Liporeduction by endocoagulation

BACKGROUND

Plastic surgery and dermatologic techniques are constantly being improved, but clinical expression of the aging process and its surgical management remains a challenge.

OBJECTIVE

To evaluate an alternative surgical approach for submandibular, mental, and periorbital loose tissue treatment.

METHODS

We present a modified transcutaneous bipolar diathermy microprobe using the coaxial principle for the treatment of mental, submandibular, and periorbital loose tissue.

RESULTS

The outcome was evaluated as satisfactory for the following reasons: lower morbidity, it is a simple time-saving surgical technique, no healing difficulties, less dehiscence, no wound exposure, minimal incisions, and a faster postoperative recovery with a simple wound care.

CONCLUSION

We suggest that this procedure is a simple surgical approach that delays extensive plastic surgery.

Tretinoin peeling

BACKGROUND

Topical tretinoin has been used for a long time to improve photoaged skin, but this therapy takes quite a few months to show some clinical changes. Because of that, we think tretinoin peeling would be an excellent choice for improvement of photoaged skin.

OBJECTIVE

[corrected] Our objective was to show the clinical and histologic modifications of the skin after five sessions of tretinoin peeling.

METHODS

The authors studied the clinical and histologic modification that occurred in 15 female patients after conducting tretinoin peeling procedures twice a week in concentrations of 1-5%. Conventional sectioning of punch biopsy specimens was conducted before and after the treatment.

RESULTS

Clinical improvement was observed in the skin texture and appearance. Through histologic examinations, a decrease in the corneous layer and an increase in the epidermal thickness were noticed, inducing an improvement of its stratification, as well as the formation of cristae cutis.

CONCLUSION

It was concluded that the peeling conducted with serial tretinoin showed good clinical and histologic results, especially for the treatment of photoaged skins I and II, melasma, ephelis, and acne degree I, as well as being practical, quick, and easily accomplished with no side effects.

Onychomycosis caused by Scytalidium dimidiatum. Report of two cases. Review of the taxonomy of the synanamorph and anamorph forms of this coelomycete

The authors report two cases of onychomycosis in the dystrophic form, one of them involving an HIV-positive patient, provoked by Scytalidium dimidiatum, previously called Scytalidium lignicola. The subject is reviewed from the taxonomic viewpoint, considering the anamorph Hendersonula toruloidea as a synonym of Nattrassia mangiferae, and having Scytalidium dimidiatum as the major synanamorph. According to many mycologists, Scytalidium hyalinum may be a separate species or a hyaline mutant of Scytalidium dimidiatum. Scytalidium lignicola Pesante 1957 was considered to be the type-species of the genus by ELLIS (1971)13 and later to be a "conidial state" of Hendersonula toruloidea by the same author, today known as Nattrassia mangiferae. The microorganism lives only on the roots of certain plants (mainly Platanus and Pinus). It produces pycnidia and is not considered to be a pathogen, although it is considered as a possible emerging agent capable of provoking opportunistic fungal lesions. The importance of this topic as one of the most outstanding in fungal taxonomy, so likely to be modified over time, as well as its interest in the field of dermatologic mycology, are emphasized.

Efficacy, safety and tolerability of terbinafine for Tinea capitis in children: Brazilian multicentric study with daily oral tablets for 1,2 and 4 weeks

BACKGROUND

Tinea capitis is a common skin disease seen predominantly in children. The standard therapies for this disease are griseofulvin and ketoconazole. Nevertheless, these drugs have drawbacks in that they are only fungistatic and require treatment for at least 6 weeks. Previous studies with oral terbinafine for the treatment of Tinea capitis have shown that this agent is effective when given for 4 weeks, comparable to an 8-week regimen with griseofulvin. To date there is no data on the use of oral terbinafine in Brazilian children.

OBJECTIVES

To assess the efficacy, safety and tolerability of oral terbinafine in short-term treatments (1-, 2- and 4-week treatment) of Tinea capitis in children.

PATIENTS AND METHODS

One hundred and thirty-two children aged 1-14 years were enrolled in this study, but only 107 were considered for the final efficacy analysis. Diagnosis included clinical assessment and examination by Wood's light. Confirmation was obtained by direct microscopy and culture for fungus. Terbinafine dosage (125 or 250 mg/day) was adjusted according to patient weight. Efficacy was evaluated both by clinical and mycological assessment. Safety and tolerability variables included data on adverse reaction and clinical laboratory evaluations.

RESULTS

Mycological evaluation in the follow-up visit at week 12 showed negative direct microscopy and culture results in 48.6, 60.5 and 69.7% patients in groups 1-, 2- and 4-week, respectively (n.s.). At week 12, 84.8% patients in group 4-week achieved clinical cure with a significant difference compared to groups 1- and 2-week, 54.3 and 60.5%, respectively (P < 0.01). Adverse reactions were present in 4.8, 6.8 and 10.9% of patients in groups 1-, 2- and 4-week, respectively. terbinafine was not associated with clinically relevant increases in liver function tests.

CONCLUSIONS

Terbinafine is an effective, well tolerated and safe antifungal agent for the treatment of Tinea capitis in children. The shorter duration of treatment resulted in lower cure rates. However, it is important to note that depending on the severity of the disease, a 1-week-only treatment can also be effective in this indication.

Periodontal aspects of the juvenile form of paracoccidioidomycosis

Three cases of the juvenile form of paracoccidioidomycosis are reported. Emphasis has been given to the oral manifestations, particularly the periodontal involvement. The main periodontal findings were: generalized and progressive alveolar bone destruction leading to gingival recession with exposure of the tooth roots, and spontaneous tooth losses. The gingival mucosa was predominantly smooth, erythematous and slightly swollen. These aspects, although rare, may be the earliest signs of the disease and sometimes its only manifestations.

Histoplasmin reaction. Comparison of a polysaccharide antigen to the filtrate antigen

This work was planned by taking into account all the knowledge accumulated from the immunological study of paracoccidioidomycosis. It aimed at comparing a polysaccharide antigen from Histoplasma capsulatum to a classic histoplasmin with the help of intradermal tests of delayed type of hypersensitivity. Tests were applied to 115 individuals in Santo Amaro, a town in the State of São Paulo. Positive results using classic histoplasmin were obtained in 46.0% cases whereas positive results using the polysaccharide antigen at its highest concentration were obtained in 51.30% cases. The major conclusion in this investigation is that it is possible to use the polysaccharide antigen as histoplasmin instead of the filtrate antigen.

[Evaluation of the possible influence of Montenegro's intradermal reaction on a serological assay for the diagnosis of American cutaneous leishmaniasis]

Influence of Montenegro skin test for American tegumentar leishmaniasis was evaluated to verify possible interference in serological diagnosis for this disease, performed by immunoenzymatic assay (ELISA). If this interference could occur, it would hamper scientific, epidemiological and patient care; happily we did not find any interference on serological diagnosis by performance of skin testing.

Cellular immunity and immunostimulation in paracoccidioidomycosis

We have evaluated clinical and laboratorial effects of immunostimulation scarification with antigen of Paracoccidioides brasiliensis in patients with paracoccidioidomycosis, who often show depressed immunity. We have studied 62 Brazilian patients with paracoccidioidomycosis, 46 with active disease and 16 cured, in a 10-year period between 1982 and 1992. Among the 46 patients with active disease: 10 had acute form, 12 chronic unifocal form and 24 the chronic multifocal form of the disease; 16 showed positive paracoccidioidin intradermal reaction and 30 negative reaction. Amongst 16 cured patients, 5 showed negative paracoccidioidin intradermal reaction and 11 positive reaction. We immunostimulated 20 patients by scarification with polysaccharide antigen of Paracoccidioides brasiliensis. All 20 immunostimulated patients had negative paracoccidioidin intradermal reaction, and 18 patients had active disease and 2 were cured. Out of 18 immunostimulated patients with active disease, 3 had active form, 10 chronic multifocal form and 5 chronic unifocal form of the disease. Before and after immunostimulation, each patients was inmunologically evaluated by in vivo and in vitro methods; in vivo methods consisted of intradermal reactions and DNCB sensitization tests; and in vitro methods consisted of total sub-set lymphocyte counting, leukocytes migration inhibition test, chemotaxix of total leukocytes and monuclear leukocyte phagocytosis. Remaining 42 patients served as a non-immunostimulated control group who has followed only clinically. We have observed significant clinical and immunological improvement in immunostimulated patients. We conclude that the immunostimulation by scarification with antigen of P. brasiliensis can be a helpful adjuvant therapy for paracoccidioidomycosis.

[Subcutaneous phaeohyphomycose due to Exophiala jeanselmir. Report of 3 cases in patients with a kidney transplant]

We report three cases of subcutaneous phaeohyphomycosis due to Exophiala jeanselmei (Langeron) McGinnis et Padhye 1977, in kidney transplant patients. Exophiala jeanselmei is a dematious fungus having also ability to rarely procedure eumycetoma (black grains). According to KWON-CHUNG & BENNETT (1992) such fungus is antigenically very heterogeneous, since so far three serotypes have been identified; each serotype including subgroups. Subcutaneous phaeohyphomycosis is becoming more and more frequent in kidney transplant patients submitted to an immunosuppressive treatment. As Exophiala jeanselmei has already been isolated from the environment it becomes difficult to explain the pathogenicity of these cases by a reactivation of quiescent processes. The authors suggest an occasional fungistatic action of cyclosporine A upon Exophiala jeanselmei.

African histoplasmosis. Report of the first case in Brazil and treatment with itraconazole

We report the first case of African histoplasmosis diagnosed in Brazil. The patient was an immigrant from Angola who had come to Brazil six months after the appearance of the skin lesion. The skin of the right retroauricular area was the only site of involvement. The diagnosis was established by direct mycologic examination, culture and by histopathologic examination of the lesion. The patient was successfully treated with Itraconazole 100mg a day for 52 days. No recurrent skin lesions were observed during the ten month follow-up period.

Successful treatment of sporotrichosis with oral fluconazole: a report of three cases

We report three cases of sporotrichosis successfully treated with oral fluconazole. A verrucous lesion on the toe was cured after 126 days, and a lesion on the left foot resolved after 91 days' treatment. A case of lymphangitic-type sporotrichosis required 174 days of treatment to achieve a cure, and a higher dose (400 mg daily) was necessary in this case. Any side-effects were insignificant. We conclude that this new bis-triazole compound can be successfully used as an alternative treatment for sporotrichosis when conventional drugs must be avoided.

Mycetoma: a retrospective study of 41 cases seen in São Paulo, Brazil, from 1978 to 1989

Clinical and epidemiological aspects of 41 cases of mycetoma seen in São Paulo city from January 1978 to December 1989 are presented. Twenty-eight cases (68%) were caused by actinomycetes, while 13 (32%) were caused by true fungi. In only 22 (78%) actinomycetoma cases was it possible to identify the agent. Nocardia brasiliensis, by far the commonest actinomycete isolated, was responsible for 13 cases. Among eumycetomata, Madurella grisea was isolated from 3 cases, Scedosporium apiospermum from 2 cases, and Madurella mycetomatis from 1 case, and in 7 cases the agent was not identified. Distribution by sex and age was similar to that reported in the literature. Feet and legs were the commonest sites affected. The mean age of actinomycetoma patients was 33.2 years, while patients with eumycetomata were an average of 32.8 years. Mean duration of the disease was 6.8 and 9.8 years respectively. Most patients came from rural areas in the north-eastern region of the country and worked as field labourers. Bone involvement was frequent for both actinomycetomata and eumycetomata and was characterized by osteoporosis, periostal reaction and cavitation. The authors' elected treatment consists of combining sulfamethoxazole (800 mg) and trimethoprim (100 mg) with prednisone (10 mg) orally, daily.

[Black-grain eumycetoma due to Madurella grisea. A report of 2 cases]

Two cases of black grains eumycotic mycetoma, occurring on a foot, are reported. Both proceeded from the state of Bahia (Brazil), and in both the etiologic agent was Madurella grisea Mackinnon et al., 1949. The grains structure as well as the micromorphologic characteristics of the fungus in saprophytic life were studied. It is the author's belief that these observations correspond to the 7th and 8th cases reported in the Brazilian medical literature. The authors do consider the following Madurella species as nomen dubium or nomina confusa: M. ramiroi, M. oswaldoi, M. bovoi, M. tozeuri, M. mansonii, M. brumpti, M. reynieri, M. americana, M. lackawanna e M. ikedae and the same for Rubromadurella mycetomi. The only valid species must be Madurella mycetomatis McGinnis, 1980 (= Madurella mycetomi Brumpt, 1905) and Madurella grisea Mackinnon et al., 1949. Treatment with itraconazole in both reported cases, for a 3 month duration, did not produce any regression of the lesions, the clinical improvement being meager.

[Rhinofacial entomophthoromycosis due to Conidiobolus coronatus. A report of a case treated successfully with fluconazole]

A case of rhinofacial entomophthoromycosis caused by Conidiobolus coronatus is reported in a 30-years-old male from São Paulo, Brazil. The patient was successfully treated with oral fluconazole in a prolonged regimen. The diagnosis was confirmed by histopathological and mycological data.

Cellular immunity in paracoccidioidomycosis

Paracoccidioidomycosis was studied in 62 patients from Brazil in the 10 year period between 1978 and 1988. In 46 patients included in a first group, the disease was active and in 16 patients included in a second group, the disease was cured. The study was conducted according to both the clinical form of the disease and the response to paracoccidioidin in both groups. In the first group, 10 patients presented the acute form, 12 presented the chronic unifocal form and 24 had the chronic multifocal form of the disease. As to the response to paracoccidioidin, in the first group 16 patients were negative and 30 were positive; in the second group, 11 were positive and 5 were negative. An immunological study was performed in all patients using in vivo methods such as skin tests and sensitization to DNCB and in vitro techniques such as total lymphocyte counts, T and B cell counts, leukocyte migration inhibition test, chemotaxis of total leukocytes and mononuclear leukocyte phagocytosis.

Rhinofacial zygomycosis caused by Conidiobolus coronatus. A case report

A case of rhinofacial zygomycosis with of years duration, caused by Conidiobolus coronatus is described. The patient, a 72-years-old woman, presented with a bilateral distortion of the subcutaneous tissue and disfigurement of the face. Treatment with ketoconazole and potassium iodide did not prevent several relapses. At present she is still under treatment with fluconazole with clinical healing. Histopathological and mycological examination confirmed the dermatological diagnosis. An increasing number of cases of zygomycosis caused by fungi of the order Entomophthorales have also been reported in the Northern and Northeastern States of Brazil.

[Anatomopathology and direct and indirect immunofluorescence of lesions of endemic pemphigus foliaceous resistant to corticoid therapy]

A group of 16 patients with endemic pemphigus foliaceus under corticotherapy and still showing erythematous, papulous, verrucous, in general hyperpigmented lesions, which were characterized as cortico therapy resistant lesions, were studied. Such study was made through anatomopathology and direct immunofluorescence (DIF). Anatomopathologically, such lesions showed tendencies to epithelial hyperplasia and cleavage in variable levels at the epidermis what differs from the early lesions of EPF and coincides with the chronic injuries of the EPF of the pre-corticoid era. The DIF of the injured skin was positive for IgG in 93.75% of cases, as it happens in the early stages of EPF, being negative in a simple case in which there was not cleavage. In addition, in eight of those patients, the DIF of the healthy skin and the indirect immunofluorescence (IIF) were studied. The DIF was positive in three of these cases and in all eight the IIF was negative.

[Renal changes caused by pentavalent antimonial (Glucantime) hypersensitivity in American tegumentary leishmaniasis. Report of a case]

The authors report one case of leishmaniasis in a 60 year old patient who developed renal failure after treatment with Glucantime. With the interruption of these drug the patient recovered her normal renal function, and a new treatment with Amphotericin B was tried with complete cicatrization of the lesions.

[Itraconazole in the treatment of pityriasis versicolor: comparison between 5 and 7 days of treatment]

The authors present the results obtained in the treatment of pityriasis versicolor with Itraconazole, comparing two schemes of treatment, in an open trial: 200 mg daily, for 5 and 7 days. The clinical diagnosis was confirmed by Wood's light and mycologically, by direct examination. The patients were controlled 21 and 35 days after beginning the treatment. The evaluation of the results showed that both schemes were effective. At the second control, there was clinical and mycologic cure in 90% of the patients from the 5-day group and in 95% of the patients from the 7-day group. The tolerance was good: 2 patients from the 7-day group and 1 patient from the 5-day group showed side-effects. Since there was no significant difference between the two schemes of treatment, the authors recommend the shortest one, that is, 200 mg daily for 5 days.

[Tinea favosa. Report of a familial occurrence in Itapecerica da Serra (municipality of Greater São Paulo)]

Four cases of Tinea favosa occurred in the same family are reported in a small city of Brazil (Itapecerica da Serra--State of São Paulo). Trichophyton schoenleinii was isolated from all four cases. Treatment consisted of oral griseofulvin (10 mg/kg/day) for at least three months.

[Black grain mycetoma caused by Madurella grisea]

The authors reported one case of eumycotic mycetoma due to Madurella grisea (black grains) occurred on the right foot of the patient studied. The structure, microscopic morphology and therapeutic evolution are also studied and reported.

Treatment of chromomycosis by cryosurgery with liquid nitrogen: a report on eleven cases

Cryosurgery with liquid nitrogen was used to treat 11 cases of chromomycosis, 5 with localized lesions and 6 with generalized ones. Freezing time varied from 30 seconds to 4 minutes and the number of cycles from 1 to more than 40. All 5 cases with localized lesions responded extremely well to treatment, with no relapse for up to 53 months. Three patients with generalized lesions attained clinical and mycologic remission for up to 26 months, while 3 had significant improvement without cure. Cryosurgery with liquid nitrogen is therefore an effective treatment for chromomycosis, especially for cases presenting with localized lesions.

Evaluation of serological diagnostic indices for mucocutaneous leishmaniasis: immunofluorescence tests and enzyme-linked immunoassays for IgG, IgM and IgA antibodies

The sensitivity, specificity, positive predictive value, negative predictive value, and efficiency of immunofluorescence (IF) and enzyme-linked immunoassays (ELISA) for IgG, IgM and IgA antibodies were assessed on sera from mucocutaneous leishmaniasis patients and controls. The sensitivity of the IgG-ELISA test was 93.3% with 95% confidence interval higher than what could be due to a random test not associated with the disease. The specificity of all tests, except the IgM-ELISA, gave indices that could not have been due to chance. The IgG-ELISA and IgG-IF had the highest positive predictive value and the kappa statistic showed that the strength of agreement between the disease and the test was strongest for IgG-ELISA. The IgG-ELISA had a negative predictive value with 95% confidence limits that were not due to chance alone. Efficiency was highest for IgG-ELISA and IgG-IF. These results were obtained using sera from patients with severe or long-standing disease and from controls in whom the disease was ruled out by a negative Montenegro skin test. In field surveys where the differences between cases and controls are less easy to define the diagnostic indices of these tests may vary with the disease prevalence.

[Ulcero-vegetative candidiasis of the leg]

Os Autores apresentam caso de paciente portadora de lesão única, úlcero-vegetante, localizada no 1/3 inferior da perna direita, causada pela Candida albicans. Submetida à terapêutica com Ketoconazol na dose de 400 mg diários durante o primeiro mês de tratamento e 200 mg diários no segundo mês, evoluiu para cura, sem recidiva e com negativação do título de anticorpos anti Candida albicans (fixação do complemento).

Anti-leishmania IgA immunoenzymatic assay in mucocutaneous leishmaniasis (preliminary report)

The Authors describe an anti-Leishmania IgA-ELISA assay in mucocutaneous leishmaniasis. Increased titers were found in leishmaniasis patients, mainly in the first and second year of infection and in deep mycoses patients showing either mucosal involvement or widespread disease.

Treatment of paracoccidioidomycosis, candidiasis, chromomycosis, lobomycosis, and mycetoma with ketoconazole

The authors present the use of ketoconazole in 27 cases of paracoccidioidomycosis, eight of mycetoma, seven of chromomycosis, four of systemic candidiasis and one of lobomycosis. The drug was administered orally in a dosage of 200 to 400 mg per day within a period of up to 90 days. The results of the treatment for paracoccidioidomycosis were of cicatrization of the cutaneous lesions in three to four weeks in 24 patients and in two, from six to seven weeks. Out of 27 patients, 14 presented pulmonary lesions. The evolution within a 90-day period showed radiological cure in one case, improvement in seven, and unaltered picture in five patients. In one, there was no further control. In the three out of four cases of candidiasis there was clinical and mycological cure and in one case marked improvement. In seven cases of chromomycosis there was marked improvement in two, moderate in four, and slight in one case. There was slight improvement in one case of lobomycosis, and in eight cases of mycetoma moderate improvement in three, slight in three and none in two, but the mycological examinations were still positive. The drug tolerance was excellent.