Sociedade Brasileira de Dermatolodia Surgical & Cosmetic Dermatology


ISSN-e 1984-8773


Volume 4
Number 1



Continuing medical education

Desmoplastic melanoma

Melanoma desmoplástico

Francisco Macedo Paschoal, Vivien Lumi Yamada, Mílvia Maria Simões e Silva Enokihara, Carlos D’Apparecida Santos Machado Filho

Questions and answers of previous number

Abstract: First described in 1971 by Conley and colleagues, desmoplastic melanomas represent less than 4% of cutaneous melanomas. It is a distinctive and uncommon variant characterized by a spindle cell fibrous tumor of collagen forming cells, isolated by dense fibrous matrix. Desmoplastic melanomas are frequently misdiagnosed, mainly due to their similarity to other fibrous neoplasms. A review of about 600 reported cases unexpectedly revealed the pigmented clinical presentation of a deep and fibrous nodule that is classically associated with a precursor lesion. The ability to recognise this lesion’s characteristics is very important, due to its recurrent behaviour and subsequent need for a specialized surgical approach.


Original Article

Immunohistochemical analysis of photodamaged skin after treatment with delta 5-aminolevulinic acid

Análise imunohistoquímica da pele fotoenvelhecida após tratamento com o ácido 5 delta aminolevulínico

Ana Carolina Junqueira Ferolla, Bhertha Tamura, Consuelo Junqueira Rodrigues, Luis Carlos Cucé

Abstract: Introduction: Photodynamic therapy destroys target cells by directly harming them, injuring the vascular stroma, and activating the immune system.
Objective: To study photoaged skin's immune response to photodynamic therapy.
Methods: Thirteen female patients underwent three treatment sessions with delta 5-aminolevulinic acid combined with 630 nm diode light. The immunohistochemical response of the skin's immune system was evaluated using the markers anti-CD1a, anti-CD4+, anti-CD8+, anti-TNFa, anti-IFNy and anti-IL4 before, 24 hours after the first session, and 21 days after the third session.
Results: At the final evaluation, patients demonstrated a decrease in CD4 and CD8 lymphocytes, an increase in interleukin-4 in the epidermis and dermis, and a reduction and an increase of TNF-a in the epidermis and dermis, respectively. The Langerhans cell and INF-y populations remained unchanged.
Conclusion: Regarding the immune system, photodynamic therapy did not cause changes in Langerhans cells; therefore, there was little local immunosuppression. CD4 and CD8 lymphocyte apoptosis was observed, suggesting that photodynamic therapy can be useful in treating inflammatory diseases. The changes in TNF-a and an increase of IL4 in the dermis and epidermis suggest a humoral type response, which was also evidenced by the absence of INFy.


Nutritional factors and resistance of the hair shaft: a pilot clinic study

Fatores nutricionais e resistência da haste capilar: estudo clínico piloto

Flávia Alvim Sant'Anna Addor, Vanessa de Melo Cardoso Pereira, Felipe Fernandes de Abreu, Silvana Lima da Silva

Abstract: Introduction: The hair shaft's integrity can be compromised by the presence of some genodermatoses, with the use of cytostatic agents, and in physical-chemical traumas, such as straightening, dyeing, drying, etc.
Objective: To evaluate improvements in hair resistance after the ingestion of a dietary supplement. Methods: Patients complaining of hair loss due to breakage, with virgin or processed hair (dyed, straightened, or dyed and straightened) ingested a vitamin supplement for 90 days.
Results: There was clinical improvement in damaged strands that were removed in the pull test, in addition to statistically significant increases in the strength and shine of the hair, as perceived by patients (p <0.05).
Conclusions: Nutrition affects the maintenance of hair's resistance, and supplementation can improve the synthesis of the structures of the hair.


Physico-chemical and biological effectiveness evaluation of a liposome- enhanced mineral water on the skin

Avaliação físico-química e biológica da eficácia de uma água mineral lipossomada na pele

Samanta Nunes, Bhertha Tamura

Abstract: Introduction: Introduction: Mineral water has been used in Dermatology for its moisturizing and anti-inflammatory effects. Its penetration seems to be superficial. An elastic liposome containing mineral water was developed in efforts to improve its penetration and action in the skin.
Objectives: This study evaluated the efficacy of a 30-100 nm liposome, made of trehalose and soy phosphatidylcholine, which can cross 30 nm spaces and deliver the mineral water to deeper layers of the skin.
Methods: The RAMAN method was used to evaluate the permeation of the liposome into the skin. Its moisturizing effects were measured through the genic expression of filaggrin and acquaporin, and its anti-inflammatory effects were measured through NF-¿ß quantities.
Results: After 30 minutes, the phosphatidylcholine was localized 1-7 nm deeper in the corneum layer; 60 minutes after, the liposome had penetrated to the spinous layer; and no changes were verified after 120 minutes. The genic expression of filaggrin increased 3 times and the expression of acquaporin increased 1.8 times. NF-¿ß activity decreased 47%.
Conclusion: Nanotechnology and its benefits are very important to dermatology. The development of liposomes with Brazilian technology demonstrates the emergence of a knowledge base regarding cosmetic delivery systems in the country. Therefore, Brazil's wealth of mineral spring waters represents a considerably valuable resource and should be the object of further studies in dermatology. This study has verified that liposome-encapsulated water can permeate the skin and provide enhanced biological effects.


Evaluation of the whitening properties of combined kojic acid, arbutin, sepiwhite® and achromaxyl® vs. 2% and 4% hydro- quinone in the treatment of melasma

Estudo clínico para a avaliação das propriedades clareadoras da associação de ácido kójico, arbutin, sepiwhite® e achromaxyl® na abordagem do melasma, comparada à hidroquinona 2% e 4%

Adilson Costa, Lúcia Helena Fávaro de Arruda, Elisangela Samartin Pegas Pereira, Margareth de Oliveira Pereira, Felipe Borba Calixto dos Santos, Raquel Fávaro

Abstract: Introduction: Melasma is a common, acquired, long-lasting skin disorder that is often resistant to treatment and causes negative psychological effects on patients.
Objectives: To evaluate the efficacy, safety, and tolerability of the topical combination of kojic acid, arbutin, sepiwhite® and achromaxyl ® compared to 2% and 4% hydroquinone in the treatment of facial melasma.
Methods: A single-blind, comparative, monocentric clinical study with 120 volunteers (aged 18-50, I to IV Fitzpatrick skin types) was conducted. The study population was divided into 3 groups: Group A (n = 40; Blancy®, 2 times a day), Group B (n = 40, 2% hydroquinone at night), and Group C (n = 40, 4% hydroquinone at night), and instructed to use the study product for 90 consecutive days. Clinical (classification and quantification of melasma) and photographic evaluations were carried out, and a questionnaire assessed the impact on the patients' quality of life and the products' general efficacy.
Results: Most volunteers (n = 102, 85%) completed the study (Group A = 34, Group B = 33, Group C = 35). The Melasma Area Severity Index metrics presented a statistically significant decrease (i.e., improvement) throughout the study in all three groups (p-value < 0.001).
Conclusion: The topical use of the kojic acid, arbutin, sepiwhite® and achromaxyl® combination proved to be an effective and safe alternative for treating melasma.


Comparative histological evaluation of the effectiveness of trichloroacetic acid and subcision (isolated or combined) in the treatment of abdominal striae

Avaliação histológica comparativa da eficácia de ácido tricloroacético e subcisão, isolados e combinados, no tratamento de estrias abdominais

Mauricio Shigueru Sato, Aline Fukuda, Larissa Luvison Gomes da Silva, Fabiane Mulinari Brenner, Rebecca Tung

Abstract: Introduction: Abdominal striae(i.e. stretch marks) are considered scars, for which there are no known treatments.
Objective: To compare the effectiveness of three treatments: subcision, 20% trichloroacetic acid, and subcision + 20% trichloroacetic acid in the treatment of stretch marks.
Methods: The lower abdomens of 11 patients with stretch marks were divided into four quadrants. Each patient had one stria selected for a single treatment session; the three treatments (subcision, 20% trichloroacetic acid, and subcision + 20% trichloroacetic acid) were administered in 3 quadrants, and the 4th quadrant served as a control. Each selected stria was biopsied before and after 12 weeks. The Wilcoxon test was used to evaluate the efficacy of the treatment. The Kruskal-Wallis test was used to evaluate the differences between the treatments.
Results: In all treatments there was a reduction in the mean value after treatment, however the 20% trichloroacetic acid treatment was statistically significant for the epidermal parameter and the collagen fiber staining. The subcision associated with 20% trichloroacetic acid presented a statistically significant result in the superficial dermis parameter, while the isolated subcision was significant in the superficial dermis parameter only.
Conclusions: These treatments are safe and present low operating costs, which make them a great alternative for treating abdominal striae. Future studies should conduct a clinical-histological evaluation after a greater number of sessions.


Assessment of dermocosmetics contai- ning retinaldehyde, nicotinamide and Vitis vinifera in the cutaneous photoaging of women between 25 and 40 years old

Avaliação de dermocosmético com retinaldeído, nicotinamida e vitis vinifera no fotoenvelhecimento cutâneo de mulheres entre 25 e 40 anos de idade

Lucia Helena Favaro de Arruda, Ana Carolina B. Bazan Arruda, Paula L. Stocco, Fernanda S. Ota, Elvira C. Assumpção, Sthephani S.B. Langen, Adilson Costa, Un Sun Park, Carla A. H.V. Myashiro

Abstract: Introduction: The skin is subject to intrinsic and extrinsic aging processes, which makes treating cutaneous photoaging clinically challenging.
Objective: To use objective and subjective parameters to evaluate the safety, tolerability, and clinical efficacy of a cosmetic product containing 0.05% retinaldehyde, 4% nicotinamide, and 1% Vitis vinifera extract in the treatment of skin aging.
Methods: A monocentric, prospective, open study evaluated 40 female volunteers (25-40 years old) with Fitzpatrick skin types I to IV, who used the dermocosmetic product for 60 consecutive days. Subjective assessments were carried out by the physician and the volunteer patients. In addition, ultrasound examination and objective assessment of photographic records using the Visia® imaging system, skin biopsies, corneometry, pH metry, and sebumetry were conducted.
Results: Thirty-six volunteers completed the study. Subjective evaluations revealed improvements in wrinkles, fine lines, sagging, vitality, and overall appearance. Ultrasound and skin biopsies showed increased collagen (94.4% and 30.6%, respectively). Pictures from the Visia® device demonstrated a reduction in stains, wrinkles, and pores, and improvements in the skin's texture. Sebumetry revealed a decrease in the oiliness and the pH. Measurements taken with the corneometer remained constant.
Conclusions: This dermocosmetic product is effective and safe in the treatment of photoaging.


Sunscreen protection against visible light: a new proposal for evaluation

Proteção oferecida por fotoprotetores contra luz visível – uma proposta de avaliação

Sérgio Schalka, Flávia Alvim Sant’Anna Addor, Christiane Monteiro Agelune, Vanessa de Melo C. Pereira

Abstract: Introduction: In order to protect against visible light, pigmented sunscreens have been developed by combining organic non-particulate sunscreens and opaque pigments. No reliable method has yet been proposed to measure the protection offered by these pigments.
Objective: To evaluate the effectiveness of white and colored sunscreens in the protection against visible light. Methods: Twenty sunscreens marketed in Brazil were evaluated (13 colored and 7 white). Colorimetric measurements were used to classify the brightness and translucency of the roducts, which were applied to polymethylmethacrylate sheets. Spectrophotometric measurements were taken to evaluate the product's absorbance within the visible light spectrum between 400 and 450 nm, using the Absorptive Efficacy in the visible light range as a parameter.
Results: Colored products presented a higher Evis than white products. Statistical analysis demonstrated that there is strong correlation between absorptive effectiveness and the product's brightness and translucency. No correlation was verified between absorptive effectiveness and the products' sun protection factor.
Conclusions: Absorptive efficacy in the visible light range was a useful parameter in the assessment of sunscreens' effectiveness in protecting against visible light. Pigmented products provide more effective photoprotection within that band.


Review articles

Gynoid lipodystrophy and clinical therapy: a critical analysis of scientific papers

Lipodistrofia ginoide e terapêutica clínica: análise crítica das publicações científicas disponíveis

Adilson Costa, Caroline Romanelli T. Alves, Elisangela Samartin Pegas Pereira, Fernanda André Martins Cruz, Maria Carolina Fidelis, Rafaela Marega Frigerio

Abstract: Gynoid lipodystrophy (cellulite) is a common, unattractive dermatosis that affects many women around the world. Depending on the severity of the appearance, the condition may cause important psychosocial disorders. Many therapies have been clinically tested, and many have been proscribed, not only for their therapeutic inefficiency, but also for their risk to patients’ health. Other treatments, notwithstanding their weak scientific basis, are still in vogue. Medical devices, few of which are backed by actual scientific evidence, also currently claim to help treat this condition. This paper provides an extensive scientific literature review and analysis, and aims to help dermatologists decide what specific therapies to recommend and provide assurances regarding the clinical rationale of results when treating patients with this condition.


Diagnostic Imaging

Basal Cell Carcinoma, chrysalides-like structures, oncogenes, and sebaceous nevus: some considerations

Carcinoma basocelular, estruturas crisálides, oncogenes e nevo sebáceo: algumas considerações

Francisco Burnier Pereira

Abstract: Dermoscopy is increasingly used to diagnose non-melanocytic skin tumors. Basal cell carcinoma presents some highly suggestive structures for its diagnosis. The presence of chrysalides-like structures is also frequently found in other benign and malignant skin tumors, and their significance in basal cell carcinoma has yet to be determined. HPV is a virus with oncogenic potential and its involvement in the pathogenesis of basal cell carcinomas is also not yet clearly understood.


New Techniques

Correction of large surgical defects: double cerclage technique

Correção de defeitos cirúrgicos grandes: técnica da dupla cerclagem

Nelson Marcos Ferrari Júnior, Alessandra Cristine Marta, Andrey Augusto Malvestiti, Adriana Alves Ribeiro, Fábio Roismann Timoner

Abstract: Large surgical wounds can be closed using flaps or grafts, which are often difficult to carry out. The double cerclage technique is an effective option for direct – though partial – closure of this type of incision. The technique will be demonstrated using an illustrative case.


Post-adjusted M-plasty

M-plastia pós-ajustada

Flávio Barbosa Luz, Luciana Antunes Chagas

Abstract: Post-adjusted M-plasty can be used in any surgical defect that can be closed by direct approximation of the borders to avoid the formation of apical protrusions. It is performed without prior planning; the tissue is removed only if the surgeon detects a protrusion during surgery. This method offers the advantage of sparing healthy tissue by adjusting the incisions to each patient’s skin’s tension lines, wrinkles and junctions of cosmetic units, in addition to the possible use of the “M”s pedicle as a small advancement flap. This study describes the procedure step by step, highlighting the differences and advantages compared to traditional M-plasty.


Subdermal laser treatment of axillary hyperhidrosis

Laser subdérmico no tratamento da hiperidrose axilar

Sandra Tagliolatto, Oriete Gerin Leite, Vanessa Barcellos Duque Estrada Medeiros

Abstract: Axillary hyperhidrosis is a common pathology that disrupts patients’ social and professional lives and requires appropriate therapy. Traditional treatments include topical and systemic therapies, iontophoresis, botulinum toxin, and surgical procedures. An innovative technique that uses subdermal laser has shown excellent results, few side effects and high patient satisfaction. This paper presents a case report of treating axillary hyperhidrosis with subdermal laser with an excellent response.


Case reports

Nail tumor after mechanical trauma

Tumor ungueal após trauma mecânico

Emi Dika, Bianca Maria Piraccini , Píer Alessandro Fanti , Sabina Vaccari, Iria Neri, Annalisa Patrizi

Abstract: This article describes the case of a 62-year-old patient who developed an erosive nodular mass on the nail apparatus after receiving a trauma during a hunting incident. The lesion was initially diagnosed as an amelanotic melanoma of the nail apparatus, illustrating the fact that this type of lesion is often misdiagnosed – up to 85% of the time if the physician lacks dermatological expertise –and remains untreated for prolonged periods.


Transepidermal application of medication combined with photodynamic the- rapy in the treatment of actinic keratosis

Aplicação transepidérmica de medicamento associado a terapia fotodinâmica no tratamento de ceratoses actínicas

Luiza Erthal de Brito Pereira Kassuga, Maria Cláudia Almeida Issa, Natália Stroligo Chevrand

Abstract: Topical photodynamic therapy is an established method of treating some types of non-melanoma skin cancers. Modifications to the standard protocol have recently been adopted that increase its therapeutic efficacy. This case study describes two female patients with multiple actinic keratoses who were simultaneously treated with the standard and modified protocols for methyl aminolevulinate and fractional radiofrequency combined with ultrasound in two different, symmetrically located, affected areas. This study’s objective is to evaluate the effectiveness of the transepidermal application of drugs in photodynamic therapy combined with new methods such as the proposed treatment.


Mohs Micrographic Surgery on recurrent trichoblastoma

Cirurgia micrográfica de Mohs em tricoblastoma recidivado

Luciana Takata Pontes, André Luiz Simião, Fernando dos Ramos Seugling, Rafael Fantelli Stelini, Maria Letícia Cintra, Elemir Macedo de Souza, Aparecida Machado Moraes

Abstract: Trichoblastoma is a slow-growing and well-circumscribed rare adnexal tumor. Although considered a benign neoplasm, there are cases of aggressive trichoblastomas. This paper reports a case of a 66-year-old female patient with a recurrent and continuously growing tumor in the right nasal wing that was treated with Mohs Micrographic Surgery.


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