Tuberous sclerosis complex in a 33-year-old Filipino male: Focus on dermatologic manifestations and carbon dioxide laser ablation of facial angiofibromas

Tuberous sclerosis complex (TSC) is an autosomal dominant condition where loss-of-function mutation in 2 tumor suppressor genes, hamartin and tuberin, result in hamartoma formation in multiple organs, notably the skin, brain, kidney, retina, lungs, and heart. Many of the diagnostic features for TSC involve the skin. Because TSC is relatively rare even among Filipinos, there is limited data on the use of any treatment modality which addresses the cutaneous aspects of this disease in this population. A 33-year-old Filipino male presented with multiple skin-colored to hyperpigmented papules and nodules on the centrofacial area, which gradually progressed in size and number since childhood. He had normal growth and development. Family medical history was significant for a brother with similar facial lesions who died of a brain tumor in childhood. Further physical examination revealed shagreen patches, ashleaf spots, confetti macules, periungual fibromas, gingival fibromas and dental pitting. Work-up revealed the presence of renal angiomyolipomas and retinal hamartomas. A diagnosis of TSC was made. Histopathology of a facial nodule was consistent with angiofibroma. Desiring cosmesis, the patient underwent 2 sessions of ablation of the facial angiofibromas using a carbon dioxide laser (ESC/Sharplan) at 1.0W 3mm spot size at continuous mode, spaced one month apart. Follow-up at one month and six months post-treatment showed satisfactory results described as flattening of lesions with no noted recurrence of lesions. The dermatologic manifestations of TSC comprise majority of the features needed for diagnosis, and may warrant treatment because of cosmetic disfigurement. The role of the dermatologist in the recognition, diagnosis and management of this condition is emphasized. This case of a Filipino patient with TSC demonstrates that carbon dioxide laser treatment is effective for the facial angiofibromas of TSC, although the risk for recurrence is high. Definitive treatment still entails addressing the underlying genetic defect.

Low-dose oral zinc supplementation leading to resolution of recalcitrant common warts: A case report with 5-year follow-up

INTRODUCTION: Verruca vulgaris, or common wart, is cause by the human papillomavirus (HPV). Cases may be recalcitrant, and may reflect deficient cell-mediated immunity, one cause of which could be low serum levels of zinc, which plays a crucial role in lymphocyte development and function. Here, we report a case of recalcitrant common warts in a zinc-deficient man responding to oral zinc supplementation.CASE SUMMARY: A then 44-year-old man presented with hyperkeratotic verrucous papules on the left elbow, clinically and histopathologically diagnosed to be verucca vulgaris. Initial treatment with electrosurgery was followed by recurrence on the same site several weeks later. Further recurrences would be noted despite treatment with several sessions of electrosurgery and cryotherapy, with eventual involvement of both forearms and shins. Other treatment modalities tried by the patient included pulsed dye laser, imiquimod and a traditional topical medication containing salicylic acid. HPV typing showed HPV genotype 6. Primary immunodeficiency panel done on 2 separate occasions showed decreased CD4 count with reversed CD4:CD8 ratio, with decreased natural killer count. Whole blood and serum zinc levels were also found to be decreased on 2 separate occasions. The patient was then started on oral zinc picolinate 50mg (10mg elemental zinc) daily, eventually shifting to chelated zinc oxide 15mg (12mg elemental zinc) daily, without any other intervention. The only adverse effect reported was nausea. Follow-up at 1 year and 5 years after starting oral zinc supplementation has shown no recurrence of warts.CONCLUSION: Recent years have seen a surge of interest in high-dose oral zinc as monotherapy for recalcitrant warts. Although there is still insufficient evidence to support this, the positive response demonstrated in this case corroborates the immunomodulatory role that zinc may play for this indication. In addition, this case may show that even low doses of zinc may be beneficial as either monotherapy or as adjunct in the treatment of recurrent common warts. It is recommended that randomized clinical trials with better quality, comparing different doses and formulations of oral zinc for common warts be done, while taking into account corresponding elemental zinc values.

Cosmetic intolerance syndrome in a Filipino woman: A case report

INTRODUCTION: Cosmetic intolerance syndrome is a condition attributed to multiple exogenous and endogenous factors.m Although considered a wastebasket diagnosis by some, it has proven to be a highly challenging, if not frustrating, condition for both the dermatologist and the patient. It is believed to be quite common, but underreported.CASE SUMMARY: A 22-year-old Filipino woman presented with a 2-year history of recurrent facial redness and itching. Flare-ups of social symptoms and signs are associated with the application of cosmetics. Exacerbations have also been perceived to occur with the intake of bread, milk chocolate, cheese and shrimp, as well as handling of coins. The patient also has comedonal acne for which she has been using various topical anti-acne medications, such as benzoyl peroxide and tretinoin. She has a history of seborrheic dermatitis, allergic contact dermatitis (ACD) due to jewelry, and chronic hand dermatitis. She has a personal and family history of atopy. Diagnostic patch test was performed using the 70-allergen series. Reading after 48 hours revealed strong reactions to fragrance mix, formaldehyde, nickel sulfate, benzoyl peroxide, and thimerosal. Given the recurrent nature of facial tightness, discomfort, erythema and pruritus, noted to increase in severity with application of various cosmetics, the documentation of the above allergies, and the concomitant presence of atopy, acne vulgaris, and seborrheic dermatitis, the diagnosis of cosmetic intolerance syndrome is made.CONCLUSION:Increasing awareness and recognition of cosmetic intolerance syndrome is important. Controlling concurrent endogenous conditions, together with correct identification of exogenous triggers, as well as patient education on avoidance and substitution of culprit substances, are the cornerstones to successful management of this challenging condition.