Plasma cell cheilitis in an elderly female: A case report

Introduction@#Plasma cell cheilitis (PCC) is a rare, chronic inflammatory dermatitis of unknown etiology. Due to the limited number of cases reported, no guidelines have been established for its treatment. We present a case of PCC clinically similar to actinic cheilitis or mucosal lichen planus, and squamous cell carcinoma but showed response to topical tacrolimus 0.1% ointment. @*Case Report@#A 62-year-old female with extreme fondness to piping hot food presented with a solitary painful ulceration with some pustules and bleeding on the lower lip with three (3) months duration. Skin punch biopsy revealed a dense band-like infiltrate of plasma cells which is consistent with Plasma cell cheilitis. The patient was given tacrolimus 0.1% ointment and showed significant improvement after a month of treatment.@*Conclusion@#PCC is a rare condition that should still be considered in patients presenting with persistent cheilitis. Clinical and histological correlation is advised for proper management and prognostication.

Acral lentiginous melanoma and tuberculosis verrucosa cutis in a 78-year-old Filipino: A case report

Introduction@#Acral lentiginous melanoma is a subtype of melanoma common in Asians with one of the worst prognoses. It is usually detected late especially when situated on the plantar surface of the feet. While other forms of malignancies have been associated with cutaneous tuberculosis, melanoma is not one of them.@*Case report@#This is a case of a 78-year-old male with a six-month history of a solitary asymptomatic reddish-brown papule on the plantar aspect of the right foot, which increased in size evolving into a verrucous plaque. There was no improvement despite treatment with oral antibiotics and topical antifungals. Dermoscopic findings on different parts of the lesion were suggestive of both a granulomatous disease and a melanoma. Purified Protein Derivative (PPD) skin test was positive. Histopathologic findings showed the presence of multinucleated giant cells as well as nests of melanocytes which were highlighted by CD-68 and Melan-A respectively. With clinicopathologic correlation, diagnosis of the patient was tuberculosis verrucosa cutis and acral lentiginous melanoma. Complete excision with adequate margins was advised. The patient was started on a 6-month course of anti-Koch’s medications and was referred to a surgery and oncology for co-management. The patient was subsequently lost to follow up, until worsening of the lesions 6 months later prompted online consultation, claiming poor compliance to his anti-Koch’s regimen. Patient was referred to a surgeon who did wide excision biopsy. Histopathologic findings were consistent with acral lentiginous melanoma. Shortly after the procedure, the patient expired.@*Conclusion@#This is a rare case of acral lentiginous melanoma and tuberculosis verrucosa cutis existing concomitantly with each other. This may also be presumed to be the first reported case of acral lentiginous melanoma arising from tuberculosis verrucosa cutis.

AIDS-associated Kaposi sarcoma: A case series in the Philippine setting

Introduction@#Acquired immunodeficiency syndrome-Kaposi sarcoma (AIDS-KS) has unique clinical characteristics, often dis- seminated on presentation, a rapidly progressive course, and often fatal outcome. Describing the epidemiology and clinical characteristics of AIDS-KS in the Philippines may lead to early recognition, diagnosis, and management of this condition, which are the keys to preventing significant complications.@*Case Series@#AIDS-KS in 11 Filipino MSM patients with a mean age of 36.55 years (SD 11.54) was described. Violaceous plaques and nodules were present for an average of 5.1 months prior to diagnosis confirmed by biopsy. Histopathologic findings from all pa- tients were consistent with KS. The median CD4+ count of patients was 44 cells/microliter (range, 4 to 181). Six patients presented with opportunistic infections (OI)/AIDS-related conditions (ARC). The most common OIs observed were pulmonary tuberculosis, oropharyngeal candidiasis, and Pneumocystis jiroveci pneumonia. Nine patients improved with highly active antiretroviral therapy (HAART). One patient required modification on his HAART regimen, which was shifted to 2 NRTI and ritonavir-boosted protease inhibitor, and one patient died due to AIDS-related complications.@*Conclusion@#This series of 11 cases of AIDS-KS showed similar demographic, clinical and histopathologic characteristics to pre- viously published studies. Findings suggest the need for earlier recognition and diagnosis. While HAART afforded clinical improve- ment in a majority of patients, other treatment options such as chemotherapy should be considered for appropriate patients.

Severe Papulopustular Rosacea with Demodicosis in a 47-year-old Filipino female: A case report

Introduction@# Rosacea is a chronic relapsing inflammatory facial dermatosis often characterized by flare-ups and remissions exclusively affecting the centrofacial skin.@*Case report@#This is a case of multiple symmetric intensely erythematous papules, pustules, and plaques over both cheeks in a 47-year-old Filipino female. Dermoscopy showed brown-yellowish structureless areas, straight vessels in a polygonal pattern, dilated follicles, follicular plugs, ill-defined white rosettes, and non-specific scales. Skin punch biopsy showed spongiosis of the epidermis and demodex folliculorum within the follicular infundibulum. The dermis revealed telangiectasia of blood vessels and dense inflammatory infiltrates. Hypertrophy of sebaceous lobules was also seen. The patient was initially treated with oral lymecycline 300mg twice a day for 2 weeks without improvement. Due to the persistence of centrofacial erythema, papules and pustules, the patient was given prednisone 10mg once a day for 1 month and low dose isotretinoin 10mg once a day for 8 months which resulted in significant decrease in erythema and number of existing lesions. To further decrease the inflammation con- tributed by demodex mites, permethrin 5% cream twice a day for 1 month was applied. Long-pulsed Neodymium-doped yttrium aluminum garnet (Nd:YAG) 1064 nm laser for a total of 10 sessions together with Isotretinoin 10 mg every other day effectively maintained remission for 1 year and 5 months. Gentle skin care measures, sunscreen, metronidazole 0.75% cream once a day, and desonide 0.05% cream twice a day for 1 week in cases of acute flares were maintained during the treatment course.@*Conclusion@#An armamentarium of topical and oral antibiotics, corticosteroids, isotretinoin and non-ablative long-pulsed Nd:YAG 1064 nm laser showed significant improvement in the inflammatory papules, pustules, and centrofacial erythema of rosa- cea and proves to be beneficial in the maintenance of its long-term remission.

Cutaneous Rosai-Dorfman disease in a 40-year-old female: A case report

Introduction@#Rosai-Dorfman disease is a rare disease that manifests with painless cervical lymphadenopathy, fever, anemia, an elevated erythrocyte sedimentation rate (ESR), and hypergammaglobulinemia. Extranodal lesions occur in 1/3 of patients, and the skin is involved in more than 10% of cases. Purely cutaneous disease is uncommon and only about more than 100 cases have been reported. Cutaneous Rosai-Dorfman Disease (CRDD) appears to be a distinct entity with different age and race predilection from cases with lymph node involvement.@*Case report@#This is a case of a 40-year-old Filipino female who presented with multiple erythematous papules and plaques with pustules on the cheeks. Skin punch biopsy showed a dense dermal infiltrate of polygonal histiocytes with abundant cytoplasm and vesicular nuclei. Emperipolesis was also present. The histiocytes were highlighted by the immunohistochemical stains S-100 and CD68 and was CD1a negative. Complete blood count and ESR were normal. Cervical lymphadenopathy was absent. Findings were consistent with Cutaneous Rosai-Dorfman disease. The patient was started on methotrexate at 15mg/week with folic acid supplementation. Mild soap, benzoyl peroxide 5% gel and tretinoin 0.05% cream once daily were maintained during the treatment course. There was significant decrease in erythema and size of existing lesions after 2 months. The patient was referred to a hematologist for monitoring of possible future systemic involvement.@*Conclusion@#Because of its rarity, clinicopathological correlation is always mandatory to establish a diagnosis of CRDD. Immu- nohistochemical stains are required to differentiate this entity form other forms of Langerhans cell histiocytosis. Multidisci- plinary referral is required to rule out concomitant systemic involvement.

Widespread hemorrhagic varicella in 2 cases of HIV-AIDS

@#INTRODUCTION: Varicella or commonly known as chicken pox is caused by varicella-zoster virus (VZV) that is usually seen as a vesicular eruption in children. It is a highly contagious infection and is the result of exogenous primary infection of a susceptible individual. Immunocompromised individuals have impaired cell-mediated immunity and are prone to develop severe disease. They may have atypical presentations and lesions may sometimes appear hemorrhagic. CASE REPORT: We report two separate cases of HIV-AIDS patients presenting with erythematous umbilicated papules in which the initial clinical impression was molluscum contagiosum. Skin punch biopsy was done and revealed hemorrhagic varicella. Patients were started on intravenous acyclovir with noted remarkable improvement. CONCLUSION: This case report highlights the clinical and histopathologic features of hemorrhagic varicella. A skin biopsy is mandatory to establish the correct diagnosis and to initiate proper treatment.

Widespread lichen planus pigmentosus in a 32-year-old Filipino male treated with low dose isotretinoin and topical tacrolimus

@#INTRODUCTION: Lichen Planus Pigmentosus (LPP) is a pigmentary disorder of unknown etiology, presenting with CASE REPORT: We report a case of a 32-year-old healthy male with widespread lichen planus pigmentosus, treated with clobetasol dipropionate 0.05% ointment, tacrolimus 0.1% ointment, and lowdose isotretinoin (0.1 to 0.2 mkd) showing a decrease in the progression and hyperpigmentation of patches and plaques after six months. CONCLUSION: Based on our case and recent studies, low-dose oral isotretinoin, in combination with topical tacrolimus and topical corticosteroids, may show promising outcomes in treating cases of widespread lichen planus pigmentosus.

Rhinophyma on hemangioma: A diagnostic conundrum

@#INTRODUCTION: Rhinophyma, aside from persistent centrofacial redness is a major diagnostic criteria for rosacea. Phyma may be mistaken for hypertrophy of tissue due to an underlying hemangioma. CASE REPORT: A 35-year-old female presented with few erythematous papules on the face and nose 19 years prior to consult. Lesions evolved into multiple erythematous nodules on nose and was mistaken for tissue hypertrophy due to an adjacent congenital hemangioma. Her hemangioma was treated with pulsed dye laser 16 years prior with noted decrease in size and erythema. Recently she noticed enlargement of her nose with persistent redness. She presented with multiple firm, thick irregularly shaped erythematous nodules with prominent pilosebaceous pores and telangiectasia on the nose. Skin punch biopsy was done which revealed hypertrophy and lysis of sebaceous lobules with a moderately dense inflammatory infiltrate of lymphocytes. Histopathological diagnosis was rhinophyma. Patient was treated with low dose isotretinoin (0.20 mkd) with marked flattening of lesions in just one month. CONCLUSION: Distinguishing phyma from tissue hypertrophy caused by hemangioma poses as a diagnostic challenge. Careful dermatological examination and histopathological findings will aid in correct diagnosis. Low dose oral isotretinoin is an effective treatment for rhinophyma.

Crusted (Norwegian) scabies in an infant: A case report

@#INTRODUCTION: Norwegian or crusted scabies is a rare and highly contagious form of skin parasitosis caused by Sarcoptes scabiei var. hominis. Individuals maffffinly affected are considered to be immunocompromised such as those on prolonged glucocorticosteroid therapy, with AIDS or organ transplant patients. This disease presents as a hyperkeratotic dermatosis with an acral distribution. CASE REPORT: This is a case of a 2-month-old healthy Filipino male, who was previously managed as a case of miliaria rubra and treated with clobetasol 0.05% – ketoconazole 2% cream for 1 week. The papules and plaques became widespread. Consult with a pediatrician revealed widespread scabies and for which patient was prescribed topical permethrin with no improvement. On examination, patient presented with multiple erythematous papules and plaques with crusts on the face, trunk, extremities, palms and soles. Thickened yellowish plaques were observed on the palms and soles. Both parents also presented with widespread papules most prominent on the flexural areas accompanied by nocturnal pruritus. On dermoscopy, numerous mites and burrows were seen in a “jet with contrail pattern.” Prominent yellowish scales were also noted. Patient was admitted due to fever and superimposed bacterial infection and was given IV oxacillin, paracetamol, 8% precipitated sulfur in a hypoallergenic lotion applied twice daily and sodium fusidate ointment. On the 4th hospital day, the patient was afebrile and the lesions were noted to decrease in both erythema and crusting. Follow-up dermoscopy revealed absence scales, burrows and mites. CONCLUSION: Prolonged, unsupervised use of topical corticosteroids in our case most likely induced an immunocompromised state thus predisposing the patient to develop Norwegian scabies. In countries were cases of Norwegian scabies have been unresponsive to permethrin and when ivermectin is not available, the use of precipitated sulfur may still be the best therapeutic and safest option for infants.

Clinical analysis, diagnosis, and treatment of a 48-year-old female Filipino with Riehl melanosis

@#INTRODUCTION: Pigmented contact dermatitis (PCD) is characterized by non-eczematous pigmentation associated with contact sensitizers, usually without any active or preceding pruritus and erythema. PCD was first described by Riehl, who identified patients with brown to gray facial pigmentation concentrated on the face most commonly associated with sensitizing chemical such as cosmetics, fragrances, and textiles. CASE REPORT: This is a case of a 48-year-old female Filipino who presents with blue-grey to brown patches on the forehead of 1-year duration with no significant pathologic history. Clinical examination, dermoscopy and histology were consistent with a variant of pigmented contact dermatitis known as Riehl melanosis. Since anamnesis was unremarkable, patch testing was done to identify the contact allergen triggering the symptom. Results obtained a positive reaction to nickel, potassium dichromate, and textile dye. CONCLUSION:Treatment includes the elimination of trigger factors, hence the importance of patch testing in the investigation of its cause. Alongside adequate photoprotection, a combination treatment of 1,064 nm Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, 20% tricholoacetic acid (TCA) peel and oral retinoids, were found safe and effective in the management of facial melanosis. Three-dimensional imaging and dermoscopy were utilized to obtain a more standard and objective pre- and post-treatment comparison.

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.

Molluscum contagiosum-like lesions: A telltale sign of disseminated cryptococcosis

Introduction@#Cryptococcosis is an opportunistic fungal infection caused by Cryptococcus neoformans. This systemic fungal infection affects 6 to 13% of patients with acquired immunodeficiency syndrome (AIDS). Only 10% of patients with this condition develop cutaneous manifestations.@*Case Summary@#A 20-year-old male, newly diagnosed case of HIV (Human Immunodeficiency Virus), presented with multiple skin-colored molluscum contagiosum-like umbilicated papules on the face, neck and both arms. Lesions increased in number rapidly and were associated with respiratory distress. Histopathologic examination revealed findings of opportunistic fungal infection suggestive of cryptococcosis. Serum Cryptococcal Antigen Latex Agglutination System (CALAS) test was also positive. Patient was then diagnosed as a case of cryptococcosis and was a candidate for intravenous amphotericin B. However, before the planned medication was given, the patient experienced severe respiratory distress and expired several hours later.@*Conclusion@#Molluscum-like skin lesions may be a telltale sign of a disseminated opportunistic fungal infection, including Cryptococcosis. Early diagnosis followed by prompt and aggresive treatment would improve outcome and survival of the patient.

Primary cutaneous anaplastic large cell lymphoma in a 73-year-old Filipino male

Introduction@#Primary cutaneous anaplastic large cell lymphoma (PCALCL) is an uncommonly encountered subtype of cutaneous lymphoma under the classification of CD30-positive lymphoproliferative disorders which presents histologically as large atypical lymphocytes with pleomorphic and anaplastic cytology that localizes to the dermis. Although recurrent, PCALCL usually carries a good prognosis, with 5-year survival rates ranging from 85% to 95%.@*Case Summary@#We report a 73-year-old elderly male who consulted at our out-patient department with a 3-year and 6-month history of multifocal, gradually enlarging, erythematous nodules with dry, necrotic areas on the scalp, right auricular area, left axillary area, right forearm, and right thigh, accompanied by loss of appetite and nontender cervical, left axillary, and right inguinal lymphadenopathy. Previous skin punch biopsy and immunohistochemical stain done by the patient’s preceding dermatologist was signed out as “suggestive” of pseudolymphoma. However, management with intralesional corticosteroid injections provided no improvement. Skin punch biopsy done at our institution revealed ALK negative (-) anaplastic large cell lymphoma. Patient was then referred to an oncologist, however, the patient was lost to follow-up and succumbed to community acquired pneumonia.@*Conclusion@#This case highlights the importance of a thorough diagnostic assessment as recent studies indicate a poorer prognosis of ALK (-) cases, with overall 5-year survival rates consistently below 50%.

Clinical, dermoscopy and histopathological findings in a case of lipoid proteinosis

Introduction@#Lipoid proteinosis is a rare autosomal recessive genodermatosis with only approximately 300 cases reported worldwide. This condition is due to the loss of function mutation of the ECM1 gene which encodes for extracellular matrix protein 1 (ECM1), a secretory protein that promotes angiogenesis and is a negative regulator of endochondral bone formation.@*Case summary@#We report a case of a 23-year-old male who presented with chronic recurrent verrucous and waxy lesions on the face and body, diffuse alopecia of the scalp, and hoarseness of voice. Lesions heal leaving scars. Dermoscopy of the eyelid margins show white to yellowish clods with accentuated brownish halo. Lesions on the nape show multiple follicular symmetric whitish-yellow clods with brownish halo and well-defined borders. Lesions on the elbows show a reticular pattern with white clods and diffusely distributed brown dots. Histopathology shows basket-woven stratum corneum, spongiosis of the epidermis with vacuolar alteration, and formation of clefts in the basal cell layer. The papillary dermis shows hyaline material which also surrounds the blood vessel and the adnexal structures. There is mild superficial and mid dermal perivascular inflammatory infiltrate of lymphocytes. PAS highlights eosinophilic material in the papillary dermis which also surrounds the blood vessels and the adnexal structures. Alcian blue staining reveals positive staining for hyaline deposits.@*Conclusion@#This report highlights the importance to recognize the clinical, dermoscopic and histopathological findings of lipoid proteinosis.