potential for use in dermatology, and could represent a useful tool in cases of low complexity from primary health units.

As vasculites são constituídas por um grande grupo de síndromes caracterizadas por inflamação e necrose da parede dos vasos sangüíneos, resultando em estreitamento ou oclusão do lúmen. A distribuição dos vasos envolvidos varia consideravelmente e serve de base para a classificação das síndromes vasculíticas: grandes vasos (arterite de Takayasu, arterite temporal); pequenos e médios vasos (poliarterite nodosa, síndrome de Churg-Strauss, granulomatose de Wegener, vasculites nas doenças reumáticas); e pequenos vasos (vasculite de hipersensibilidade, púrpura de Henoch-Schonlein, poliangeíte microscópica, crioglobulinemia). Este artigo revisa as vasculites dos médios e grandes vasos e opções terapêuticas atuais; além de oferecer orientação sobre abordagem diagnóstica e tratamento dos pacientes com suspeita de vasculite cutânea. Vasculitis comprises a broad group of syndromes characterized by inflammation and necrosis on the walls of blood vessels, resulting in narrowing or occlusion of the lumen. The distribution of involved blood vessel varies considerably and serves as the basis for one classification of vasculitic syndromes: large vessels (Takayasu arteritis, giant cell arteritis); medium and small muscular arteries (polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, vasculitis in rheumatic diseases); and small vessels ("hypersensitivity" vasculitis, Henoch-Schonlein purpura, microscopic polyangiitis, cryoglobulinemia). This article reviews medium and large vessel vasculitis and current treatment options; it also presents a comprehensive approach to diagnosing and treating patients with suspected cutaneous vasculitis.

O escopo deste artigo é revisar os estados de hipercoagulabilidade sangüínea (trombofilias) mais provavelmente encontrados por dermatologista. Seus sinais cutâneos incluem o livedo reticular, necrose cutânea, ulcerações e isquemia digital, púrpura retiforme, além de úlceras nas pernas. Revisamos seu tratamento adequado, bem como ressaltamos as manifestações cutâneas que impõem pesquisa laboratorial de trombofilias e os exames indicados nessas situações. The aim of this article is to review the hypercoagulable states (thrombophilia) most probably found by dermatologists; their cutaneous signs including livedo racemosa, skin necrosis, digital ischemia and ulcerations, retiform purpura and leg ulcers; their appropriate treatment; to describe the skin manifestations that require laboratory tests for thrombophilias and the tests indicated in these clinical conditions.

A urticária apresenta-se com diversas formas clínicas e causas distintas. Constitui uma das dermatoses mais freqüentes: 15% a 20% da população têm pelo menos um episódio agudo da doença em sua vida, resultando em percentual que varia de um a 2% dos atendimentos nas especialidades de Dermatologia e Alergologia. A urticária é classificada do ponto de vista de duração da evolução temporal em aguda (inferior a seis semanas) ou crônica (superior a seis semanas). O tratamento da urticária pode compreender medidas não farmacológicas e intervenções medicamentosas, as quais são agrupadas em tratamentos de primeira (anti-histamínicos), segunda (corticosteróides e antileucotrienos) e terceira linha (medicamentos imunomoduladores). As medidas terapêuticas de segunda e terceira linha apresentam maiores efeitos adversos, devendo ser reservadas aos doentes que não apresentaram controle da doença com os de primeira linha, ou àqueles a respeito dos quais não é possível estabelecer uma etiologia, tal como nas urticárias auto-imunes. Urticaria has diverse clinical presentations and causes. It is one of the most frequent dermatological conditions: 15% to 20% of population has at least one acute eruption during their lifetime, resulting in 1% to 2% of dermatological and allergological visits. Urticaria is classified based on its temporal evolution as acute (less than 6 weeks) or chronic (more than 6 weeks). Management strategies may involve non-pharmacological measures and drug interventions, which are grouped into first- (antihistamines), second- (corticosteroids and anti-leukotrienes) and third-line therapies (immunomodulators). Stronger, but potentially riskier, second- and third-line management may be justified for patients who do not respond to first-line therapy, or whenever a specific etiology cannot be determined, such as in autoimmune urticaria.

A urticária apresenta-se com diversas formas clínicas e causas distintas. Constitui uma das dermatoses mais freqüentes: 15% a 20% da população têm pelo menos um episódio agudo da doença em sua vida, resultando em percentual que varia de um a 2% dos atendimentos nas especialidades de Dermatologia e Alergologia. A urticária é classificada do ponto de vista de duração da evolução temporal em aguda (inferior a seis semanas) ou crônica (superior a seis semanas). O tratamento da urticária pode compreender medidas não farmacológicas e intervenções medicamentosas, as quais são agrupadas em tratamentos de primeira (anti-histamínicos), segunda (corticosteróides e antileucotrienos) e terceira linha (medicamentos imunomoduladores). As medidas terapêuticas de segunda e terceira linha apresentam maiores efeitos adversos, devendo ser reservadas aos doentes que não apresentaram controle da doença com os de primeira linha, ou àqueles a respeito dos quais não é possível estabelecer uma etiologia, tal como nas urticárias auto-imunes.

Orientador: Elemir Macedo de Souza Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas Resumo: O objetivo deste estudo foi verificar o desenvolvimento de nevos melanocíticos (NM) e a ocorrência de efélides, importantes fatores de risco para melanoma cutâneo, nos alunos de uma escola particular composta majoritariamente por descendentes de holandeses na cidade de Holambra - SP, Brasil e fornecer informações sobre a influência do meio ambiente nestes indivíduos que mantiveram características fenotípicas semelhantes às de seus antepassados e que não se dispersaram, permanecendo unidos em comunidades isoladas. Em 1999, o autor iniciou estudo coorte para contagem de NM nos 282 alunos (53.9% meninos) com idades entre 3 e 17 anos. Cinco anos mais tarde, o mesmo autor realizou novo exame envolvendo 148 (52.43% de resposta) alunos, 73 (49.32%) meninos e 75 (50.67%) meninas com idades entre 8 e 22 anos, entre 2006 e 2007. Verificou-se os dados sócio-demográficos e físicos e as manifestações dermatológicas. Analisou-se a alteração das manifestações aferidas no exame dermatológico e a relação das variáveis principais (idade, sexo, fototipo, cor dos olhos, cor dos cabelos, uso de proteção solar, etnia dos alunos e dos pais) com a presença de NM e efélides no início e no final do estudo. Verificou-se que foi significativo o aumento no número de NM tanto nas áreas cobertas quanto nas áreas expostas dos alunos no final do estudo. O estudo revelou ainda que os meninos tiveram maior número total de NM (tanto nas áreas cobertas quanto nas áreas expostas) que as meninas e que houve aumento significativo na ocorrência de nevos displásticos (ND) no seguimento. Foi significativo o aumento na ocorrência de efélides nos alunos de etnia holandesa com pele, cabelos e olhos claros e que não utilizaram proteção solar. O resultado da análise de probabilidade com nível de significância 5% e intervalo de 95% de confiança para a razão de risco revelou que os meninos têm mais chance de desenvolver NM (tanto nas áreas cobertas quanto nas áreas expostas) que as meninas e que os alunos de etnia não miscigenada e miscigenada e com cabelos claros têm respectivamente mais chance de desenvolver NM que os alunos de outras etnias e com cabelos escuros. A análise revelou ainda que os alunos com fototipo I são mais propensos a desenvolver NM nas áreas cobertas que os alunos do fototipo II e III. A ocorrência de efélides foi maior nos alunos do fototipo I, com ascendência paterna e materna holandesa e com cabelos claros. Este pode ser considerado o primeiro estudo prospectivo realizado no Brasil para verificar o desenvolvimento de NM e os dados obtidos neste estudo contribuíram para demonstrar que os alunos que mantiveram as características fenotípicas de seus antepassados têm maior probabilidade de desenvolver NM e efélides que os alunos pertencente aos outros grupos étnicos. Abstract: The objective of this study was to verify the development of melanocytic nevi (MN) and ephelides, important risk factors for cutaneous melanoma, in students of a private school who were mostly Dutch and Dutch descendants in Holambra, Brazil and to obtain information about the effects of environmental factors on these individuals who maintained phenotypical characteristics similar to those of their ancestors. In 1999, the author began a cohort study to count NM in 282 students (53.9% boys) aged between 3 and 17 years. Five years later, the study follow-up was carried out by the same author involving 148 (52.43% response) students, 73 (49.32%) boys and 75 (50.67%) girls aged between 8 and 22 years, from 2006 to 2007. The social-demographic and physical characteristics, as well as the cutaneous manifestations were verified. Cutaneous manifestations alterations and the relationship of these main variables (age, sex, skin phototype, eye color, hair color, photoprotection mechanisms and ethnic group) with the presence of MN and ephelides at the beginning and at the end of study were verified. The increase in number of MN, both in covered areas and exposed areas was significant at the end of study. The study also revealed that the boys had a higher total number of MN, both in covered areas and exposed areas, than the girls and there was significant increase of dysplastic nevi (DN) at the end of study. The increase of occurrence of ephelides in students from the non-mixed group, with skin phototype I, with light-colored hair and eyes and in those who never used protection was significant. The result of probability analysis with a 5 % significance level and 95% confidence interval for the odds ratio revealed that the boys have greater probability of developing nevi in covered and exposed areas than the girls, and that the non-mixed and mixed ethnic groups with light-colored hair had respectively greater probability of developing MN than the students from other ethnic groups and those with dark-colored hair. The analysis also revealed that the students with skin phototype I had greater probability of developing MN in the covered areas than the students with skin phototype II and III. The occurrence of ephelides was greater in the students with skin phototype I, with paternal and maternal Dutch ascendants and with light-colored hair. This study may be considered the first prospective study carried out in Brazil to verify the development of MN. The data obtained in this study contributed to demonstrate that the students that retain the phenotypical characteristics of their ancestors have greater probability of developing MN and ephelides than the other ethnic groups. Doutorado Clínica Médica Doutor em Ciências Médicas

Orientador: Elemir Macedo de Souza Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas Resumo: O lúpus eritematoso (LE) é uma doença auto-imune com espectro clínico variado. O lúpus eritematoso cutâneo (LEC) inclui o lúpus eritematoso agudo (LECA), o subagudo (LECSA) e o crônico (LECC). Lesões acrômicas podem ocorrer durante a evolução do LE, embora nunca tenham sido estudadas histologicamente. O objetivo deste trabalho é descrever os achados clínicos, laboratoriais e histológicos das lesões acrômicas no LE. Foram selecionados 12 pacientes com LE de um grupo de 220 atendidos no período de 2005 a 2008, sendo sete com LECC e cinco com LECSA. Doze pacientes com vitiligo e 10 controles de pele sã foram usados para comparação. As alterações histológicas encontradas foram: infiltrado inflamatório (75%); hiperceratose e espessamento da zona da membrana basal (ZMB) (66,7%); retificação da epiderme (58,3%); ceratinócitos apoptóticos epidérmicos, elastose e telangectasias (50%); fibrose (41,7%); degeneração vacuolar da ZMB (33,3%); rolhas córneas (16,7%). O diagnóstico histológico de LE foi possível em quatro casos. Melanina pela coloração de Fontana Masson (FM) foi vista em cinco casos e incontinência pigmentar em quatro. Melanócitos foram evidenciados em amostras de cinco doentes através da reação imunohistoquímica pelo HMB45 e Melan-A, com diferença estatística em relação aos controles. Quando comparado ao vitiligo, a diferença foi estatisticamente significante para os achados histológicos: ceratinócitos apoptóticos epidérmicos (p=0,014), espessamento da ZMB (p=0,009) e fibrose (p=0,037). Em relação à quantificação dos melanócitos, não houve diferença estatística entre o grupo LE e vitiligo usando os anticorpos Melan-A e HMB45. Concluímos que as lesões acrômicas no LE correspondem a lesões residuais, decorrentes de processo inflamatório liquenóide prévio que destrói os melanócitos. Não é possível diferenciar as lesões vitiligóides das duas dermatoses pela presença ou ausência de melanócitos, embora a repigmentação seja possível em ambas as doenças devido a presença de melanogênese ativa comprovada pela positividade pelo HMB45 Abstract: Lupus Erythematosus (LE) is an autoimmune disorder with multiple clinical manifestations. Skin damage is a hallmark of the disease. Cutaneous LE (CLE) includes acute LE (ACLE), subacute LE (SCLE) and chronic LE (CCLE). Although achromic lesions are often found in patients with LEC, there are no detailed data about the histological features of such lesions. Therefore, we designed this study to determine clinical, laboratorial and histological profile of patients with LEC presenting achromic lesions. Between 2005 and 2008, we identified 12 individuals with LEC and acromic lesions from a larger group of 220 patients with LEC that were followed at the Dermatology outpatient clinic. There were seven patients with LECC and five with LECSA. Twelve patients with chronic stable vitiligo and 10 controls of unaffected skin were used for comparison. The most frequent histological abnormalities found in LEC-related achromic lesions were inflammatory infiltrates (75%); hyperkeratosis and thickening of the basement membrane (BM) (66.7%); epidermal flattening (58.3%); apoptotic epidermal keratinocytes, elastosis and vasodilation (50%); fibrosis (41.7%); hydropic degeneration of the basal cells (33.3%); follicular plugging (16.7%). These achromic lesions retained histological features that enabled the diagnosis of CLE to be established in four patients. Fontana Masson (FM) staining was positive for melanin in five cases and revealed pigmentary incontinence in four. Immunohistochemistry for HMB45 and Melan-A identified melanocytes in five CLE-related achromic lesions. Melanocyte counts were significantly smaller in achromic lesions when compared to unaffected skin samples. When compared to vitiligo, CLE-related achromic lesions showed more frequently apoptotic epidermal keratinocytes (p=0,014), thickening of the BM (p=0,009) and fibrosis (p=0,037). Melanocyte counts according to immunohistochemistry were similar in CLE and vitiligo groups. Our results indicate that CLE-related achromic lesions represent residual scars due to chronic lichenoid inflammation that leads to melanocyte destruction. Melanocyte count does not help to distinguish CLE-related achromic lesions and true vitiligo lesions. Despite this, HMB45 staining was sometimes positive in both conditions, which indicates active melanogenesis and suggests that repigmentation may be possible at least for some individuals Doutorado Clínica Médica Doutor em Clínica Médica

This update and revision of the international guideline for urticaria was developed following the methods recommended by Cochrane and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group. It is a joint initiative of the Dermatology Section of the European Academy of Allergology and Clinical Immunology (EAACI), the Global Allergy and Asthma European Network (GA(2)LEN) and its Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs), the European Dermatology Forum (EDF; EuroGuiDerm), and the Asia Pacific Association of Allergy, Asthma and Clinical Immunology with the participation of 64 delegates of 50 national and international societies and from 31 countries. The consensus conference was held on 3 December 2020. This guideline was acknowledged and accepted by the European Union of Medical Specialists (UEMS). Urticaria is a frequent, mast cell-driven disease that presents with wheals, angioedema, or both. The lifetime prevalence for acute urticaria is approximately 20%. Chronic spontaneous or inducible urticaria is disabling, impairs quality of life, and affects performance at work and school. This updated version of the international guideline for urticaria covers the definition and classification of urticaria and outlines expert-guided and evidence-based diagnostic and therapeutic approaches for the different subtypes of urticaria., Urticaria and Angioedema Centers of Reference and Excellence (UCAREs and ACAREs); European Union (EU); 6th Framework Programme; Global Allergy and Asthma European Network (GA2LEN); European Academy of Allergology and Clinical Immunology (EAACI); Asia Pacific Association of Allergy, Asthma and Clinical Immunology (APAAACI); European Dermatology Forum (EDF)

This document summarizes the aims of GA2 LEN/HAEi Angioedema Centers of Reference and Excellence (ACAREs) and elaborates the requirements that ACAREs must fulfill to become certified. It also provides (see Appendix S1) background information on GA2LEN and HAEi, including HAEi member organizations and regional patient advocates, on why we need an Angioedema Center of Reference and Excellence (ACARE) program and network, and on the accreditation and certification process, governance and funding, and on the interaction with other GA2LEN networks of centers of reference and excellence. The protocols, aims, requirements, and provisions related to becoming a certified CARE are based on (a) the experience of the GA2LEN UCARE network and (b) input from angioedema patients, general practitioners, and angioedema specialists.

Orientadores: Elemir Macedo de Souza, Maria Letícia Cintra Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas Resumo: As etapas cruciais da carcinogênese cutânea incluem disfunção da proteína supressora tumoral p53 e angiogênese. A contribuição de tais eventos, individual e sinergicamente, ainda não está bem estabelecida na cascata de fenômenos que resultam no carcinoma espinocelular cutâneo. Objetivou-se avaliar a expressão imuno-histoquímica da p53, o índice proliferativo e a angiogênese nos estádios evolutivos do carcinoma espinocelular cutâneo, e investigar a relação da expressão da p53 com as demais variáveis. Foram estimadas as porcentagens de células imunomarcadas para p53 e Ki-67 em três grupos de cânceres: 30 queratoses solares, 30 carcinomas espinocelulares superficialmente invasores e 30 carcinomas espinocelulares invasores. O método Chalkley foi utilizado para quantificar a área microvascular, empregando-se marcador de neoangiogênese (CD105) e pan-endotelial (CD34) em cada grupo. A área microvascular em amostras marcadas pelo CD105 aumentou, significantemente, com a progressão do carcinoma espinocelular cutâneo. O mesmo não ocorreu com o uso do CD34. Contudo, nos três grupos (queratose solar, carcinoma espinocelular superficialmente invasor e invasor) encontrou-se aumento significante da área microvascular, com ambos os marcadores (CD34 e CD105), em comparação à respectiva pele adjacente. Não houve diferença significante na taxa de células positivas para p53 e Ki-67 entre os grupos. Encontrou-se correlação positiva e significante entre a área microvascular marcada pelo CD105 e o índice de marcação para a p53 no carcinoma espinocelular superficialmente invasor, bem como entre o índice de marcação para p53 e para o Ki-67 no carcinoma espinocelular invasor. A conversão angiogênica é um evento precoce no carcinoma espinocelular cutâneo, e a neovascularização é paralela à progressão do tumor. O uso do CD105 permite avaliar a atividade angiogênica no tumores escamosos. A angiogênese no estádio inicial da invasão e a atividade proliferativa na fase francamente invasora estão associadas com a expressão imuno-histoquímica da proteína p53. A perda da função supressora tumoral da p53, em etapas progressivas, atua diretamente na carcinogênese cutânea Abstract: Multistep skin carcinogenesis crucially involves loss of function of p53 tumor suppressor protein and angiogenesis. The contribution of such events, individually and synergically, is not well established in the cascade of phenomena that results in cutaneous squamous cell carcinoma. We aimed to evaluate the immunohistochemical expression of p53, the proliferative index and angiogenesis in spectral stages of cutaneous squamous cell carcinoma, and investigate the relationship between p53 expression with the other variables. We estimated the percentages of immunostained cells for p53 and Ki-67 (proliferation marker) in three groups of cancer: 30 solar keratoses, 30 superficially invasive squamous cell carcinomas and 30 invasive squamous cell carcinomas. The Chalkley method was used to quantify the microvascular area by neoangiogenesis (CD105) and panendothelial (CD34) immunomarker in each group. The microvascular area in CD105-stained specimens significantly increased with cutaneous squamous cell carcinoma progression. However, no differences between groups were found in CD34 sections. Solar keratosis, superficially invasive squamous cell carcinoma and invasive squamous cell carcinoma samples showed significant increases in microvascular area for both CD34- and CD105-stained specimens compared with the respective adjacent skin. There was no significant difference for the rate of p53- and Ki-67-positive cells between the groups. Significant positive correlation was found between the CD105 microvascular area and the rate of p53 positive cells in superficially invasive squamous cell carcinoma as well as between the rate of p53- and Ki-67-positive cells in invasive squamous cell carcinoma. The angiogenic switch is an early event in cutaneous squamous cell carcinoma, and the rate of neovascularization is parallel to tumor progression. In contrast to panendothelial markers, CD105 use allows evaluating angiogenic activity in squamous tumors. Neovascularization in the initial stage of invasion and proliferative activity in the frankly invasive stage were both associated with p53 immunoexpression. Loss of p53 tumor suppressor function through progressive steps is directly involved in skin carcinogenesis Doutorado Clínica Médica Doutora em Ciências FAPESP 07/52603-0