SummaryBackground. The fixed drug eruption is a common adverse drug reaction. Clear identification of the culprit drug is not always possible in the clinical setting, and oral rechallenge may induce new lesions or severe reactions. Objectives. The main purpose of this study was to evaluate the diagnostic value of patch testing in establishing an aetiological diagnosis in fixed drug eruptions. Method. A retrospective analysis was conducted evaluating 52 patients (17M/35F, mean age 53±17 years) with clinical diagnoses of fixed drug eruptions submitted to patch tests in a 20-year period in a Dermatology Department. Nonsteroidal anti-inflammatory drugs (NSAID) were clinically suspected in 90.4% of the cases, followed by antibiotics (28.9%) and paracetamol (15.4%). Results. Patch tests on pigmented lesions were reactive in 21 patients (40.4%), 20 of those to NSAID (nimesulide, piroxicam and etoricoxib) and 1 to an antihistamine (cetirizine). All patch tests using other drugs were negative, even under conditions of high clinical suspicion. Oral rechallenge allowed confirmation of drug imputability in 5 of 31 test-negative cases. Cross reactivity was frequently observed between piroxicam and other oxicams, and between different antihistamines. Conclusions. Patch testing was shown to be a simple and safe method to confirm drug imputabililty in fixed drug eruption, mainly when NSAID or multiple drugs are suspected. Persistent lack of reactivity to drug classes such as antibiotics and allopurinol represent an important limitation.

Lipschütz Ulcer, or ulcus vulvae acutum, is a rare and probably underdiagnosed entity that usually presents as an acute painful vulvar ulcer in young women. The etiology is unknown, although recent reports have associated it with the Epstein-Barr virus. The diagnosis is made by exclusion after ruling out sexually transmitted diseases, autoimmune causes, trauma, and other etiologies of genital ulcerations. We report a case of a young woman who developed flu-like symptoms and painful vulvar ulcers. Complementary examinations ruled out sexually transmitted diseases and the other usual causes of genital ulcers; lesions healed with no sequelae or recurrences. This case represents a rare important differential diagnosis of genital ulceration. Keywords: Genital diseases, female; Infectious mononucleosis; Ulcer Resumo: A Úlcera de Lipschütz, ou ulcus vulvae acutum, é uma entidade rara mas provavelmente subdiagnosticada, que se apresenta como úlcera vulvar aguda dolorosa numa mulher jovem. A etiologia é desconhecida embora relatos recentes a tenham associado à primo-infecção pelo vírus Epstein-Barr. O diagnóstico é estabelecido após exclusão de doenças sexualmente transmissíveis, causas autoimunes, traumáticas e outras etiologias de úlceras genitais. Relatamos o caso de uma jovem que desenvolveu quadro gripal e dolorosas úlceras genitais. Os exames complementares excluiram doenças sexualmente transmissíveis e as outras causas habituais de ulceração genital. As lesões cicatrizaram sem sequelas e sem recorrências. Este caso representa um diagnóstico diferencial importante e raro de ulceração genital. Palavras-chave: Doenças dos genitais femininos; Mononucleose infecciosa; Úlcera

Background Nodular melanoma (NM) is more likely to be fatal compared with other melanoma subtypes, an effect attributed to its greater Breslow thickness. Methods Clinicopathological features of NM and superficial spreading melanoma (SSM) diagnosed in 17 centers in Europe (n = 15), the United States, and Australia between 2006 and 2015, were analyzed by multivariable logistic regression analysis, with emphasis on thin (T1 ≤ 1.0 mm) melanomas. Cox analysis assessed melanoma-specific survival. All statistical tests were two sided. Results In all, 20 132 melanomas (NM: 5062, SSM: 15 070) were included. Compared with T1 SSM, T1 NM was less likely to have regression (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.29 to 0.72) or nevus remnants histologically (OR = 0.60, 95% CI = 0.42 to 0.85), and more likely to have mitoses (OR = 1.97, 95% CI = 1.33 to 2.93) and regional metastasis (OR = 1.77, 95% CI = 1.02 to 3.05). T1 NM had a higher mitotic rate than T1 SSM (adjusted geometric mean = 2.2, 95% CI = 1.9 to 2.5 vs 1.6, 95% CI = 1.5 to 1.7 per mm2, P < .001). Cox multivariable analysis showed a higher risk for melanoma-specific death for NM compared with SSM for T1 (HR = 2.10, 95% CI = 1.24 to 3.56) and T2 melanomas (HR = 1.30, 95% CI = 1.01 to 1.68), and after accounting for center heterogeneity, the difference was statistically significant only for T1 (HR = 2.20, 95% CI = 1.28 to 3.78). The NM subtype did not confer increased risk within each stratum (among localized tumors or cases with regional metastasis). Conclusions T1 NM (compared with T1 SSM) was associated with a constellation of aggressive characteristics that may confer a worse prognosis. Our results indicate NM is a high-risk melanoma subtype that should be considered for inclusion in future prognostic classifications of melanoma.

Background Whether melanoma in histological contiguity with a naevus [naevusassociated melanoma (NAM)] is distinctly different from melanoma arising de novo remains unclear. Objectives To determine whether the characteristics of de novo melanoma differ from NAM and are not due to naevus obliteration in thicker tumours. Methods We conducted a multicentre retrospective study of de novo melanoma and NAM in seven referral centres in Europe, Australia and the USA between 2006 and 2015. Results In a total of 9474 localized melanomas, de novo melanoma was associated with thicker tumours and body site differences compared with NAM. In the subset of T 1 melanomas (n = 5307), similar body site differences were found in multivariate analysis by body site. When compared with NAM, de novo melanoma was more likely to affect older individuals (≥ 70 years) when located on the head/neck [odds ratio (OR) 4Á65, 95% confidence interval (CI) 2Á55-8Á46], the trunk (OR 1Á82, 95% CI 1Á40-2Á36) or the upper extremity (OR 1Á69, 95% CI 1Á14-2Á50), was more likely to affect female patients when located on the lower extremities (OR 1Á36, 95% CI 1Á03-1Á80), and was more likely to be of the nodular melanoma subtype (OR 2Á23, 95% CI 1Á14-4Á35) when located on the trunk. De novo melanoma was less likely to have regression present compared with NAM.

Mitotic rate is no longer considered a staging criterion for thin melanoma in the 8th edition of the American Joint Committee on Cancer Staging Manual. The aim of this observational study was to identify prognostic factors for thin melanoma and predictors and prognostic significance of sentinel lymph node (SLN) involvement in a large multicenter cohort of patients with melanoma from nine tertiary care hospitals. A total of 4249 consecutive patients with thin melanoma diagnosed from January 1, 1998 to December 31, 2016 were included. The main outcomes were disease‐free interval and melanoma‐specific survival for the overall population and predictors of SLN metastasis ( n = 1083). Associations between survival and SLN status and different clinical and pathologic variables (sex, age, tumor location, mitosis, ulceration, regression, lymphovascular invasion, histologic subtype, Clark level, and Breslow thickness) were analyzed by Cox proportional hazards regression and logistic regression. SLN status was the most important prognostic factor for melanoma‐specific survival (hazard ratio, 13.8; 95% CI, 6.1‐31.2; P < 0.001), followed by sex, ulceration, and Clark level for patients who underwent SLNB. A mitotic rate of >2 mitoses/mm 2 was the only factor associated with a positive SLN biopsy (odds ratio, 2.9; 95% CI, 1.22‐7; P = 0.01. SLN status is the most important prognostic factor in thin melanoma. A high mitotic rate is associated with metastatic SLN involvement. SLN biopsy should be discussed and recommended in patients with thin melanoma and a high mitotic rate.

Figure 1 Acro-ischaemic lesions in a patient infected with COVID-19. Lesions were mainly purpuric, haemorrhagic bullae and necrotic, affecting fingers (a) and toes (b).

A 56-year-old woman presented with a 3-month history of erythematous plaques covered by scales and limited to the right side of her body. The plaques were arranged along Blaschko’s lines with a marked mid-line cutoff. The histopathologic analysis of a skin biopsy in conjunction with the anamnesis allowed the diagnosis of linear psoriasis. Our patient showed a good clinical response to antipsoriatic treatment.

Background Contact allergy to local anaesthetics is relatively common. Patch testing with benzocaine in the European baseline series is recommended for diagnosis, even though a caine mix has been previously suggested to be superior. Objectives To assess the frequency and patterns of contact allergy to local anaesthetics by using a caine mix (benzocaine, tetracaine, and cinchocaine) in the baseline series, and evaluate its efficiency as compared with benzocaine alone. Methods We reviewed the results of 2736 patch tests performed between 2000 and 2010, identifying patients with positive reactions to caine mix or to one of seven local anaesthetics. Results One hundred and twelve patients (4.1%) had at least one allergic reaction to local anaesthetics; 86 were tested with all seven local anaesthetics, resulting in 71 reactions in 53 patients. Cinchocaine gave the most reactions (50.7%); these occurred as a single reaction in 83.3% of patients, mostly with current or past relevance (97%). Benzocaine represented 22.5% of reactions, many of which were non‐relevant (44%) or resulting from cross‐reactions with para‐compounds. Conclusions Almost 70% of allergic reactions to local anaesthetics would have been missed if benzocaine had been used as a screening allergen. This study supports a recommendation to replace benzocaine with a caine mix containing cinchocaine in the baseline patch test series.