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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Epidermolysis bullosa &#40;EB&#41; composes a group of hereditary bullous disorders in which the blisters arise spontaneously or are triggered by minimal trauma&#46; Koebner suggested this denomination in 1886&#46; EB is divided into four major types &#40;simplex&#44; junctional&#44; dystrophic&#44; and Kindler syndrome&#41; and several distinct clinical phenotypes&#44; according to the level of skin cleavage&#44; as well as clinical and molecular characteristics&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Epidermolysis bullosa simplex with mottled pigmentation &#40;EBS-MP&#41; is an uncommon subtype of epidermolysis bullosa simplex &#40;EBS&#59; Online Mendelian Inheritance in Man &#91;OMIM&#93; No&#46; 131960&#41;&#46; It is characterized by non-cicatricial blisters&#44; mainly at the distal extremities&#44; and progressive mottled hyperpigmentation&#46; Until 2013&#44; only 15 families and eight sporadic cases had been reported&#44; according to the data from the Hospital Infantil Universit&#225;rio Ni&#241;o Jesus&#44; in Madrid&#44; which motivated this report&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 2-year-old girl&#44; phototype III&#44; with a history of blistering skin since birth&#46; On dermatological examination she had desiccated blisters on the feet&#44; as well as hyper- and hypochromic macules scattered over the tegument with mottled appearance &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Normochromic papules on the dorsal region of the fingers and onychodystrophy were also seen&#46; The blisters appeared spontaneously or after minimal trauma&#44; according to the mother&#39;s report&#44; and were located mainly at the distal extremities of the limbs&#46; At two months of age&#44; the hyper- and hypochromic macules began&#46; The mother also referred episodes of oral mucositis&#46; Immunomapping result &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; coupled with the patient&#39;s clinical and laboratory findings confirmed the diagnosis of EBS-MP&#46; This is probably a sporadic case since family history fo EB or other bullous disese is negative&#46; The patient is under outpatient clinic follow-up&#46; Family orientations were conducted in order to reduce the occurrence of new blisters and improve the coexistence of the patient with her genodermatosis&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">First described in 1979 by Fischer and Gedd-Dahl&#44; EBS-MP begins in childhood and has a genetic origin&#46; It is a basal EBS caused by a mutation in the KRT5 gene that encodes cytokeratin 5&#46; It occurs most commonly due to a punctual heterozygous p24L mutation in the non-helical V1 domain of cytokeratin 5&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of this dermatosis is based on typical clinical findings&#44; family history&#44; immunomapping&#44; and&#47;or transmission electron microscopy&#44; as well as molecular&#47;mutation analysis when possible&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinically&#44; it is characterized by non-cicatricial blisters&#44; mainly at the distal extremities&#44; as well as progressive mottled hyperpigmentation&#44; which does not occur at the site of the blisters and often disappears in adulthood&#46; Some cases may be accompanied by hypopigmented macules&#44; as could be seen in this patient&#46; There are also reports of palmar and plantar focal hyperkeratosis&#46; Small acral verrucous papules&#44; onychodystrophy&#44; and mild involvement of the oral mucosa can be observed during childhood&#46; Uncommon findings include photosensitivity and dental disorders &#40;caries&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The differential diagnosis of EBS-MP includes other types of EBS &#40;mainly the herpetiformis type of Dowling-Meara&#41;&#44; Kindler syndrome&#44; Naegeli-Franceschetti-Jadassohn &#40;NFJ&#41; ectodermal dysplasia&#44; other forms of dyschromia&#44; Dowling-Degos disease&#44; and even atypical cases of Darier&#39;s disease with mutations in ATP2A2&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Due to the clinical hypothesis of EB and to determine the level of skin cleavage&#44; immunomapping or transmission electron microscopy should be performed&#46; The immunomapping has diagnostic accuracy similar to transmission electron microscopy&#44; with the advantage of simple and fast execution and reading&#46; It is associated with the use of monoclonal antibodies and may be considered an indirect immunofluorescence technique&#46; In the EBS&#44; the skin cleavage occurs in the basal layer &#40;intra-epidermal&#41;&#44; and fluorescence deposition on the blister floor &#40;dermal side&#41; is seen with all antigenic markers &#40;bullous pemphigoid antigen&#44; laminin&#44; collagens IV and VII&#41;&#44; as observed in this case&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Ultrastructural analysis of the pigmented areas in this form of EBS demonstrates abundant mature melanosomes within the basal cells&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Thus&#44; this report details a rare case of a possibly sporadic EBS-MP&#46; The authors emphasize the rarity of this subtype of EBS and its remarkable clinical characteristics favoring future diagnoses&#44; and highlight its benign character&#44; with no scarring or deforming lesions and regression of hyperpigmentation in adulthood&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Fl&#225;via Regina Ferreira&#58; Approval of final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Carolina Fernandes Pereira&#58; Approval of final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Juliana Carvalho Moretto&#58; Approval of final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Mariana Patriota Naville&#58; Approval of final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Case Letter
Sporadic form of epidermolysis bullosa simplex with mottled pigmentation
Flávia Regina Ferreira
Autor para correspondência
dermagica@uol.com.br

Corresponding author.
, Carolina Fernandes Pereira, Juliana Carvalho Moretto, Mariana Patriota Naville
Dermatology Service, Hospital Universitário de Taubaté, Taubaté, SP, Brazil
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Epidermolysis bullosa &#40;EB&#41; composes a group of hereditary bullous disorders in which the blisters arise spontaneously or are triggered by minimal trauma&#46; Koebner suggested this denomination in 1886&#46; EB is divided into four major types &#40;simplex&#44; junctional&#44; dystrophic&#44; and Kindler syndrome&#41; and several distinct clinical phenotypes&#44; according to the level of skin cleavage&#44; as well as clinical and molecular characteristics&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Epidermolysis bullosa simplex with mottled pigmentation &#40;EBS-MP&#41; is an uncommon subtype of epidermolysis bullosa simplex &#40;EBS&#59; Online Mendelian Inheritance in Man &#91;OMIM&#93; No&#46; 131960&#41;&#46; It is characterized by non-cicatricial blisters&#44; mainly at the distal extremities&#44; and progressive mottled hyperpigmentation&#46; Until 2013&#44; only 15 families and eight sporadic cases had been reported&#44; according to the data from the Hospital Infantil Universit&#225;rio Ni&#241;o Jesus&#44; in Madrid&#44; which motivated this report&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 2-year-old girl&#44; phototype III&#44; with a history of blistering skin since birth&#46; On dermatological examination she had desiccated blisters on the feet&#44; as well as hyper- and hypochromic macules scattered over the tegument with mottled appearance &#40;<a class="elsevierStyleCrossRefs" href="#fig0005">Figs&#46; 1 and 2</a>&#41;&#46; Normochromic papules on the dorsal region of the fingers and onychodystrophy were also seen&#46; The blisters appeared spontaneously or after minimal trauma&#44; according to the mother&#39;s report&#44; and were located mainly at the distal extremities of the limbs&#46; At two months of age&#44; the hyper- and hypochromic macules began&#46; The mother also referred episodes of oral mucositis&#46; Immunomapping result &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41; coupled with the patient&#39;s clinical and laboratory findings confirmed the diagnosis of EBS-MP&#46; This is probably a sporadic case since family history fo EB or other bullous disese is negative&#46; The patient is under outpatient clinic follow-up&#46; Family orientations were conducted in order to reduce the occurrence of new blisters and improve the coexistence of the patient with her genodermatosis&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">First described in 1979 by Fischer and Gedd-Dahl&#44; EBS-MP begins in childhood and has a genetic origin&#46; It is a basal EBS caused by a mutation in the KRT5 gene that encodes cytokeratin 5&#46; It occurs most commonly due to a punctual heterozygous p24L mutation in the non-helical V1 domain of cytokeratin 5&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The diagnosis of this dermatosis is based on typical clinical findings&#44; family history&#44; immunomapping&#44; and&#47;or transmission electron microscopy&#44; as well as molecular&#47;mutation analysis when possible&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Clinically&#44; it is characterized by non-cicatricial blisters&#44; mainly at the distal extremities&#44; as well as progressive mottled hyperpigmentation&#44; which does not occur at the site of the blisters and often disappears in adulthood&#46; Some cases may be accompanied by hypopigmented macules&#44; as could be seen in this patient&#46; There are also reports of palmar and plantar focal hyperkeratosis&#46; Small acral verrucous papules&#44; onychodystrophy&#44; and mild involvement of the oral mucosa can be observed during childhood&#46; Uncommon findings include photosensitivity and dental disorders &#40;caries&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The differential diagnosis of EBS-MP includes other types of EBS &#40;mainly the herpetiformis type of Dowling-Meara&#41;&#44; Kindler syndrome&#44; Naegeli-Franceschetti-Jadassohn &#40;NFJ&#41; ectodermal dysplasia&#44; other forms of dyschromia&#44; Dowling-Degos disease&#44; and even atypical cases of Darier&#39;s disease with mutations in ATP2A2&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Due to the clinical hypothesis of EB and to determine the level of skin cleavage&#44; immunomapping or transmission electron microscopy should be performed&#46; The immunomapping has diagnostic accuracy similar to transmission electron microscopy&#44; with the advantage of simple and fast execution and reading&#46; It is associated with the use of monoclonal antibodies and may be considered an indirect immunofluorescence technique&#46; In the EBS&#44; the skin cleavage occurs in the basal layer &#40;intra-epidermal&#41;&#44; and fluorescence deposition on the blister floor &#40;dermal side&#41; is seen with all antigenic markers &#40;bullous pemphigoid antigen&#44; laminin&#44; collagens IV and VII&#41;&#44; as observed in this case&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Ultrastructural analysis of the pigmented areas in this form of EBS demonstrates abundant mature melanosomes within the basal cells&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Thus&#44; this report details a rare case of a possibly sporadic EBS-MP&#46; The authors emphasize the rarity of this subtype of EBS and its remarkable clinical characteristics favoring future diagnoses&#44; and highlight its benign character&#44; with no scarring or deforming lesions and regression of hyperpigmentation in adulthood&#46;</p><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Authors&#8217; contributions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Fl&#225;via Regina Ferreira&#58; Approval of final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; collection&#44; analysis&#44; and interpretation of data&#59; intellectual participation in the propaedeutic and&#47;or therapeutic conduct of the studied cases&#59; critical review of the literature&#59; critical review of the manuscript&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Carolina Fernandes Pereira&#58; Approval of final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Juliana Carvalho Moretto&#58; Approval of final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Mariana Patriota Naville&#58; Approval of final version of the manuscript&#59; conception and planning of the study&#59; drafting and editing of the manuscript&#59; critical review of the literature&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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