A Review and Case Study of Genital and Extragenital Human Papillomavirus Type 6 and 11 Infections in Men Who Have Sex with Men Accompanied by Human Immunodeficiency Virus Infection.

Extragenital warts caused by HPV types 6 and 11 are rarely reported. However, major risk factors for anogenital warts (AGW) include men who have sex with men (MSM) and Human Immunodeficiency Virus (HIV) infection. The incidence of extragenital warts among these populations has not been reported. This study presented a case report of a 33-year-old male with high-risk sexual behavior who showed symptoms of flesh-colored and hyperpigmentation papules. Furthermore, verrucous surfaces were observed at genital and extragenital. The patient had a history of using the same razor for pubic and armpit hair, bathing with a mesh scrub, and scratching the anal area. The histopathological result showed koilocytes, while polymerase chain reaction (PCR) examination for both genital and extragenital lesions confirmed HPV type 6 and 11. This represented the first reported case describing the incidence of extragenital and AGW caused by HPV types 6 and 11. The transmission of extragenital warts was facilitated through fomites autoinoculation, particularly in the immunocompromised condition induced by HIV, which was common among MSM. Extragenital warty-like lesions were considered as warts caused by HPV type 6/11, in HIV-infected persons, specifically MSM.

Efficacy and Safety Profile of Tuberculin Protein Purified Derivative Injection As Immunotherapy For the Treatment of Cutaneous and Anogenital Warts: A Review Article.

Introduction: Various treatments available today for anogenital and cutaneous warts have limitations, including time-consuming, challenging to perform, and the risk of scarring. A new treatment using tuberculin purified protein derivative (PPD) has been developed, which is expected to generate cellular immunity against HPV. Objective: To assess the evidence for the efficacy and safety of PPD treatment for cutaneous and anogenital warts. Materials and methods: A literature search was performed with the keyword-based search on digital libraries, including the National Library of Medicine, Cochrane Controlled Register of Trial, and Google Scholar, using the following terms: anogenital warts, condyloma acuminata, cutaneous warts, human papillomavirus, immunotherapy, and tuberculin purified protein derivative. Original studies on treating cutaneous or anogenital warts with PPD were included. The results were 47 clinical trials and 4 case reports. Most of the research was done in countries with common Mycobacterium tuberculosis infection. The treatment showed good efficacy. Comparative studies showed that the treatment has similar efficacy with other immunotherapies. No significant side effects were reported, with evidence of the safety use on the pregnant population. Conclusion: Based on good efficacy and safety, PPD can be considered an alternative therapy, especially in countries where tuberculosis is frequent.

The Importance of p16 and p53 Immunohistochemical Staining in Diagnosing Vulvar Lichen Simplex Chronicus Mimicking Vulvar Intraepithelial Neoplasia with False-Positive Human Papillomavirus Type 66.

Vulvar intraepithelial neoplasia (VIN), the precursor lesion of vulvar squamous cell carcinoma (VSCC), may present as pruritic or asymptomatic lichenified plaques surrounded by single or multiple discrete or confluent macules or papules. VIN is divided into high-grade squamous intraepithelial lesion (HSIL), which is human papillomavirus (HPV)-driven, and differentiated VIN (DVIN), which develops independently of HPV. Histopathological examination and HPV genotyping polymerase chain reaction (PCR) tests should be performed to distinguish between HSIL and DVIN. Lichenified plaques surrounded by multiple papules are found not only in VIN but also in vulvar lichen simplex chronicus (LSC). This chronic inflammatory skin disease mostly appears in labia majora and is triggered by sweating, rubbing, and mental stress. IHC staining of p16 and p53 are recommended as the most commonly used biomarkers for VIN in diagnostically challenging cases. IHC staining is also beneficial to confirm the accuracy of the HPV detection technique, as p16-negative staining may also represent a false-positive result. We report a case of the importance of p16 and p53 IHC staining in diagnosing vulvar LSC mimicking VIN with false-positive HPV-66. The patient was previously diagnosed with VIN based on clinical examination. HPV-66 was detected by PCR from a vulvar biopsy sample. Histopathological examination revealed stromal lymphocytic infiltration with non-specific chronic dermatitis; neither atypia nor koilocyte was observed. Both p16 and p53 IHC staining were negative. The patient was diagnosed and treated as vulvar LSC with 10 mg cetirizine tablet, emollient, and 0.1% mometasone furoate cream. Clinical improvement was observed as the lesions became asymptomatic hyperpigmented macules in the 4 weeks of follow-up, without recurrence after 3 years of follow-up. Both p16 and p53 IHC staining might help distinguish HSIL and DVIN mutually and from other vulvar mimics in diagnostically challenging cases.

Generalized Asymptomatic Nodulo-Ulcerative Lesions Without Systemic Symptoms in a Secondary Syphilis Patient Co-Infected with HIV.

Syphilis is a sexually-transmitted disease with various clinical stages. Secondary syphilis manifestations may mimic other skin lesions. Patient co-infected with Human Immunodeficiency Virus (HIV), with CD4 cell counts of 200-499 cells/mm3, often manifests an atypical cutaneous lesion, which may also occur as nodular or ulcerative lesions. Generalized nodulo-ulcerative lesions without systemic symptoms in secondary syphilis patients with HIV co-infection are rarely reported. A 22-year-old man presented with generalized asymptomatic multiple erythematous papules and plaques with scales, as well as nodular and nodulo-ulcerative lesions on the trunk, both arms, and both legs. His lesions spread progressively without the presence of any prodromal symptoms or adenopathy. He was previously diagnosed with HIV and is currently on antiretroviral medications, with a CD4 cell count of 388 cells/µL. His venereal disease research laboratories (VDRL) result was reactive (titer of 1:256). His Treponema pallidum hemagglutination assay (TPHA) result was also reactive (titer of 1:10,240). A skin biopsy was performed from the nodulo-ulcerative lesion on his back. Hematoxylin-eosin staining revealed a hyperplastic epidermis, a massive influx of plasma cells, and lymphocyte infiltration into the deep dermis, especially in the peri-adnexal, peri-vascular, and peri-muscular regions. The patient was diagnosed with secondary syphilis with HIV co-infection. He had no previous history of drug allergy. A single dose of 2.4 million units of benzathine penicillin G was administered. Almost all the lesions became hyperpigmented macules after two weeks and resolved completely after one month. His VDRL titer declined to 1:32 after three months. The various atypical lesions of secondary syphilis may lead to misdiagnosis and delayed treatment. The presence of multiple asymptomatic nodulo-ulcerative lesion without prodromal symptoms may indicate the presence of secondary syphilis, notably in patients co-infected with HIV. Therefore, knowledge of atypical cutaneous manifestations of secondary syphilis is warranted in order to treat patients accordingly.

Vitamin D Receptor Gene Polymorphisms and Association with Vitiligo in Indonesian Population.

Introduction: Vitiligo is an acquired depigmenting skin disorder due to the loss of melanocyte function in the epidermis and hair follicles. The pathogenesis of vitiligo is multifactorial, with genetics being a predisposing factor. Previous studies had varying results regarding whether or not polymorphisms of vitamin D receptor (VDR) gene are associated with the risk of vitiligo in specific populations. This study investigated the association between three frequently analyzed VDR gene polymorphisms (ApaI, BsmI, TaqI) and susceptibility to vitiligo in Indonesian population. Methods: Thirty-four vitiligo patients and 34 age- and sex-matched healthy subjects aged ≥18 years old were recruited in the Dermatology and Venereology Outpatient Clinic of Dr. Hasan Sadikin General Hospital, Bandung, Indonesia. Genomic deoxyribonucleic acid (DNA) was extracted from the peripheral blood using a DNA isolation kit. VDR gene polymorphisms (ApaI, BsmI, and TaqI) were investigated using the polymerase chain reaction-restriction-fragment length polymorphism method. The differences of genotype distributions and allele frequencies were statistically compared between case and control groups using Chi-square test. Results: VDR gene polymorphisms were identified in 68 participants, consisting of Aa (n = 14), aa (n = 20), Bb (n = 15), bb (n = 19), and TT (n = 34) genotypes in the case group. In the control group, Aa (n = 6), aa (n = 28), Bb (n = 17), bb (n = 17), and TT (n = 34) genotypes were identified. However, only subjects with ApaI Aa genotype polymorphism had a 3.267-fold increased risk of developing vitiligo. Conclusion: This study showed that ApaI Aa genotype polymorphism of the VDR gene increases the risk of vitiligo in Indonesian population.

A Case of Genital and Extragenital Warts Unresponsive to Immunotherapy Using Measles, Mumps, Rubella Vaccine.

Anogenital warts (AGWs) are globally recognized as the most common sexually transmitted infections (STIs) caused by the human papillomavirus (HPV), particularly types 6 and 11. Meanwhile, immunotherapy is one of the treatments of choice for patients with extensive AGWs. Measles, mumps, and rubella (MMR) vaccine induce the production of various T helper 1 cytokines to elicit immune responses, resulting in the clearance of both treated and untreated warts. This study reported a case of extensive genital and extragenital warts in a 53-year-old male which had occurred for five years, with no pseudo-Koebner phenomenon. The history of MMR vaccination was uncertain but the patient received oral antibiotics for one week, one month before seeking consultation. Physical examination showed extensive verrucous and hyperkeratotic papules, plaques, and nodules in the lower abdomen, pubic, inguinal, genital, and gluteal regions. Acetowhite test results were positive, while polymerase chain reaction (PCR) results were positive for HPV types 6 and 11. The patient received an intralesional injection of 0.5 mL MMR vaccine into the largest warts with a 3-week interval. However, during the one-month follow-up after the third injection, no improvement was observed in either the size or number of warts. Based on the results, several factors must be considered to determine the best candidate for immunotherapy, particularly with MMR vaccine, to achieve an optimal outcome. These factors include the active state of diseases, duration of diseases, as well as a history of sensitization, and broad-spectrum antibiotics.

Molluscum Contagiosum in HIV Patient Treated with 20% Topical Glycolic Acid After Resistance with Topical Tretinoin.

Molluscum contagiosum (MC) is a benign papular skin infection caused by Molluscum contagiosum virus (MCV). Over the past 30 years, the incidence of MK has continued to increased association with sexually transmitted infections and human immunodeficiency virus (HIV) infection. The incidence of MC in HIV patients is quite high at 5-8%. Until now there is no standard therapy used for the treatment of MC in patients with HIV. In HIV patients, anti retro viral therapy (ARV) is the main therapy with several other additional therapies such as cantaridin, chemical peeling agents such as glycolic acid (20-70%) and trichloroacetic acid (20-100%), cryosurgery, electrosurgery, incision, lactic acid, laser surgery, podophyllin, retinoic acid, and urea. There have been no studies regarding the administration of topical 20% glycolic acid in MC patients. We report a case of MC in an HIV patient who was treated with 20% topical glycolic acid after failing treatment with topical tretinoin. The diagnosis was made clinically, cytologically, and histopathologically, a white mass was found on compression of the lesion and Henderson-Paterson bodies. The lesions on the face, arms, and legs were given glycolic acid lotion 20% which was applied once a day at night. The lesions started to show responses to the treatment at week 6th as some of the MC papules became hyperpigmented macules. The side effects of therapy that appeared were itching and hyperpigmentation. Topical 20% glycolic acid can be used for MC therapy with minimal side effects, easy to apply and safe.

Chronic Venous Leg Ulcer in Klinefelter Syndrome Treated with Platelet-Rich Fibrin: A Case Report.

Venous leg ulcers (VLUs) are the most common causes of leg ulcers due to venous insufficiency. Most cases persist for more than 6 weeks, referred to as chronic VLUs. These chronic ulcers have been described as a manifestation of Klinefelter syndrome (KS). Platelet-rich fibrin (PRF) is a second-generation platelet concentrate, which contains growth factors required for chronic wound healing. The use of PRF in the management of VLUs in KS has not been reported, to the best of our knowledge. We report a case of chronic VLU associated with KS in a 41-year-old man treated with PRF. Dermatological examination showed a tender, shallow, irregular ulcer partly covered with hard, yellow necrotic tissue on the anterior side of the lower-left leg and hyperpigmented indurated skin on both lower legs. The diagnosis of venous ulcer was established based on clinical manifestation and supported by the result of Doppler ultrasound showed chronic venous insufficiency. Histopathological examination, which showed epidermal acanthosis, dermal fibrosis, and thickening with hemosiderin deposits consistent with the diagnosis of venous ulcer. The patient presented with eunuchoid features characterized by long extremities, gynecomastia, increased fat distribution around the hips, scanty pubic hairs, and small testes. Laboratory tests found decreased levels of testosterone, increased levels of follicle-stimulating and luteinizing hormone, and bilateral testicular atrophy was found from testicular ultrasound. These physical examinations and laboratory findings supported the diagnosis of KS. The patient was treated with PRF dressing once a week. After 7 weeks of treatment with PRF, the ulcer almost reached complete closure. PRF gives a good result in a chronic VLU with KS.

A Case Report of Extensive Pyoderma Gangrenosum on the Upper Third of the Body.

Pyoderma gangrenosum (PG) is a sterile inflammatory neutrophilic dermatosis that can present as a peristomal, pustular, bullous, vegetative, or ulcerative variant. It commonly affects the lower extremities, mainly in the pretibial area. We describe a case of extensive PG in an 18-year-old Indonesian man, involving the upper third of the body. Dermatological examination showed multiple painful ulcers with violaceous borders on the face, occipital region of scalp, neck, shoulder, upper chest, and back. The diagnosis of PG was established based on the histopathological examination that revealed massive dermal neutrophilic infiltration mixed with lymphocytic inflammatory infiltrates accompanied by leukocytoclastic vasculitis. The patient was treated with methylprednisolone equivalent to 1 mg/kg/day of prednisone. An excellent response to therapy also confirmed the diagnosis of PG. Since lesions of PG can appear on any part of the body, including the upper third of the body, a complete and appropriate examination is useful in establishing diagnosis.