Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773


Volume 3
Number 3


Portuguese | English




Dra. Bogdana Victoria Kadunc


Continuing medical education

Mohs micrographic surgery

Cirurgia micrográfica de Mohs

Nilton de Ávila Reis, Luciana Cirillo Maluf Azevedo, Hamilton Ometto Stolf, Keyvan Nouri, Arash Kimyai-Asadi, Leonard Harry Goldberg

Questions and answers of previous number

Abstract: Mohs Micrographic Surgery is regarded as a very useful technique for the excision of difficult to han- dle skin cancers. The procedure is divided into clearly defined steps: tumor evaluation and marking, tumor exeresis, tissue preparation and mapping, histologic processing and analysis, and closing of the surgical wound. The histologic analysis of all surgical margins leads to higher cure rates and tissue conservation, which make the procedure safer and more reliable.


Original Article

Acne recurrence after treatment with oral isotretinoin: 5-year follow-up

Recidiva de acne após tratamento com isotretinoína oral: seguimento de cinco anos

Carolina Ribas do Nascimento, Ana Luíza Grizzo Peres Martins, Simone de Padua Milagres, Ivander Bastazini Jr


Introduction: Isotretinoin was initially used to treat severe inflammatory acne and is now widely recognized as an effective therapy for acne vulgaris. Many factors are associated with the recurrence of this condition, which ranges from 5.6-65.4%. There is much con- troversy regarding the importance and contribution of each factor.
Objectives: To determine the recurrence rate in patients who underwent full treatment with oral isotretinoin (dose between 120 and 150 mg/kg) and risk factors.
Methods: Retrospective study of data from 276 patients treated with isotretinoin. The analysis was carried out after a minimum of 30 months after the end of the treatment. Recurrence was defined as the appearance of new active lesions that required retreatment.
Results: While the recurrence rate in patients who underwent the full dose was 25.53%, it reached 81.03% in those who received an incomplete dose. The other studied factors presented no statistical significance.
Conclusion: Oral isotretinoin therapy is effective in producing a significant and long- term reduction of acne. Nevertheless, it is important to note that recurrence can occur, especially when recommended doses are not reached.


Phototype comparison between caucasian and asian skin types

Comparação do fototipo entre caucasianos e orientais

Heliane Sanae Suzuki, Mariana Hammerschmidt, Patricia Kakizaki, Maira Mitsue Mukai


Introduction: Evaluating the response of various skin types to ultraviolet radiation expo- sure is very important in dermatology. The Fitzpatrick system is the most frequently used classification technique. It is straightforward and practical, assesses photodamage and skin cancer risks, and helps in defining light-based treatments. Nevertheless, there seem to be limitations to its use in non-Caucasians.
Objective: To compare the subjective phototype evaluation method to the Fitzpatrick classification in Caucasian and Asian (East and Southeast Asian, in particular) skin types.
Methods: Caucasian and Asian women (n = 42) were classified using 3 evaluation meth- ods (clinical, Fitzpatrick and Modified Fitzpatrick). The data were collected through ques- tionnaires and analyzed using non-parametric methods. A 5% significance level was adopted.
Results: There were no statistically significant differences within each group between the clinical evaluation, Fitzpatrick classification and the Modified Fitzpatrick classification (Caucasian cr2 = 0.375, p = 0.93 and Asians cr2 = 3.5, p = 0.182).
Conclusion: The three methods evaluate phototypes equally, yet studies with larger pop- ulation samples are still necessary.


Biochemical and toxicological assessment of a Brazilian mineral water and its effects on the skin

Avaliação bioquímica e toxicológica de uma água mineral brasileira e seus efeitos cutâneos em uso tópico

Samanta Nunes, Bhertha Miyuki Tamura


Introduction:The French cosmetics industry sells spring mineral waters that are advertised as having biological benefits.
Objective: This study analyzes, in vitro and in vivo, a Brazilian mineral water's oligomin- erals composition, as well as its physical and chemical characteristics and biological effects.
Methods: Tests to evaluate physical chemical properties, cytotoxicity (viable cells) and irritability (het-cam test) were conducted. In vitro studies were performed to evaluate its capacity to induce the genic expression and immunohistochemical detection of filaggrin and aquaporin 3, nf-kb activity and fibroblast proliferation compared to Milli Q water.
Results: This water was found to be non-cytotoxic and non-irritating. In addition, it pre- sented a high content of strontium (0.61 mg/ml). The expression of filaggrin and its immunohistochemical tests were relevant. The aquaporin 3 increased 1.8 times and nf-kb decreased its activity by 47%. It was also capable of stimulating fibroblast proliferation.
Conclusion: The initial evaluation of the mineral water from Serra do Japi (SP, Brazil) indicates that it has the potential to be an adjuvant treatment in dermatology, since the results suggest it moisturizes the skin barrier, stimulates the proliferation of fibroblasts, and repairs and inhibits inflammatory reactions. Clinical studies should be done in order to reassure the in vitro results achieved on the present study.


Treating vitiligo with Excimer laser: a retrospective study

Excimer Laser no tratamento do vitiligo em 123 pacientes: estudo retrospectivo

Carlos Roberto Antonio, João Roberto Antonio, Aline Maria de Vita Marques


Introduction: Vitiligo is cosmetically disfiguring and can cause significant psychological morbidity. Most therapies require protracted treatments and can lead to disappointing results. More recently, 308 nm Excimer laser has proven to be effective in treating vitiligo.
Objective: To analyze the effectiveness and patient satisfaction of 308 nm Excimer treat- ment for vitiligo patches in a variety of locations on the body.
Methods: Patients with generalized or localized vitiligo (n = 123, 321 lesions), were studied. The patients were treated at a private practice between 2007 and 2010. Two inde- pendent examiners analyzed the response to the therapy by comparing clinical and pho- tographic records before and after treatment.
Results: More than half (n = 77) of the patients presented repigmentation greater than 60%, 26 presented 40-59%, and 20% had levels less than 39%. Facial lesions responded better to treatment than those in other body parts. Elbows, hands and feet were the less sensitive areas. In general, the patients were satisfied with the treatment.
Conclusion: The use of Excimer laser for treating vitiligo was effective and safe, produc- ing satisfactory cosmetic results and improving patients' self esteem.


Radiological evaluation of Calcium Hydroxyapatite-based cutaneous fillers

Avaliação radiológica de implantes cutâneos com Hidroxiapatita de Cálcio

Mikeli Arfelli Cabrera, Fabiane Mulinari-Brenner


Introduction: Calcium hydroxyapatite is a radiopaque material that was traditionally used to provide radiologic contrast. It has recently been approved for use in cutaneous filling.
Objectives: To define the radiologic characteristics of Calcium hydroxyapatite and its potential to compromise radiologic evaluations.
Methods: Twelve patients received Calcium hydroxyapatite filler in the malar eminence and had radiography of the face (frontal, lateral, mentum-nasal-plaque (Waters), and Hirtz axial incidence technique) 1-8 weeks after the procedure. The X-rays were examined by two radiologists – one of whom was unaware of the filling procedure.
Results: The Hirtz axial incidence technique demonstrated amorphous radiopaque images in the suprazygomatic soft tissues in all cases, in both evaluations. Radiesse® was not detected using the other techniques, and did not illustrate the filler's position and symmetry. The evaluation of subjacent osseous structures was not compromised by the material's presence.
Discussion: Calcium hydroxyapatite can be identified in facial radiography when evaluat- ed using a method that avoids overlapping with adjacent osseous structures. Although it does not impair the osseous evaluation, it is recommended that the radiologist or dentist is noti- fied of the material's presence.
Conclusion: Cutaneous fillings containing Calcium hydroxyapatite can be identified, although not precisely located, using conventional X-ray.


Randomized, double-blind study of minocycline vs. placebo in the treatment of progressive macular hypomelanosis

Estudo duplo-cego randomizado e comparativo entre minociclina e placebo no tratamento da hipomelanose macular progressiva

Ada Regina Trindade de Almeida, Daniela Satico Yoshida Nei, Janete Gonçalves de Almeida


Introduction: Progressive macular hypomelanosis is a common skin hypopigmentation found in all ethnicities, yet it is seldom diagnosed. It affects young adults, especially women, and is often mistaken with pityriasis alba and pityriasis versicolor. It is character- ized by symmetric, well-defined, non-desquamative nummular hypopigmented macules in body areas with a greater concentration of sebaceous glands (trunk, thorax, abdomen and lumbar regions). Its etiology is poorly understood, and there is no effective treatment. A red fluorescence has recently been discovered in the lesion, suggesting the presence of porphyrin, produced by Propionibacterium acnes.
Objective: To compare the efficacy of 100 mg/day minocycline vs. placebo in the treat- ment of progressive macular hypomelanosis.
Methods: Patients over 18 (n = 20), who had suffered from the condition for more than 3 months (without treatment in the previous 3 months), who did not have an allergy to tetracycline, were randomized to receive minocycline or placebo. Wood's Lamp examina- tions and clinical evaluations (with descriptions and classifications using a color scale), and standardized picture records were conducted at baseline and 30 and 90 days after treatment.
Results: Eighteen patients completed the study. The group treated with minocycline pre- sented a statistically significant improvement (p < 0.05) compared to the control group.,br> Conclusion: 100 mg/day minocycline for 30 days was effective in treating progressive macular hypomelanosis, meaning that Propionibacterium acnes probably has a role in the condition's pathogeny.


Evaluation of quality of life improvement in melasma patients, measured by the MELASQoL following the use of a botanical combination based on Bellis perennis, Glycyrrhiza glabra e Phyllanthus emblica.

Avaliação da melhoria na qualidade de vida de portadoras de melasma após uso de combinação botânica à base de Bellis perennis, Glycyrrhiza glabra e Phyllanthus emblica comparado ao da hidroquinona, medido pelo MELASQoL

Adilson Costa, Margareth de Oliveira Pereira, Thaís Abdalla Moisés, Tatiana Cordero, Ana Roberta Dias Silva, Fabiana T. P. Amazonas, Fabíola Bentivoglio, Elisangela S. Pegas Pereira


Introduction: Melasma is a common hypermelanosis that mainly affects women and has a negative impact on the quality of life. It is a chronic and recurrent condition, and a number of treatments have already been proposed.
Objective: Assessment of quality of life for women with melasma before and after treatment with botanical extracts and hydroquinone.
Methods: A clinical, phase IV, randomized, blinded study was conducted at a clinical research institute. Women (n = 56) aged 18-60, with phototypes I-IV, were randomized into two groups (epidermal or mixed melasma). The Melasma Quality of Life Scale was used to compare the patients' quality of life before and after the use of Bellis perennis, Glycyrrhiza glabra and Phyllanthus emblica botanical extracts twice a day (Group A), or 2% hydro- quinone used at night (Group B). The Melasma Area and Severity Index was used to assess the treatments' efficacy.
Results: Appearance, frustration, embarrassment and feeling less attractive were the Melasma Quality of Life Scale variables that had the greatest negative impact on quality of life at the beginning of the study. After 60 days of treatment, there was improvement in all MELASQoL aspects, with no statistical differences between the two groups.
Conclusion: The improvement in melasma patients' self esteem provided by the use of the botanical extracts matched that of 2% hydroquinone.


Review articles

Periorbital hyperchromia

Hiperpigmentação periorbital

Daniela Moraes Souza, Cristiane Ludtke, Emanuelle Rios de Moraes Souza, Karina Melchiades Pinheiro Scandura, Magda Blessmann Weber

Abstract: Periorbital hyperchromia (dark eye circles) is a recurrent complaint in dermatologic consultations, as it interferes with patients’ self esteem. The eyes are central in the communication process, and dark eye circles are very noticeable and make the face look tired; thus they have a considerable impact on patients’ quality of life. Although many treatment options are available, publications on periorbital hyperpigmentation are scarce, and the vast majority lack a sound scientific basis to prove their efficacy and duration. This article analyzes the palpebral region’s anatomy and periorbital hyperchromia’s epidemiology, etiopathogeny, and treatments recommended in the literature.


Diagnostic Imaging

Dermatoscopy in pregnancy

Dermatoscopia na gestação

Juliana Machado Canosa, Eduard René Brechtbühl, João Pedreira Duprat Neto3

Abstract: Cutaneous melanoma’s prognoses depend primarily on the tumor’s thickness; early detection of melanomas is extremely important to increase a patient’s chances of survival. The use of dermatoscopy can be up to 90% accurate. Changes in pigmented lesions may occurduring pregnancy, however the challenge lies in knowing whether such changes are benign or whether they indicate a melanoma. Dermatoscopy is an important diagnostic tool that increases the accuracy of detection and diagnosis of the margins of melanomas in their earliest stages, which consequently improves patients’ prognosis and survival rates.


New Techniques

Minimally invasive technique for repairing complete earlobe cleft

Técnica minimamente invasiva para correção de lóbulo de orelha totalmente fendido

Ana Rosa Magaldi Ribeiro de Oliveira, Maria Cristina Cardoso de Mendonça, Ronaldo Figueiredo Machado, Maria das Graças Tavares Lopes Silva, Beatriz Julião Vieira Arestrup

Abstract: In an effort to avoid some common undesirable consequences of surgical techniques for repairing earlobe clefts, such as notch formation and cosmetic deformities, the authors describe a minimally invasive technique for repairing a complete earlobe cleft. A single simple suture was followed by 90% trichloroacetic acid applications to transform a complete earlobe cleft into an incomplete cleft. Due to its ease of execution, low cost and good functional results, this technique is a good option for repairing complete earlobe clefts.


Lip filling with microcannulas

Preenchimento labial com microcânulas

Andre Vieira Braz, Luana Vieira Mukamal

Abstract: This paper describes a lip filling technique that administers hyaluronic acid using microcannulas. This technique considerably reduces the number of punctures compared to the conventional method, which uses needles. In addition, the microcannula’s blunt tip reduces the risks of intravascular injection of the substance and of disrupting key structures such as vessels and nerves. The results obtained by the authors confirm the less frequent occurrence of adverse effects and a high degree of physician and patient satisfaction.


Case reports

Surgical treatment of scalp ulcers

Abordagem cirúrgica de úlcera do couro cabeludo

Dadi Bucusso Netemo

Abstract: The scalp has a key role in maintaining the integrity of the osseous structure that protects the central nervous system. Its restoration, especially keeping the aesthetic appearance and shape following lesions, is challenging. The present study describes the case of a child with extensive slough and bone exposure in the scalp following a necrotising cellulitis-type infection, which was treated with debridement, microperforation of the calvaria, and application of a gauze bandage with vaseline. Granulation tissue formed after 10 days. A partial skin graft was later carried out with satisfactory results.


Upper lip basal cell carcinoma: surgical treatment and reconstruction with transposition flap

Carcinoma basocelular no lábio superior: tratamento cirúrgico e reconstrução com retalho de transposição

Lauro Lourival Lopes Filho, Lauro Rodolpho Soares Lopes, Adelman de Barros Villa Neto, Thalisson de Sousa Costa

Abstract: Basal cell carcinoma is the most common human malignant tumor, and is most frequently located on the face. The excision of lesions greater than 2 cm from the upper lip requires a complex and difficult reconstruction. The authors describe the case of a 74-year-old female patient who had a nodular basal cell carcinoma of approximately 2 cm on the upper lip, which crossed the vermillion border. The lesion was excised and the reconstruction carried out using a nasolabial transposition flap with an inferior base. Histologic analysis showed there was a complete resection, with a satisfactory aesthetic result after one year.


Bleomycin in refractory giant keloids: a new treatment alternative

Bleomicina para queloide rebelde e gigante - nova opção de tratamento

Glaysson Tassara Tavares, Felipe Osta de Oliveira, Rafael de Abreu Moraes, Thaís Sanai Batista

Abstract: Keloids were first described several centuries ago, however their handling and treatment are still often inadequate. A number of treatments are available, such as intralesional corticotherapy and compressive therapy. The case of a 24-year-old female patient with a 5 year history of keloids in the ear lobules, with recurrence after treatment, is reported. She experienced a full regression of the lesions (for 2 years) after surgical reduction followed by intralesional bleomycin injections. Bleomycin is emerging as a therapeutic option with few side effects and lasting results for keloids that are unresponsive to conventional treatments.


Upper lip lifting associated with mechanical dermabrasion

Lifting de lábio superior associado à dermabrasão mecânica

Maurício Pedreira Paixão, Josue Montedonio, Wail Queiroz Filho, Carlos Eduardo Teixeira Pouza, Antônio Esau Ferraz de Almeida

Abstract: The aging process causes significant changes to the face. There is an increasing demand for aesthetic facial procedures such as blepharoplasty, rhytidectomy, and the use of filling substances and botulinum toxin, among others. The subnasal region receives comparatively less attention. This report aims to demonstrate the use of upper lip lifting combined with dermabrasion as an option to obtain greater facial harmony. In addition, it emphasizes the possibility of its use in association with other surgical procedures.


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