Hypertrophic Lichen Planus in a 38-year-old Filipino male: A case report

@#Hypertrophic lichen planus (HLP) is a papulosquamous eruption presenting with extremely pruritic hyperkeratotic flat-topped papules, plaques, and nodules. This is a case of 38-year-old male who presented with a 2-month history of generalized erythematous-to-hyperpigmented papules, patches, and plaques topped with white-to-gray oyster shell-like scales on a background of hyperpigmented macules and patches. There was no involvement of the conjunctival, otic, oral, and genital mucosae, and palmar and plantar aspects of the hands and feet. Dermoscopy showed reticular pearly white structures corresponding to the Wickham striae, comedo-like openings, blue-gray dots, brownish-black dots, and scales. Histopathologic examination revealed marked compact hyperkeratosis, wedge-shaped hypergranulosis, irregular saw-toothed epidermal acanthosis, scattered dyskeratotic keratinocytes, and superficial perivascular lichenoid infiltrate of lymphocytes, histiocytes, and melanophages. The patient was managed as a case of HLP. He was started on methotrexate 10 mg per week, bath psoralen photochemotherapy (PUVA) three times a week, betamethasone valerate 1mg/g cream twice a day for 2 weeks alternating with tacrolimus 0.1% ointment twice a day for another 2 weeks, 10% lactic acid, emollients, and sunscreen. After 6 months of treatment, there was almost 80% improvement of lesions and relief of pruritus.

Knowledge, attitudes, and practices on teledermatology among dermatologists in the Philippines

Background@#Teledermatology has been widely used during the coronavirus disease 2019 (COVID-19) pandemic to overcome barriers in access to care. The objective of this study was to assess the current knowledge, attitudes, and practices regarding teledermatology among dermatologists in the Philippines.@*Materials and Methods@#This was a cross-sectional and analytical study conducted from January 2022 to April 2022, among Filipino dermatologists using a self-administered online questionnaire. Descriptive statistics was used to summarize the demographics of the participants. The two-sample t-test, Chi-square test, and multiple logistic regression model were used to analyze the data.@*Results@#Out of 113 respondents, 108 (95.5%) had adequate knowledge and a positive attitude toward teledermatology. The majority (110/113, 97.35%) practiced teledermatology. The most commonly used platform was instant messaging applications(78/100, 70.91%), and the most common factor that influenced their practice was patient demands or needs(74/110, 67.27%). Those who did not practice teledermatology cited technological difficulties as the main reason.@*Conclusion@#Teledermatology was widely used by Filipino dermatologists to provide remote care during the COVID-19 pandemic. However, to fully utilize its potential and limit potential issues associated with its use even after the pandemic, continuous training and education among dermatologists and a more enabling technological environment may be needed.

A literature review and clinical consensus guidelines on the management of Bullous Pemphigoid

@#Bullous pemphigoid (BP) is the most common autoimmune blistering disease primarily characterized by tense blisters and occasionally with urticarial plaques, affecting the skin and mucous membranes. These are caused by autoantibodies against BP180 and BP230 which target antigens on the basement membrane zone. The diagnosis relies on the integration of clinical, histopathological, immunopathological, and serological findings. The management depends on the clinical extent and severity. We present in this article a literature review and the clinical consensus guidelines of the Immunodermatology Subspecialty Core Group of the Philippine Dermatological Society in the management of BP.

Childhood bullous pemphigoid: A case report

Introduction@#Bullous pemphigoid (BP) is an acquired autoimmune subepidermal bullous disease characterized by linear depo- sition of IgG and C3 along the basement membrane. It rarely occurs in childhood, especially in adolescence, with only 14 cases identified in literature. Treatment of choice is systemic corticosteroids but other treatment options such as anti-inflammatory antibacterials and methotrexate are available.@*Case report@#A 16-year-old Filipino girl presented with a three-month history of generalized vesicles and bullae. Nikolsky and Asboe-Hansen signs were negative. Histopathology and direct immunofluorescence were consistent with BP. ELISA to BP180 au- toantibody levels was elevated at 135 IU (normal <9 IU). Complete blood count showed leukocytosis with increase in neutrophils. Chest x-ray revealed pulmonary tuberculosis. The patient was given quadruple anti-Koch’s medication (pyrazinamide, rifampi- cin, ethambutol, isoniazid), prednisone, oral erythromycin and topical clobetasol propionate. Complete remission was attained at 10 months and is sustained at the time of writing.@*Conclusion@#To establish a definitive diagnosis and appropriate management, BP requires clinical, histopathologic, and immuno- logical correlation. Childhood BP has good prognosis and rapid treatment response, with rare relapses.

A case of anti-BP230 antibody-positive dyshidrosiform bullous pemphigoid secondary to dipeptidyl peptidase-4 inhibitor in a 65-year-old Filipino female

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> Bullous pemphigoid (BP) is a chronic, relapsing autoimmune blistering disorder commonly found in adults older than 60 years of age. It is mediated by autoantibodies directed against the hemidesmosomal proteins BP180 and BP230, which trigger an inflammatory cascade leading to blister formation. BP may present with pruritus, followed by an erythematous plaque or urticaria, and subsequently by bullae formation with or without mucosal involvement. It develops sporadically but can also be triggered by ultraviolet light exposure, radiation therapy, and medications such as dipeptidyl peptidase-4 inhibitor (DPP4i). Since 2006, the increasing use of DPP4i (also known as gliptins) for their good safety profi le in treating Type II Diabetes Mellitus has led to a further increase in the incidence of bullous pemphigoid.</p><p style="text-align: justify;"><strong>CASE REPORT:</strong> This is a case of a 65-year-old hypertensive and diabetic elderly Filipino female presenting DPP4i (linagliptin)-induced bullous pemphigoid with an atypical dyshidrosiform pattern, negative direct immunofluorescence (DIF), and Enzyme-linked immunosorbent assay (ELISA) that is negative for anti-BP180 antibodies but positive for anti-BP230 antibodies.</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> The increasing use of DPP4i for diabetes mellitus for its good safety profile may be an essential contributing factor to the increasing incidence of BP in elderly hypertensive and diabetic patients with a simultaneous increasing incidence of atypical BP presentations such as the dyshidrosiform variant. Inability to recognize these factors carries significant therapeutic implications, including prolonged multidrug immunosuppression and increased patient morbidity and mortality.</p><p style="text-align: justify;"><strong>KEYWORDS:</strong> Bullous pemphigoid, gliptin, ELISA</p>

lgA pemphigus, intraepidermal neutrophillic type in an 8-year old Filipino female: A case report

INTRODUCTION@#lgA pemphigus is a rare, chronic, relapsing, benign group of autoimmune intraepidermal blistering dermatosis with an unknown etiology. It is characterized by significantly pruritic, vesiculopustular lesions that occur mainly on the trunk and proximal extremities. Histopathologic and immunofluorescence studies show intraepidermal blisters and deposition of immunoglobulin A in the intercellular spaces of the epidermis, respectively.@*CASE REPORT@#To our knowledge, we present the first reported pediatric case of lgA pemphigus, intraepidermal neutrophilic type, in an 8-year old Filipino female with a 2-year history of generalized papules and flaccid pustules, some forming an annular pattern. Diagnosis was confirmed by histopathology and direct immunofluorescence. Enzyme-linked immunosorbent assay for Desmoglein 1 was negative. Complete clearance of lesions was achieved with dapsone, colchicine and prednisone.

A case report on alopecia areata incognita in a 19 year old Filipino female

INTRODUCTION@#Alopecia areata incognita is a rare form of alopecia areata which was first reported in 1987. The prevalence of this disease is unknown but it is more common in women. The usual presentation of alopecia areata incognita is acute, diffuse hair thinning. In most cases, it lacks the typical alopetic patches seen in alopecia areata. It may resemble telogen effluvium and androgenetic alopecia. The prognosis of this disease is favorable and recovery is rapid and spontaneous. Case: A 19- year-old Filipino female presents with a two-month history of alopecia areata incognita. She initially had a solitary round patch of hair loss on the scalp with proximally tapered hair, rapidly evolving into diffuse hair thinning. CBC, TFTS, FBS, HBA 1 c, ANA and VDRL were unremarkable. Histopathology demonstrated dense peribulbar lymphocytic infiltrate, miniaturized hair and increased catagen hair consistent with alopecia areata. There was gradual hair growth after treatment with minoxidil 5% lotion and topical betamethasone dipropionate 0.05% lotion.

Prevalence of Mucosal and Cutaneous disorders among HIV/AIDS adult Filipino patients 18-60 years old seen in a tertiary hospital in Makati City

Background@#With the recent rise in number of HIV/AIDS patients in the Philippines, knowledge of the most common mucosal and cutaneous findings among HIV/AIDS patients can be a valuable tool of assessment.@*Objectives@#To determine the different mucosal and cutaneous disease findings of HIV/AIDS patients; evaluate their frequency and association with the latest CD4 cell counts, and to determine patients’ demographic and medical profiles.@*Methods@#This is a cross-sectional study done at a tertiary hospital in Makati city from January 2017 to September 2018. Walk-in patients or those referred by Infectious Disease specialists were evaluated using a standardized history and physical examina- tion form. Latest CD4 counts were also obtained.@*Results@#A total of 93 patients were enrolled. Majority were males (98%), with a mean age of 32 +/- 7.08, employed (64%), and on HAART (87%). A large part of the group (45%) has severe immunosuppression (CD4 counts <200/mm3). The most common manifes- tations were the following: non-infective, fungal, and drug-related dermatoses, with the most common dermatoses being seb- orrheic dermatitis, xerosis, pruritic papular eruptions (PPE), superficial fungal infections, drug hypersensitivity reactions, and syphilis. PPE was noted to be significantly associated with low CD4 counts.@*Conclusion@#Due to small population size, significant associations between the other dermatoses with their CD4 counts were not seen except for PPE, which was significantly associated with CD4 counts <200/mm3. Nevertheless, a strong suspicion for any underlying HIV//AIDS infection is still warranted in the presence of these dermatoses.

Drug-induced chronic bullous disease of childhood in a two-year-old Filipino male triggered by cefaclor or cefuroxime: A case report

Introduction@#Chronic bullous disease of childhood (CBDC) is a rare immune-mediated subepidermal vesiculobullous eruption, characterized by linear IgA deposition along the basement membrane zone of the skin. Although mostly idiopathic, CBDC may be triggered by factors such as infection, and drugs. Clinical and immunohistopathological features of drug-induced cases are heterogeneous and indistinguishable from the idiopathic form.@*Case report@#A two-year-old Filipino male presented with pruritic vesicles and bullae on the back several days after finishing a course of cefuroxime, and cefaclor. Examination revealed multiple tense vesicles and bullae, some coalescing into a rosette pattern with central crusts on the perioral, scalp, neck, back, perineal, and perianal areas. Histopathology showed a subepidermal split with neutrophilic and eosinophilic infiltrates. Direct immunofluorescence revealed strong linear deposition of IgA, and granular deposits of C3 and IgM at the basement membrane zone, thus confirming the di- agnosis of CBDC. Dapsone at 2mg/kg/day was started, with oral prednisolone (1.3mg/kg/day), and cloxacillin syrup (40mg/kg/day). Topical care with betamethasone dipropionate and mupirocin ointment was included. After eight weeks, patient showed significant im- provement with few vesicles and resolved lesions healing with post-inflammatory hyperpigmentation.@*Conclusion@#We report a case of a two-year-old male presenting with vesiculobullous lesions after a course of cefuroxime, and cefaclor. As both were given and withdrawn in a period of close proximity, it is difficult to determine the probable culprit drug. Spontaneous resolution upon withdrawal of the suspected drug is variable. Systemic therapy such as dapsone may be necessary for treatment.

Procedural dermatology in the COVID-19 era: an online survey of the Philippine Dermatological Society members and practical recommendations for safe practice

@#BACKGROUND: The novel COVID-19 (Coronavirus Disease 19) predisposes the general population to a high risk of infection. The 106 million population of the Philippines would be considered an at-risk group due to the high density of the populace in cities. As the situation in each country differs during this era of the COVID-19 pandemic, this paper aims to give practical recommendations for safe procedural dermatology practice in the Philippine setting after the lifting of the government-mandated quarantine. METHODS: An online survey was conducted among Philippine Dermatological Society members. The survey was sent electronically on March 22, 2020. RESULTS: A total of 466 or 42% of the PDS’s 1100 current members replied to the survey. The top 10 procedures performed among the respondents are: 1. Electrocautery (N=437, 94.38%), 2. Chemical peeling (N=422, 91.13%), 3. Laser & energy based device treatment (N= 341, 73.65%), 4. Botulinum toxin injection (N=323, 69.76%), 5. Excision (N=263, 56.80%), 6. Acne surgery (N=176, 38.01%), 7. Injectable Filler (N=171, 36.93%), 8. Cryotherapy (N=145, 31.32%), 9. Platelet rich plasma injection (N=111, 23.97%) and 10. Scar revision (N=85, 18.36%). The majority of the respondents have access to personal protective equipment (PPE) such as surgical masks (N=457, 98.7%), face shields (57.67%), goggles (46.00%), protective gown (42.76%) and bonnets (32.83%). Before the government quarantine, the majority (N=375, 81.17%) of respondents see patients on a firstcome, first-serve system. Only 18.83% (N=87) see patients only by appointment. Regarding teledermatology, most respondents answered that they would advise patients to do digital consultation with only a minority responding they would not consider doing teledermatology. CONCLUSIONS: In the Philippine setting, the best ways to prevent COVID infection inthe procedural dermatology setting include: 1. Education of staff and patients on proper exposure prevention and sanitation measures. 2. Ensuring the correct usage of PPE. 3. Ensuring physical distancing and reducing patient wait times by scheduling visits on an appointment basis. 4. Sufficient protocols must be made for sanitation before and after each patient visit. 5. Teledermatology in pre-procedure consults and post-procedure follow-ups would reduce the risk of COVID-19 transmission for both patient and physician.

Diffuse cutaneous mastocytosis in a Filipino newborn: A case report

INTRODUCTION@#Cutaneous mastocytosis is the accumulation of mast cells in the skin. Diffuse cutaneous mastocytosis is a rare variant accounting for only 1.74% of al mastocytosis cases reported. Ninety percent of cases are seen in children presenting with multiple erythematous to yellow-tan papules and plaques with leathery texture. The pathogenesis is in the structure and activity of kit receptor expressed on mast cells, melanocytes and other cells.@*CASE SUMMARY@#This is a female neonate born to an 18 year old mother, G1P1 via vaginal delivery at 37 weeks age of gestation. Patient presented with a generalized involvement of multiple, well defined, indurated, leathery, brown papules and confluent plaques. Darier sign was positive. Histopathological examination revealed diffuse involvement of the dermis with mast cells. Giemsa stain was positive. Patient was diagnosed both clinically and histopathologically with diffuse cutaneous mastocytosis without systemic involvement. She was treated with H1 antihistamines and topical glucocorticoids.@*CONCLUSION@#Diffuse cutaneous mastocytosis can be diagnosed both clinically and histopathologically. Treatment is mostly symptomatic. It is always prudent to inform co-managing physicians, the patient, and their families of potential mast cell degranulating stimuli and to watch out for signs and symptoms for systemic involvement.

Pachyonychia congenita affecting only the nails: A case report

INTRODUCTION@#The nails have many functions for daily life including protection of the digits against different kinds of trauma. The nail apparatus is composed of multiple kinds of keratins. Defects in keratin may produce several genodermatoses, which include Pachyonychia congenita. This is a rare genodermatosis that is either automosal dominant or sporadic. The usual involved keratins are KRT6a, KRT6b, KRT6C, Kl 6 and Kl 7. Keratin defects may manifest on the hair, mucosa, skin and nails. Different presentations of each patient depends on the involved mutated keratins, In rare cases, nail dystrophy may be the only manifestation of the keratin defect.@*CASE SUMMARY@#A 23 -year-old female presented with a 13-year-history of nail thickening on both fingernails and toenails with no other associated symptoms. She denied oral and skin lesions. She had been unsuccessfully treated with both oral and topical antifungals by several dermatologists. No family members have any similar conditions. She admitted to having hoarseness. On physical examination, nails of both hands and feet marked subungual hyperkeratosis, yellowish to brown- gray discoloration and hypercurvature and rough surface of all 20 nails. The histopathology report revealed marked compact hyperkeratosis, hypergranulosis, papillomatosis and acanthosis. Fungal culture and PAS stain revealed no fungal elements. Patient responded well to nail avulsion and good nail regrowth was noted. She plans treatment of all nails with avulsion.@*CONCLUSION@#Thorough history, physical examination and histology may help confirm the diagnosis of Pachyonychia congenita, which at times may be mistaken for other nail problems. Treatment is based upon the clinical presentation of the patient. Prognosis for life is good but complications such as infections should be properly addressed.

Classic dermatomyositis in a 36-year-old Filipino female: A case report with emphasis on the early recognition of cutaneous findings of dermatomyositis

INTRODUCTION@#Dermatomyositis is a rare idiopathic inflammatory myopathy with characteristic skin manifestations and proximal muscular weakness. In 30 percent of classic dermatomyositis, skin findings precede muscle weakness. Since the initial skin lesions are not always highly characteristic of dermatomyositis, there may be a delay in diagnosis and treatment.@*CASE REPORT@#This is a case of a 36-year-old Filipino female who initially presented with erythematous patches and plaques on the face, arms, and thighs. One week later, she developed multiple, well-defined, erythematous to violaceous, edematous, tender patches and plaques on the face, V of the neck, upper back, proximal extremities and buttocks. Seven weeks later, she developed proximal muscle weakness described as difficulty in raising her arms and difficulty in standing up from a sitting position. Histopathology was consistent with dermatomyositis. SGPT, C3, ANA, and anti-ds-DNA were normal. SGOT and creatine kinase were 5 and 15 times the normal value, respectively. She was treated with prednisone from the first week of illness and hydroxychloroquine from the fifth week of illness. Her condition greatly improved with no progression of the disease for the succeeding 3 years.@*CONCLUSION@#Even in the absence of muscle weakness, there should be a high index of suspicion for dermatomyositis in patients with confluent, erythematous patches and plaques on the face, trunk and proximal extremities. Adequate work-up and clinical monitoring will pave the way for early diagnosis and consequently early treatment and a better patient outcome.

A descriptive study on the clinical, dermoscopic and histopathologic features of pigmented skin lesions among Filipino adults

Background@#Dermoscopy increases the diagnostic accuracy of clinical visual inspection by 5% to 30%. This has led to a reduction of unnecessary excision of benign skin lesions and the earlier diagnosis of malignant skin lesions.@*Objectives@#To compare the concordance agreement of the clinical versus histopathologic diagnosis to the concordance agreement of the dermoscopic versus histopathologic diagnosis of pigmented lesions.@*Research Design@#This is a prospective, cross-sectional study of the clinical, dermoscopic and histopathological features of pigmented skin lesions on patients seen at the Out-Patient Departments of Quirino Memorial Medical Center and Ospital ng Makati from March 2013 to June 2014.@*Methods@#Sixty-eight subjects fulfilled the criteria and were all included in the final analysis. Classification and definitive diagnosis of the lesion as benign or malignant were determined thru clinical, dermoscopic and histopathologic features by one dermatopathologist. Kappa and concordance analyses were performed to determine the statistical and concordance agreement among the results of the three diagnostic procedures, respectively.@*Results@#The statistical agreement between clinical versus histopathologic classification as benign or malignant was good (kappa=0.872), while the statistical agreement was high (kappa=0.872) between dermoscopic versus histopathologic classification. Concordance agreement between clinical versus histopathologic diagnosis showed fair agreement (concordance coefficient=0.2397) as compared to a high agreement (concordance coefficient=0.98) in dermoscopic versus histopathologic diagnosis.@*Conclusion@#The use of dermoscopy in pigmented lesions aids the dermatologist in giving an accurate diagnosis without invasive procedures. Knowledge of the dermoscopic features will help in the early clinical detection and management of benign and malignant pigmented skin lesions.

Primary cutaneous anaplastic large-cell lymphoma with metastases in an 81-year-old Filipino female

Introduction@#Primary Cutaneous Anaplastic Large Cell Lymphoma (PC-ALCL) is a rare Non-Hodgkin lymphoma (NHL) representing approximately 9% of all cutaneous lymphomas.3 It usually manifests as a slow-growing, solitary tumor which has a tendency to regress spontaneously. However, metastasis is reported in 5-10% of cases.2@*Case Summary@#Our case is an 81-year-old female with a four-month history of an enlarging nodule on the left upper back. The initial impression was a malignant cutaneous tumor. Histopathology revealed epidermotropic large atypical lymphocytes and diffuse infiltrates of hyperchromatic, pleomorphic mononuclear cells and lymphocytes. Immunohistochemistry showed CD3+, CD20-, CD30+, epithelial membrane antigen (EMA)- and anaplastic lymphoma kinase (ALK)- consistent with PC-ALCL. Metastatic work-up revealed pulmonary involvement. The patient underwent two cycles of multi-agent chemotherapy with marked improvement. However, patient declined further treatment and expired five months after the diagnosis.@*Conclusion@#This case emphasizes that although PC-ALCL commonly presents with an indolent course, extracutaneous spread can occur. Prompt treatment with chemotherapy increases survival significantly with a cure rate of 92%.2

Dermoscopic features of red tumors among Filipino patients seen at two centers

Background@#Dermoscopy, a non-invasive diagnostic tool, has been proven to improve the diagnostic accuracy of vascular tumors since it can aid in identifying vascular structures as well as morphology of vessels. Tumor depth and precise vascular structures can also be evaluated through dermoscopy.@*Objective@#The study aimed to describe the dermoscopic features of red tumors in Filipino patients seen at the Outpatient Dermatology Department of two centers from January 2013 to July 2014.@*Methods@#Patients with red tumors were recruited to the study. Dermoscopic features were described for each tumor, and histopathology was done.@*Results@#A total of 44 patients were included in the study, and 45 red tumors were evaluated. The tumors were located on the face (31%), trunk (36%), and extremities (33%). The majority of the red tumors were confirmed to be vascular tumors (78%) on histopathology. Dermoscopic features that were found in the majority of vascular tumors seen were lacunae and reddish homogenous areas. For non-vascular tumors, vessels were identifiable in 90% of the tumors seen.@*Conclusion@#In this study, the use of dermoscopy in the diagnosis of red tumors proved to be a useful preliminary tool that aided in the observation of vascular pattern, albeit red lacunae, red to dark red homogenous areas, and different types of vessels. The identification of these structures may aid in arriving at a more precise diagnosis and help differentiate vascular from non-vascular tumors.