The evolution of medicine has allowed an increasingly in-depth knowledge of diseases and medications, involving cellular structures and associated molecules. In dermatology, we begin to unveil cell modulation associated to the use of substances such as botulinum toxin, hyaluronic acid, among others. This new era allows us to comprehend information that goes beyond a macroscopic view and explore cell interaction, leading to a broader knowledge to optimize dermatologic treatment.

Keywords: Biology; Cells; Dermatology

INTRODUCTION: Stretch marks are an everyday challenge to the dermatologist. In the search for alternative therapies, we find 5-fluorouracil (5-FU) and microneedling for associating the following properties: inhibition of fibrosis, stimulation of collagen renovation and induction of skin pigmentation. Objective: To evaluate the efficacy and safety of 5-FU, in isolation or associated to microneedling, for the treatment of white stretch marks (striae alba).
METHODS: Comparative, double-blind study over 180 days, between 3 groups: Group A: microneedling and 5-FU; Group B intralesional 5-FU and Group C microneedling without medication. We measured improvement through a numerical scale of skin coloration, considering positive results those with reduction of the discrepancy between the adjacent skin and the stretch mark. We also evaluated patient satisfaction and irritation with each technique.
RESULTS: Group A achieved 10% of excellent clinical improvement, 10% very good and 60% mild. In group B, none of the patients had excellent of very good improvement. In group C, there was 20% of very good clinical improvement and 70% of mild.
CONCLUSIONS: All techniques showed some degree of improvement of the lesions. Therefore, we propose new studies comparing all three techniques, with a larger sample, to evaluate if more treatments would result in better results.

Keywords: Cosmetic Techniques; Fluorouracil; Striae Distensae; Therapeutics

INTRODUCTION: Actinic keratosis (AK) is a pre-malignant lesion that can progress to squamous cell carcinoma. The diagnosis is through clinical, dermatoscopic and confocal microscopy assessment. Currently, the approach is the treatment of the field cancerization, comprising of clinically visible and subclinical AKs, for which photodynamic therapy (PDT) is a therapeutic option.
OBJECTIVE: To evaluate improvement of AKs and cancerization field in patients submitted to daylight PDT, with clinical, dermatoscopic and confocal microscopy assessment.
METHODS: Ten patients with multiple AKs on the face were selected. Daylight PDT was performed using methyl aminolevulinate and clinical, dermatoscopic and confocal microscopy photographic documentation was performed before and 60 days after the treatment.
RESULTS: Of the nine patients who completed the treatment, 8 (88.8%) showed clinical improvement and reduction in the severity of AK with one treatment. On dermatoscopy, 4 patients (44.4%) showed significant improvement, 3 patients (33.3%) showed partial improvement and 2 patients (22.2%) had no change. On confocal microscopy, 6 (66.6%) patients presented reduction in the severity of the lesion.
CONCLUSIONS: Daylight PDT proved to be effective for the treatment of AKs, with high tolerability and efficacy, besides a good safety profile.

Keywords: Dermoscopy; Keratosis, Actinic; Microscopy, Confocal; Photochemotherapy

INTRODUCTION: Healing is a phenomenon that occurs after tissue injury and involves complex cellular and molecular mechanisms. Growth factors seem to be an effective and safe complement for the treatment of wounds.
OBJECTIVE: To evaluate wound healing after electrocoagulation, comparing the vehicle in isolation and its association with epidermal growth factor.
METHODS: Double-blind clinical trial in a Dermatology service between 2016 and 2018. Patients of both genders, older than 18 years of age, submitted to electrocoagulation of two lesions and subsequent application of the vehicle (cold cream) on one and epidermal growth factor in cold cream on the other were included. Evaluations after 7, 14 and 28 days, analysed erythema, edema, crusting, discharge and healing. Analyzed: edema, edema, crusting, discharge and healing. The binomial test was used for two ratios and Fisher’s exact test was used for dichotomic data.
RESULTS: Variable results were found regarding erythema, edema, crusting and discharge, sometimes favoring the vehicle, sometimes the growth factor, however with no statistical significance. Regarding healing, epithelialization was quicker with with epidermal growth factor (p<0.05).
CONCLUSIONS: This study evaluated the impact of epidermal growth factor in the healing process, and its results reinforce scarce data of the current literature and are a foundation for future studies.

Keywords: Epidermal growth factor; Evaluation; Wound healing

INTRODUCTION: Hidrocystomas are skin-colored or translucent cysts, single or multiple, appearing on the face. They originate in the eccrine or apocrine sweat gland and are sometimes disfiguring. They can be excised by surgery, electrodissection, or by caustics, but are usually recurrent and the treatments can leave scars or dyschromia. Botulinum toxin A (BoNT-A) has been suggested as therapy in few cases in the literature.
OBJECTIVE: To analyze the effects of BoNT-A in cases of facial hidrocystomas.
METHODS: Retrospective observational study of case series. Patients with facial hidrocystomas treated with BoNT-A at the Cosmiatry Outpatient Dermatology Clinic of the Hospital do Servidor Público Municipal de São Paulo, were evaluated.
RESULTS: Of the 13 patients evaluated, 5 were included, the largest case series described so far. Of these, all lesions treated showed clinical improvement during the period evaluated. Four patients showed partial regression and one, total regression of the lesions.
CONCLUSION: In this series of cases, BoNT-A showed positive and long-lasting results in the treatment of facial hidrocytsomas, with no adverse effects.

Keywords: Botulinum toxins; Hidrocystoma; Therapeutics

INTRODUCTION: It is estimated that in Brazil, a large number of civil responsibility lawsuits against the medical professional are in place at the courts.
OBJECTIVES: To analyze the rulings of Justice Tribunals of the Southeast and South regions of Brazil, involving dermatologists and their civil responsibility.
METHODS: Definition of a research protocol on the site of the Justice Tribunals of the Southeast and South regions of Brazil.
RESULTS: Forty-seven rulings were identified in the States of the Southeast and South regions. The main causes motivating civil responsibility of the dermatologist are linked to aesthetic procedures, to patient dissatisfaction regarding therapies chosen and to diagnostic error. Compensations sought in lawsuits against dermatologists were mostly for moral damage. Medical evaluation was requested by the judges in most lawsuits and in 87.2% the reports did not observe a causal relationship. Court decision were in favor of the dermatologists in 82.9% of the cases. It was not possible to see the full lawsuit, only the final report.
CONCLUSION: We can conclude that factors such as adequate training of the dermatologist, their attention to doctor-patient relationship and when filling out patient’s records and documents necessary to medical practice were essential to an adequate medical evaluation, crucial to court decisions favoring dermatologists in most cases included in this study.

Keywords: Damage Liability; Dermatology; Legal Process

INTRODUCTION: The chest is a photoexposed area that shows effects of photodamage. Microneedling is a safe option for the rejuvenation of this area, also leading to improvement in dyschromias.
OBJECTIVE: To evaluate histologic cutaneous response after three monthly sessions of microneedling for the treatment of dyschromias on the chest.
METHODS: Three monthly sessions of microneedling, with 1.5mm length needles were performed, as well as skin biopsies before and 90 days after commencement of the study. Histologic samples were evaluated with H&E and Fontana-Masson stains. Melanin content was measured based on dermal clusters.
RESULTS: Six patients between 38 and 67 years of age, phototypes II-III, Glogau scale II-IV were included. A positive correlation was observed between the time and dermal content of melanin (p=0.029): three sessions of microneedling reduced this content on D90 compared to the beginning (6.4 ± 1.7 MC on D0 versus 3.1 ± 0.4 on D90, p = 0.05). Three patients reported global skin improvement on D90.
CONCLUSIONS: The proposed mechanism of microneedling to promote lightening includes fibroblast proliferation and neocollagenesis in the upper dermis. This is the first study to evaluate the histology of the findings associated to lightening of the chest due to microneedling.

Keywords: Histology; Melanins; Needles; Thorax

INTRODUCTION: Lysine is one of the essential amino acids, with a role in the prophylaxis of recurrent orolabial herpes simplex that has been demonstrated in scientific studies. Facial resurfacing procedures with laser and other technologies can reactive herpes simplex.
OBJECTIVE: To evaluate the incidence of cases of orolabial herpes in patients submitted to treatments with fractional ablative and non-ablative lasers and robotic microneedling, under prophylactic l-lysine.
METHODS: A sample of 100 was selected to have prophylactic l-lysine for herpes simplex. A re-evaluation of all patients was conducted seven days after laser treatment. If herpes infection was detected, doses of oral antiviral similar to those used for herpes-zoster treatment would be prescribed, guided by the literature.
RESULTS: Only 2% of the sample demonstrated herpes simplex after the procedure with prophylactic l-lysine. Both patients underwent ablative fractional laser treatment and had past history of herpes simplex infection.
CONCLUSIONS: Besides the low cost, l-lysine is a natural product that proved to be safe and effective for the prophylaxis of herpes simplex in resurfacing procedures, with a similar or lower rate of viral activation to the use of antivirals.

Keywords: Herpes Simplex; Herpes Labialis; Lysine; Laser Therapy; Lasers

Onychomatricoma is a tumor of the nail matrix with well-known clinical features; however, sometimes underdiagnosed. It is often mistaken for onychomycosis due to thickening of the nail plate. dermoscopy of the plate and its free margin allows the visualization of important features for the diagnosis, many times not seen with the naked eye.

Keywords: Dermoscopy; Nail Diseases; Nails/Pathology; Neoplasms

Skin biopsy is an important introductory tool and also essential for the dermatologist. The conventional biopsy method, with the use of local anesthetics, sterile fields, surgical instruments (punch, scalpel, forceps, scissors) and suture material demand staff, time and considerable financial investment. Criobiopsy is a simple method, where by using the cryocautery an extraction of good quality skin fragments is made for histopathologic analysis, making it an excellent alternative to the conventional biopsies.

Keywords: Ambulatory Surgical Procedures; Biopsy; Cryosurgery; Dermatology; Histology

This study demonstrated the clinical and histologic result of the treatment of one disseminated superficial actinic porokeratosis patient with non-ablative fractional laser. The patient was treated with seven sessions of 1340-nm Nd:YAP laser, with 4 or 5 week-intervals. Biopsies and photographs were performed before and after treatment, which was well tolerated and lead to improvement in the erythema and texture of the lesions. There was a 1-year follow-up. Histopathologic examination after treatment revealed little changes in the cornoid lamella.

Keywords: Biopsy; Laser Therapy; Lasers; Porokeratosis

Brooke-Spiegler syndrome is a rare autosomal dominant genetic disease with predisposition to many adnexal tumors, including trichoepithelioma, cylindroma and spiroadenoma. Tumors appear in the second decade of life, progressively increase with age, and their prevalence is higher in women. It is caused by a mutation in the CYLD gene, localized in the chromosome 16q12-q13. We report a exuberant case of giant eccrine spiradenoma associated to this syndrome.

Keywords: Dermatologic Surgical Procedures; Facial Neoplasms; Neoplasms, Adnexal and Skin Appendage

Type 1 neurofibromatosis has multiple cutaneous lesions and limited treatment options. CO₂ laser is a useful tool for the removal of neurofibromas, the main source of cosmetic disfiguration for these patients. We present the treatment of neurofibromas with CO₂ laser in a patient over 4.5 years. The patient had lesions with variable diameter, diffusely distributed. After 16 sessions of CO₂ laser, we observed clinical improvement. Although it is a palliative treatment, the cosmetic improvement achieved substantiates the demanded effort and time in view of the psychological gains for the patient.

Keywords: Lasers, Gas; Laser Therapy; Neurofibromatosis 1

Milia are keratin cysts of 1-3mm in diameter that occur due to the obstruction of eccrine sweat glands or hair follicles. We describe the case of a female patient with multiple white-yellow papules over a tattoo made six months prior to the consultation. Conservative treatment is an option, since there is the possibility of the lesion being transient and that it will spontaneously resolve. We opted for a conservative treatment with excellent final cosmetic outcome.

Keywords: Primary Treatment; Tattooing; Ink; Therapeutics

This letter is a reflection that arose from the lecture given by Professor Fatimata Ly, from University Cheikh Diop in Dakar (Africa) in the latest Congress of the European Academy of Dermatology and Venereology in Paris. Professor F. Ly gave the lecture "Depigmentation: when, where and how”. An even skin tone is one of the criteria for beauty. This letter does not concern those patients that come to our practices and are carefully followed and monitored by thorough dermatologists. She wants to raise attention to those that do not come to our practices, that use prescriptions given to acquaintances, or that use a dermatologist prescription indefinitely, after a single consultation. I was recently part of "discussion” forums over the internet, anonymously, of lay people on melasma. The intensity and speed of sharing of what they recommend using are impressive. They are very creative suggesting the use of products that could cause harm. Among the most used lightening products are steroids, hydroquinone, mercury and acids. There must be an awareness campaign to warn the population regarding the dangers of using skin depigmenting agents without a specific indication by the dermatologist.

Keywords: Hyperpigmentation; Melanosis; Skin Care; Skin Pigmentation; hidroquinones