Stage III eumycetoma successfully treated with oral ketoconazole and surgical debulking

Mycetoma is a chronic, debilitating, granulomatous disease affecting the subcutaneous tissue, fascia, muscle, bone and adjacent organs characterized by triad of tumefaction, draining sinus, and grains. The ten-year incidence in our institution from 2000 to 2010 is 3 out of 81,015 cases. We present a 33-year-old man with a nine-year history of painless nodules and draining sinuses on the left foot which were unresponsive to oral antibiotics and topical antifungals. Biopsy of a nodule was consistent with mycetoma. Fungal culture revealed Madurella mycetomatis growth confirming eumycetoma. X-ray of the left foot showed poorly marginated lucencies on the calcaneus and navicular bones. Ultrasound revealed mixed hyperreflective echoes and multiple small cavities. We diagnosed the patient with Stage III eumycetoma based on the radiographic classification of bone involvement and prescribed oral ketoconazole 400 mg daily for nine months achieving 50-60% decrease in lesion size. Surgical debulking was done and ketoconazole was continued at the same dose for another nine months. There was good granulation tissue formation and no appearance of new lesions after surgery.

The misadventures of a traveler: Penicilliosis in a Filipino with HIV-AIDS

We report a case of penicilliosis in a Filipino man with HIV-AIDS who presented with skin-colored and erythematous to hyperpigmented, umbilicated papules and nodules on the face, trunk, and extremities associated with fever, lymphadenopathy, and anemia. The diagnosis was made through skin biopsy and fungal culture, which showed characteristic paintbrush-like hyphae and conidiophores. The patient was treated with intravenous amphotericin B at 0.6 mg/kg/day for 14 days followed by oral itraconazole 200 mg twice daily for 10 weeks resulting to flattening of lesions with hyperpigmentation, and prevention of appearance of new lesions. Resolution of fever, lymphadenopathy and improvement of anemia were also noted. He was placed on maintenance regimen with itraconazole 200 mg once daily to prevent relapse. Early diagnosis and appropriate management is important because mortality of disseminated disease is high if diagnosis and treatment are delayed.

A multi-center retrospective study on atopic dermatitis at the outpatient departments of Philippine Dermatological Society-accredited training institutions from 2007-2011

BACKGROUND: To date, no multicenter studies have been conducted on the prevalence and clinical profile of AD in the Philippines. Since AD is one of the top 10 skin diseases seen in the outpatients departments of all the Philippine Dermatologic Society (PDS)- accredited institutions, conducting a multicenter study provides important epidemiological information about this disease and serve as a valuable reference for future studies. OBJECTIVES: To determine the prevalence and clinical profile of patients with atopic dermatitis (AD) seen at the outpatient departments (OPD) of Philippine Dermatological Society (PDS) - accredited training institutions from 2007 to 2011. METHODS: Records of patients with a diagnosis of AD seen from January 1, 2007 to December 31, 2011 were retrieved and clinical data were collected. RESULTS: There were 744,673 dermatological consults in the 10 PDS-accredited outpatient clinics from 2007-2011. A total of 4,275 records of atopic dermatitis were reviewed for this study. The prevalence of atopic dermatitis was determined to be 0.57%. Most institutions reported a prevalence rate of less than 1% except for St. Luke's Medical Center (3.36%), and Research Institute for Tropical Medicine (7.07%). More than half of the patients (65.1%) were children between 1 to 12 years old. Twenty-four percent (24%) were infants less than one year. The average age was seven years old while the youngest was one month and the oldest was 94 years old. There were more females (56.1%) than males (42.75%). Bronchial asthma was the most prevalent co-morbid medical condition. Majority of AD patients seen in institutions were newly diagnosed. Those with previous consultations were mostly seen by dermatologists and pediatricians. Moisturizers and topical corticosteroids were the most commonly used topical preparation while antihistamines followed by oral antibiotics were the commonly prescribed oral medications. Follow-up rate was low. CONCLUSION: The prevalence of atopic dermatitis among the 10 PDS-accredited institutions is low except for SLMC and RITM. The clinical profile of patients is consistent with published literature. However, this study revealed the patient follow-up is low. This practice needs to be addressed since optimal management of this chronic disease requires close and regular follow-up to prevent complications and irrational drug use.

Bubbly orange baby: A rare case of diffuse cutaneous mastocytosis, bullous type

Mastocytosis is an uncommon, sporadic, heterogenous illness resulting from hyperplasia of mast cells. Diffuse cutaneous mastocytosis is the rarest subtype of mastocytosis affecting children, with bullous mastocytosis being its least common variety. Systemic manifestations like nausea, vomiting, bone pain, diarrhea, and central nervous system abnormalities are less common in children than adults. We report a four-month old male who presented with a two-month history of generalized yellowish to tan macules, papules and plaques with peau d'orange texture, with some blisters and erosions on the back, abdomen and scalp. Darier's sign was positive. Baseline laboratory workup were negative for systemic involvement. CD117 and Giemsa staining were positive for mast cells. Based on the clinical findings and histopathologic results, a diagnosis of bullous mastocytosis was made. Treatment included ketotifen drops, mupirocin cream and cetirizine drops, which resulted in flattening of most lesions and resolution of blisters and erosions.

Correlation of disease severity and quality of life (using scoring atopic dermatitis index and Filipino translation of children's dermatology life quality index-cartoon version) in children with atopic dermatitis

BACKGROUND: Atopic dermatitis is a chronic, relapsing inflammatory condition of the skin that is commonly diagnosed among infants and children. Although it is known that AD can affect the quality of life of children, there is ambiguous information about the relationship of disease severity and quality of life in children with AD. To the best of our knowledge, such correlation study has not yet been conducted within the Philippine population.OBJECTIVE: To determine if disease severity using Scoring Atopic Dermatitis (SCORAD) index and quality of life using the Filipino translation of the Children's Dermatology Life Quality Index (CDLQI)-cartoon version is correlated in Filipino children with ADMETHOD: Children aged 4-12 years diagnosed with atopic dermatitis at the outpatient dermatology clinic of a tertiary government hospital were recruited in the study. The severity of their disease was assessed by the investigator using the SCORAD index. Quality of life was evaluated using the Filipino translation of the CDLQI-cartoon version. Both were measured at initial consultation and at the follow-up visit one month after. The relationship between these parameters was statistically analyzed using Spearman's correlation.RESULTS: Forty children were included in the analysis. The mean SCORAD index was 41.08 (SD= +16.54) at baseline and 14.3 (SD = +8.52) on follow-up, while the mean CDLQI score was 12.92 (SD = +5.64) at baseline and 3.35 (SD = +1.98) on follow-up. Majority of the participants had moderate negative effect on QOL at baseline and only a small negative effect on follow-up. Spearman's correlation showed a high positive correlation between the SCORAD index and CDLQI both at initial consultation (Spearman's p= 0.8647) and follow-up visit (Spearman's p= 0.8058). Majority of the children were affected by symptoms of pruritus and sleep disturbance.CONCLUSIONS: Disease severity (using SCORAD index) and quality of life (using the Filipino translation of the CDLQI-cartoon version) were positively correlated among Filipino children with AD. The Filipino translation of the CDLQI-cartoon version is a valid tool which may be used as an additional subjective measure to the clinical objective scoring tools used in the assessment of AD in the Philippines.

Safety and efficacy of oral fusidic acid as a steroid-sparing agent in the treatment of lepra reactions : A randomized controlled assessor-blinded clinical trial

BACKGROUND: Lepra reactions occur in 10-30% of patients with leprosy. The standard of treatment is prednisone. However , prolonged steroid use may cause side effects such as osteoporosis, hypertension, hyperlipidemia, atherosclerosis and infections. Fusidic acid targets cytokine systems responsible for the production of Type 1 lepra reaction (T1R) and erythema nodosum leprosum (ENL). It may be given as a steroid-sparing agent in treating lepra reactions. OBJECTIVE: To determine the safety and efficacy of fusidic acid as a steroid-sparing agent in the treatment of  Type 1 and Type 2  lepra reactions. METHODS: A randomized controlled trial was conducted on 67 subjects with lepra reactions, aged 18-60, each assigned to receive either prednisone or prednisone + fusidic acid for 12 weeks. Severity of lepra reactions were graded quantitatively using a modified scale by Walker et al and van Brakel et al, and qualitatively using modified National Leprosy Control Program (NLCP) Guidelines at baseline, weeks 2,4,6,8,10 and 12. Doses of prednisone needed to control lepra reactions were also noted at each follow up and statistical analyses were done . Adverse reactions were noted. RESULT: Sixty subjects (89.55%) completed the study. The prednisone + fusidic acid group had lower quantitative and qualitative scores compared to the prednisone group. There were significant differences between the two groups for the quantitative severity scores (p=1.44x10-11) and qualitative severity grading (p=9.36x10-14) at week 12. The mean dose of prednisone was 21.5 mg in the prednisone group and 2 mg in the prednisone + fusidic acid group at week 12 (p=1.01x10-12). No adverse reactions were reported. CONCLUSION: Fusidic acid tablet 250mg/tab two tablets three times a day is an effective and safe steroid-sparing agent for the treatment of lepra reactions.

Topical antioxidants: A useless expense or a need to dispense?

Everyone, old and young, is concerned about skin aging, a complex process that can be caused by both intrinsic (chronologic), and extrinsic (environmental) factors. The formation of free radicals is a widely accepted mechanism leading to aging. Free radicals are highly reactive molecules with an odd number of electrons that are generated from oxygen; they cause easy oxidation of other molecules (can extract electrons or hydrogen from, or add oxygen to, another substance). Reactive oxygen species (ROS) initiate signal transduction cascade resulting in up-regulation of AP-1, NF-kB, and down-regulation of transforming growth factor (TGF)-b. Downstream, NF-kb signals increase in interleukin-1 and tumor necrosis factor-alfa levels, and AP-1 activates matrix metalloproteinase (MMP). Decrease in TGF-b expression leads to decrease in collagen synthesis. Cumulatively, these changes lead to increase in collagen breakdown, and increase in elastin production in extracellular matrix, and eventually manifest as the clinical signs of photoaging such as solar elastosis, wrinkles, coarse textures, telangiectasis, and pigmentation.

Urticaria pigmentosa in an 11-month-old patient: A case report

This is a case of an 11-month-old male who presented with multiple scattered mildly pruritic brown macules, papules and patches on the face, trunk and extremities, sparing the palms and soles. Darier sign was positive. Patient did not present with hepatosplenomegaly, lymphadenopathy and gastrointestinal symptoms. He was treated with emollients, potent topical steroids, antihistamines and a mast cell stabilizer with clinical improvement of cutaneous lesions after two weeks.

A case of localized scleroderma successfully treated with systemic corticosteroid and colchicine

Localized scleroderma, otherwise known as morphea, is a rare fibrosing disorder of the skin and underlying tissues with equal prevalence in adults and children. It is a distinct and separate disease entity from sytemic sclerosis. Although the etiology and pathogenesis have not been identified, the clinical manifestations are due to the thickened collagen bundles infiltrating the entire dermis and extending into the subcutaneous fat. This condition is self-limiting and may last for 3 to 5 years. We report a case of a 45-year-old man who presented with multiple, ill-defined, warm, indurated, slightly erythematous to hyperpigmented plaques with central atrophy on both thighs and lower legs of five months' duration. He was successfully treated with colchicine and sytemic corticosteroids.

A randomized, double-blind, placebo-controlled study on the safety and efficacy of 0.025% capsaicin (Capsicum annuum var. longum) cream against 1% hydrocortisone cream as an anti-inflammatory and anti-pruritic preparation for mosquito bites

BACKGROUND: Mosquito bite is a common dermatological complaint with various treatments but with no gold standard treatment regimen. OBJECTIVE: To compare the safety and efficacy of 0.025% capsaicin cream against 1% hydrocortisone cream and placebo as anti-inflammatory and anti-pruritic preparation for mosquito bites. METHODS: Seventy-five volunteers were enrolled in the placebo-controlled trial and randomized into three treatment groups. They were exposed to laboratory-reared mosquitoes to incur bites and to apply the designated cream. Anti-inflammatory and anti-pruritic effects were determined by mean lesion size, physician's global assessment, pruritus intensity score and 100mm visual analog scale. RESULTS: The mean lesion size and physician's global assessment, pruritus intensity score and visual analog scale showed no significant difference between 0.025% capsaicin and 1% hydrocortisone and they were both found to be superior to placebo (p-valueCONCLUSION: 0.025% capsaicin is comparable to 1% hydrocortisone as an anti-inflammatory and anti-pruritic preparation for mosquito bites.

Childhood epidermolysis bullosa acquisita

We describe a case if a 4 year-old girl who consulted our institution because of multiple tense vesicles and bullae on the perioral area, trunk, elbows, knees and dorsum of hands and feet. Biopsy of the lesion revealed subepidermal cleft with few ill-defined acantholytic cells and patchy areas of vacuolar degeneration showing infiltration with numerous neutophils and occasional eosinorphils. There was linear deposition of C3, IgG and IgA on basement membrane zone. The diagnosis was epidemolysis bullosa acquisita, IgA bullous dermatosis-like presentation. The patient was treated with topical corticosteroid for 1 1/2 months with complete resolution of lesions and appearance of milia on the perioral area and dorsum of hands and feet. Patient remained in remission.

Secondary syphilis in a 15-year old male

We report a case of a 15 year-old male who presented with multiple erythematous,non-tender, annular plaques on the penis, scrotal area, face, scalp, hands and feet and a reactive RPR test. Biopsy revealed a marked irregular psoriasiform hyperplasia of the stratum malphigii and permeation of the epidermis with neutrophils and lymphocytes. The dermis shows a moderately dense lichenoid or band-like inflammatory infiltration consisting of innumerable plasma cells, histiocytes, neutrophils and some lymphocytes. There is also noted mild superficial and deep perivascular as well as periappendageal inflammatory infiltration. The inflammatory cells around the appendages consist if plasma cells, histiocytes and few lymphocytes. The blood vessels are shown to have endothelial cells swelling with mild extravasated red blood cells. The diagnosis was secondary syphilis. The patient was treated with a single dose of benzathine penicillin G 1.8 M units intramuscularly. Marked improvement of the lesions was noted after 1 week.

Hypertrophic lichen planus in a 10-year old patient

We describe a case of a 10-year old female who consulted at our institution with plaques on the scalp, neck, trunk and extremities. The lesions were multiple, erythematous to violaceous, flat-topped papules and plaques with Wickham's striae. The nail involvement showed thinning of the nail plate, onycholysis, onychodystrophy, longitudinal ridging, and starting pterygium. Biopsy showed orthokeratosis, wedge-shaped hypergranulosis, irregular acanthosis and lichenoid pattern (mostly lymphocytes). Focal vacuolar alteration is also noted with few melanophages present and few Civatte bodies are noted. Negative HBsAg, anti-HBs and HCV were noted. The patient was treated with clobetasol dipropionate ointment,prednisone 10mg/day, oral antibiotic and antihistamine with marked clinical improvement after 2 weeks.

Familial combined hyperlipidemia with tuberous and tendinous xanthomas: A case report

Familial combined hyperlipidemia, otherwise known as type IIb hyperlipoproteinemia or multiple lipoprotein-type hyperlipidemia is an inherited disorder of high serum cholesterol or high blood triglycerides. This disease is genetic and inherited, although the specific defective genes have not been identified. The person's cholesterol or triglyceride become elevated during the teenage years and continue to be high throughout life. The types of elevated lipoproteins may vary between affected family members. Its clinical manifestations include lipid disposition on the skin or tendons called "xanthomas" as well as on the arteries. People with this condition have an increased risk of cardiovascular disease so that it is essential to recognize early this type of disorder. We report a case of a 37 year-old male who presented with a bilateral yellowish to reddish nodules on the elbows, knees, ankles, malleoili, ventral aspect of both hands, fingers, feet and toes, metacarpophalangeal & proximal interphalangeal joints, back and buttocks of six years duration with an elevated levels.

Secondary syphilis in a 55 year-old homosexual male

We report a case of a 55-year old sexually active homosexual male who presented with one month duration of erythematous, non-pruritic papules on the forehead, nape, scalp, chest, back, extremities and genitals and the presence of coppery-red, slightly scaling macules on the palms and soles. RPR (>1:16 dilution) and TPPA were reactive. A 4-mm skin punch biopsy revealed hyperplasia of the epidermis, focal areas of erythrocytic exocytosis with mild spongiosis and vacuolar degeneration of the basal cell layer, and many superficial and deep moderately dense perivascular granulomous inflammatory infilitrates consisting of histiocytes, lymphocytes, many plasma cells, some neutrophils, nuclear dusts and few eosinophils. The patient was given a single dose of 2.4M units of benzathine penicillin G, divided into each buttock. A repeat quantitative RPR was scheduled after 6 and 12 months to monitor the patient's titer.

Squamous cell carcinoma of the scalp: A case report

Nonmelanoma skin cancers are the most common human cancers. To this group basal cell carcinoma and cutaneous squamous cell carcinoma. Squamous cell carcinoma (SCC) is the second most common skin cancer in darkly pigmented patients and majority of the SCC's develop in non-sun exposed areas. We describe a case of a 72-year old male who consulted in the outpatient department of the Research Institute for Tropical Medicine for a 2-month history of non-healing ulcer on the scalp. Histopathologic examination revealed diagnosis of invasive squamous cell carcinoma. Patient was referred for surgical excision.

A randomized, double-blind, placebo-controlled study on the efficacy and safety of 50% and 75% capsaicin ointment as compared to a topical local anesthetic cream (eutectic mixture of lidocaine 2.5% and prilocaine 2.5%) as a topical anesthetic agent

BACKGROUND: Capsicum frutescens or 'siling labuyo' is known for its nutritional and pharmacological properties. Its most potent and predominant chemical entity is capsaicin. A recent study on rabbits concluded that 'siling labuyo' fruit extract is comparable to a topical local anesthetic medication containing lidocaine and prilocaine as an anesthetic agent.OBJECTIVES: This study aimed to determine the efficacy and safety of capsaicin ointment as a topical anesthetic agent in comparison with a topical local anesthetic cream (eutectic mixture of lidocaine and prilocaine) and placebo ointment in healthy human volunteers.METHODS: A patch test was done prior to clinical testing. Thirty (30) healthy adult volunteers were enrolled. Irritation potential of 50% and 75% ointments were determined. On the clinical trial phase, 85 patients were included. The following test drugs were used: 50% capsaicin ointment, 75% capsaicin ointment, eutectic mixture of 2.5% lidocaine and 2.5% prilocaine, and placebo ointment. Allocation of the test drugs to the marked boxes on the patient's forearm was done through simple randomization using a computer-generated random allocation scheme. Both the subjects and the investigators were blinded on the test drugs applied. Test ointments and placebo were applied on the marked areas of the forearms and occluded with a transparent plastic film. After 60 minutes, the investigator recorded any adverse reactions. The marked areas were then tested for pain sensation using a needle lever apparatus that enabled the sharp point of the needle to thrust uniformly and perpendicularly on the marked test areas. The subjects were asked to assess the pain by a verbal response scale for pain. Adverse reactions were again noted on the 24th and 72nd hour.RESULTS: In the patch test, the primary irritation index (PII) scores of both 50% and 75% ointments (0.05 and 0.18), were classified as non-irritant and probably safe for intact human skin contact.In the clinical trial phase, the data were analyzed using Wilcoxon signed ranks test. It established that the positive control (cream containing eutectic mixture of lidocaine and prilocaine) had significantly lower pain scores than 50% and 75% capsaicin ointments and placebo. Capsaicin ointments were no better than placebo in terms of mean pain scores.CONCLUSION: In humans, 50% and 75% capsaicin ointments are not effective as a topical anesthetic agent as compared to the eutectic mixture of lidocaine and prilocaine. Capsaicin ointment is associated with mild adverse reactions which were described as stinging and itching sensations which were seen in 84.7% of patients.

Classical juvenile pityriasis rubra pilaris

We report a case of a 9-year old male who presented with 2 months history of well-defined keratotic follicular papules on an erythematous base located on the scalp, face, trunk and extensor aspects of the extremities. Of the 5 clinical types of pityriasis rubra pilaris (PRP), our patient was classified as type III or the classical juvenile pityriasis rubra pilaris. Treatment modalities focused on the giving of topical corticosteroids, emolients and keratolytics which showed marked improvement on the cutaneous lesions.

Verrucous carcinoma of the penis not associated with HPV

Verrucous carcinoma of the penis is a rare invasive carcinoma that originates from squamous epithelial cells. It comprises 5 to 24 percent of all penile malignancies and 5 to 16 percent of all squamous cell carcinoma. In 5 % of cases, it is associated with human papilloma virus (HPV). We describe a case of a 42 year old male, with a I year history of a slowly enlarging verrucous mass which initially presented as a warty papule on the penile shaft.

Lichen amyloidosis in a 57 year old female: A case report

We describe a case of a 57 year old female who presented with multiple papules on bilateral extremities with no other systemic findings. Skin lesions consisted of multiple hyperpigmented scaly papules in a rippled pattern some coalescing into plaques. Histologic examination showed deposits of amorphous eosinophilic materials in the papillary dermis. The diagnosis of lichen amyloidosis was made. Treatment with high potency topical steroid in combination with salicylic acid ointment, emollients, and systemic antihistamine which afforded improvement after 2 weeks. There was 90 percent clearance of lesion within 5 months of therapy. The origin and clinical features of papular primary localized cutaneous amyloidosis (PLCA) are reviewed.