Human ; Male ; Female ; Dermoscopy ; Dermatology ; Melanoma

INTRODUCTION: 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.

CASE REPORT: 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.

CONCLUSION: 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.

KEYWORDS: Bullous pemphigoid, gliptin, ELISA

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.
Dermoscopy

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.
HIV ; Acquired Immunodeficiency Syndrome ; CD4 Lymphocyte Count

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
Lymphoma, T-Cell ; Neoplasms

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.
Dermoscopy

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.
Methotrexate