The economic burden of psoriasis: A cross-sectional study in a tertiary hospital in the Philippines

@#<p style="text-align: justify;"><strong>INTRODUCTION:</strong> Costs associated with chronic psoriasis impart a significant economic burden.</p><p style="text-align: justify;"><strong>OBJECTIVES:</strong> This study aims to determine the direct and indirect cost of psoriasis patients in a tertiary government hospital in Davao City.</p><p style="text-align: justify;"><strong>METHODS:</strong> Plaque-type psoriasis patients who were actively seeking care at the Southern Philippines Medical Center Department of Dermatology for at least 6 months prior to the study period were included. The participants reported on socioeconomic status, productivity loss and monetary funding through questionnaires. Work impairment was evaluated using the Work Productivity and Activity Impairment questionnaire and was used to compute the indirect cost. A 6-month retrospective review of the health information system and medical charts generated the healthcare resource utilization data as well as the medical data used to compute the direct cost.</p><p style="text-align: justify;"><strong>RESULTS:</strong> Among the 43 participants enrolled, 53% had a monthly household income of less than PHP8,000 (USD157) and 27% were unemployed. There was an overall work impairment of 65.4%, and 55% had experienced a change in employment status due to psoriasis. The mean 6-month direct cost of psoriasis was PHP22,672.28 ($445). The mean 6-month indirect cost was PHP 26,071.20 ($511) for employment status change and PHP 75,804.30 ($1,486) for work impairment. Government agencies provided financial aid for treatment but majority of the costs came from the participants' own pockets.</p><p style="text-align: justify;"><strong>CONCLUSION:</strong> The economic burden of psoriasis increased substantially due to the indirect cost, which in turn increased remarkably due to work impairment and employment status change.</p>

A fatal case of Staphylococcal Scalded skin syndrome associated with Iatrogenic Cushing syndrome due to potent topical steroid application in a 3-month-old female: A case report

Introduction@#Cushing syndrome caused by application of topical corticosteroids is rarely reported. Systemic side effects like suppression of hypothalamic-pituitary-adrenal axis, growth retardation in children and iatrogenic Cushing syndrome can occur even in small doses of potent topical steroids.1@*Case Summary@#This is a case of a 3-month old female who was referred to our department due to generalized erythema with desquamation. History revealed that the patient had recurrent eczema and the mother applied an over-the-counter medication containing Ketoconazole+Clobetasol 10mg/500mcg per 7-gram cream thrice daily for ten weeks. The estimated topical steroid applied weekly was around 8.5 grams and at time of admission, the patient had been exposed to approximately 50 grams of a potent topical corticosteroid. The patient presented with fever, irritability, and had positive Nikolsky sign thus managed as a case of staphylococcal scalded skin syndrome associated with topical steroid – induced iatrogenic Cushing syndrome. Unfortunately, patient’s condition worsened and with progressive pneumonia, she expired on the 23rd hospital day. The fatal outcome was due to SSSS which was complicated by progressive pneumonia and topical steroid – induced iatrogenic Cushing syndrome. The complex interplay of these features eventually led to sepsis and death.@*Conclusion@#This case highlights the risks related to abuse of potent steroid-containing preparations and the importance of education to prevent severe and catastrophic outcomes of injudicious steroid use.

Acral Lentiginous Melanoma treated by wide excision with split-thickness skin graft: Case in images

@#Acral lentiginous melanoma (ALM) is the rarest of the four subtypes of cutaneous melanoma.1 It accounts for only 2-8% of melanomas in caucasians.2 Only 52 cases of ALM have been recorded in the Philippine Dermatological Society Health Information System from 2011 to 2016.3 Histopathologic demonstration of cytologic atypia, presence of mitoses in the deep dermis, pagetoid spread of epidermal melanocytes and lack of maturation of nests with descent into the dermis are features diagnostic of melanoma.2 4 ALM is primarily managed through wide surgical excision. The most common sites for ALM are the soles, palms, and subungual areas.2 The rarity of ALM, the inconspicuousness of the locations of some lesions, and the difficulty in discerning ALM from benign lesions and traumatic changes usually delay the diagnosis and contribute to the poor prognosis of the disease.4 5 6 A 53-year-old male consulted us for an enlarging pigmented plaque on the sole of his left foot. The lesion started as a junctional nevus, which the patient had since birth. The nevus, originally measuring approximately 0.5 x 0.5 cm, started to increase in size one year prior to the consultation. One month before consultation, the patient noted a black nodule on the center of the lesion. A week before consultation, the lesion bled and became painful after manipulation by the patient. Dermatologic examination of the plantar aspect of the left foot revealed a 1.7 x 1.6 cm, dark brown-black, asymmetric plaque with cobblestone-like surface and a black indurated nodule on the center (Figure 1A). Dermoscopic findings of bluish white veil and irregular pigmentation with variable hypopigmented blotches are suggestive of acral melanoma (Figure 1B). Skin punch biopsy and immunohistochemical stains for S100, Melan A, HMB-45, and KI-67 confirmed the diagnosis of ALM (Figure 2, 3). We did a wide local excision of the lesion with a 2-cm margin from the tumor edge, with depth up to the suprafascial level (Figure 4A). The excisional defect was repaired with a split-thickness skin graft taken from the patient’s skin on the right thigh (Figure 6), which provided excellent aesthetic result. We also did a sentinel lymph node biopsy on the left inguinal area (Figure 5A,B). Frozen section biopsy showed solid nests of atypical melanocytes invading the surrounding fibrous stroma. Individual cells exhibit round to oval, deeply basophilic nuclei and abundant, clear to eosinophilic cytoplasm. Some areas showed prominent melanin pigmentation. Sections along lines of resection, lymphovascular channels, nerves and adipose tissues of the excised mass (Figure 4 B,C) and lymph nodes from sentinel biopsy were all devoid of malignant tumor cells. Histopathologic findings from frozen section biopsy and permanent section biopsy were both consistent with malignant melanoma with 3 mm Breslow thickness. The patient’s postoperative course, including wound healing, was uneventful (Figure 7). During the patient’s 12-month follow up period, we did not observe any signs of local or distant recurrence of the tumor.

Acral Lentiginous Melanoma treated by wide excision with split-thickness skin graft: Case in images

@#Acral lentiginous melanoma (ALM) is the rarest of the four subtypes of cutaneous melanoma.1 It accounts for only 2-8% of melanomas in caucasians.2 Only 52 cases of ALM have been recorded in the Philippine Dermatological Society Health Information System from 2011 to 2016.3 Histopathologic demonstration of cytologic atypia, presence of mitoses in the deep dermis, pagetoid spread of epidermal melanocytes and lack of maturation of nests with descent into the dermis are features diagnostic of melanoma.2 4 ALM is primarily managed through wide surgical excision. The most common sites for ALM are the soles, palms, and subungual areas.2 The rarity of ALM, the inconspicuousness of the locations of some lesions, and the difficulty in discerning ALM from benign lesions and traumatic changes usually delay the diagnosis and contribute to the poor prognosis of the disease.4 5 6 A 53-year-old male consulted us for an enlarging pigmented plaque on the sole of his left foot. The lesion started as a junctional nevus, which the patient had since birth. The nevus, originally measuring approximately 0.5 x 0.5 cm, started to increase in size one year prior to the consultation. One month before consultation, the patient noted a black nodule on the center of the lesion. A week before consultation, the lesion bled and became painful after manipulation by the patient. Dermatologic examination of the plantar aspect of the left foot revealed a 1.7 x 1.6 cm, dark brown-black, asymmetric plaque with cobblestone-like surface and a black indurated nodule on the center (Figure 1A). Dermoscopic findings of bluish white veil and irregular pigmentation with variable hypopigmented blotches are suggestive of acral melanoma (Figure 1B). Skin punch biopsy and immunohistochemical stains for S100, Melan A, HMB-45, and KI-67 confirmed the diagnosis of ALM (Figure 2, 3). We did a wide local excision of the lesion with a 2-cm margin from the tumor edge, with depth up to the suprafascial level (Figure 4A). The excisional defect was repaired with a split-thickness skin graft taken from the patient’s skin on the right thigh (Figure 6), which provided excellent aesthetic result. We also did a sentinel lymph node biopsy on the left inguinal area (Figure 5A,B). Frozen section biopsy showed solid nests of atypical melanocytes invading the surrounding fibrous stroma. Individual cells exhibit round to oval, deeply basophilic nuclei and abundant, clear to eosinophilic cytoplasm. Some areas showed prominent melanin pigmentation. Sections along lines of resection, lymphovascular channels, nerves and adipose tissues of the excised mass (Figure 4 B,C) and lymph nodes from sentinel biopsy were all devoid of malignant tumor cells. Histopathologic findings from frozen section biopsy and permanent section biopsy were both consistent with malignant melanoma with 3 mm Breslow thickness. The patient’s postoperative course, including wound healing, was uneventful (Figure 7). During the patient’s 12-month follow up period, we did not observe any signs of local or distant recurrence of the tumor.