Arsenic is a known human carcinogen and skin manifestations are the earliest and most specific markers of chronic arsenic poisoning. A 43-year-old man from Luzon presented at the Section of Dermatology with a one-year history of hyperkeratotic papules and plaques on the palms and soles. Numerous round hypopigmented macules were scattered on the upper back. Initial 24-hour urine arsenic level was elevated at 288mcg/liter. The patient underwent successful chelation with N-acetylpenicillamine and the palmoplantar keratoses were treated with cryotherapy and topical 20% salicylic acid in white petrolatum. In cooperation with the Department of Health, a comprehensive health and environmental assessment was conducted in the affected communities. This case highlights the role of dermatologists in the diagnosis and management of this public health problem.

Arsenic Poisoning ; Philippines ; Keratoderma, Palmoplantar

OBJECTIVE: The study aimed to assess the efficacy and safety of Senna alata (akapulko) plant extracts compared with topical antifungals in the treatment of superficial fungal skin infections.

METHODS: A systematic review and meta-analysis of randomized controlled trials that studied patients with diagnosed cutaneous tinea or dermatophytosis (excluding hair and nail), tinea versicolor, or cutaneous candidiasis, via microscopy or culture, and compared the efficacy and safety of S. alata (akapulko) extract versus topical antifungals. Two authors independently screened titles and abstracts of merged search results from electronic databases (The Cochrane Skin Group Specialized Register, CENTRAL, MEDLINE, EMBASE (January 1990 to December 2011), Health Research and Development Information Network (HERDIN), and reference lists of articles), assessed eligibility, assessed the risk of bias using the domains in the Cochrane Risk Bias tool and collected data using a pretested Data extraction form (DEF). Meta-analyses were performed when feasible.

RESULTS: We included seven RCTs in the review. There is low certainty of evidence that S. alata 50% lotion is as efficacious as sodium thiosulfate 25% lotion (RR 0.91, 95% CI, 0.79 to 1.04; 4 RCTs, n=216; p=0.15; I2=52%) and high quality evidence that S. alata cream is as efficacious as ketoconazole (RR 0.95, 95% CI, 0.82 to 1.09; 1 RCT, n=40; p=0.44) and terbinafine cream (RR 0.93, 95% CI, 0.86 to 1.01; 1 RCT, n=150; p=0.09) in mycologic cure. For adverse effects, there is very low certainty of evidence of increased harm with S. alata 50% lotion compared to sodium thiosulfate 25% lotion (RR 1.26, 95% CI, 0.46, 3.44; 2 RCTs, n=120; p=0.65; I2=19%). Adverse effects were few and mild.

CONCLUSION: S. Alata 50% lotion may be as efficacious as sodium thiosulfate 25% lotion and is as efficacious as ketoconazole 2% and terbinafine 1% creams. There is insufficient evidence to compare the safety of S. alata 50% lotion with sodium thiosulfate 25% lotion.

Tinea Versicolor

Key Findings Among patients with confirmed COVID-19 infection and hypertension, there is insufficient evidence that RAS antagonists are associated with mortality or severe COVID-19 disease. • There is uncertainty with regards to the safe use of renin-angiotensin system (RAS) antagonists, such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), for COVID-19 patients with hypertension and other comorbidities (heart failure, chronic kidney disease) because of two possible contradictory mechanisms 1) upregulation of ACE2 receptors that may facilitate the virus entry into the lung. and 2) control of unabated angiotensin II levels reducing acute lung injury. • Based on very low-quality retrospective cohort studies, there is insufficient evidence that RAS antagonists are associated with increased mortality (6 studies) or severe disease (10 studies) among patients with confirmed COVID-19 infection and hypertension. • There are 36 ongoing studies (21 RCTs, 1 single-arm trial, 4 prospective cohorts, 4 retrospective cohorts, 4 casecontrol, and 2 cross-sectional) on this topic. • The European Society of Cardiology (ESC) Council on Hypertension, the International Society of Hypertension (ISH) and the joint statement by the American College of Cardiology (ACC), American Heart Association (AHA), and Heart Failure Society of America (HFSA) all caution against discontinuing RAS-related treatments in patients with hypertension who become infected with COVID-19.
Covid-19