Hansen’s disease remains a critical health issue in tropical countries like the Philippines. Delayed diagnosis, especially in the context of indiscriminate corticosteroid use, can lead to severe complications. This case highlights the importance of proper referral, ruling out infections, and cautious steroid use.

A 29-year-old Filipino male presented with a 4-year history of erythematous, scaly plaques on his face and scalp, for which he had not sought treatment. One year later, the plaques spread to his trunk, accompanied by arthralgia. Misdiagnosed with psoriasis, he self-medicated with clobetasol and dexamethasone for three years. Over time, he developed signs of Cushing syndrome. Two months before consultation, after a fall, he experienced lower extremity weakness, hypoesthetic plaques on his legs, and blurred vision, but continued using steroids. Upon admission, he was diagnosed with iatrogenic Cushing syndrome. Steroid tapering reduced generalized edema, revealing nodules on his ears and extremities. Slit-skin smear and histopathology confirmed Hansen’s disease. Unfortunately, he succumbed to septic shock before completing treatment.

Misdiagnosis and prolonged steroid use pose risks by masking infections like leprosy. In regions where infectious diseases are prevalent, clinicians should exercise caution before prescribing steroids, as overuse can lead to “therapeutic incognito,” complicating diagnosis. Early referral to dermatologists for undiagnosed or refractory skin lesions is critical in preventing complications. This case emphasizes the importance of educating healthcare providers on judicious steroid use and ruling out infections. Delayed diagnosis of leprosy, as demonstrated here, can lead to severe outcomes, reinforcing the need for timely intervention and thorough patient evaluation.

Cutaneous metastases are uncommon dermatologic manifestations, occurring in 0.7–0.9% of cancer patients. They typically originate from malignancies of the breast, lung, or gastrointestinal tract, with only a few reported cases arising from malignant cardiac tumors. Herein, we present a rare case of cutaneous metastasis from a primary cardiac myxofibrosarcoma (MFS). Based on available literature, this is the first documented case in the Philippines.

A 26-year-old man presented with rapidly enlarging nodules on the mandible and left thigh following the early recurrence of a previously excised cardiac myxoma. A biopsy of the skin lesions demonstrated a bottom-heavy distribution of atypical spindle cells in a myxoid stroma, raising suspicion of either a primary spindle cell neoplasm or cutaneous metastasis. This prompted a multidisciplinary investigation into the underlying malignancy. Histopathology and immunohistochemical staining of both the cardiac mass and skin lesions confirmed a diagnosis of cardiac MFS with cutaneous metastasis. The aggressive nature of MFS, combined with the presence of metastasis and the patient’s decision to decline further treatment, led to rapid clinical deterioration and ultimately, death.

Cutaneous metastasis from cardiac tumors is exceedingly rare and difficult to diagnose given the paucity of reported cases. This case highlights the pivotal role of dermatologists in recognizing these dermatologic manifestations, prompting further investigation into the underlying malignancy. Dermatologists must maintain a high index of suspicion when evaluating skin lesions of patients with a history of malignancy, given the significant treatment and prognostic implications.

INTRODUCTION: Telemedicine is the practice of remote consultations that utilize computer-mediated communication. Given the visual nature of dermatology, it is most well-suited to adopt telecommunication practices. This enables remote medical care during public health emergencies like the current COVID-19 pandemic; limiting the risk of exposure for both patients and doctors alike.

OBJECTIVES: This study aimed to describe the demographic and clinical profile of teledermatology patients from April to August 2020. Data were also compared with face-to-face consultations during the same period in 2019 in order to establish whether telemedicine can be a viable and reliable substitute to face-to-face consultations during a pandemic.

METHODS: We retrospectively analyzed chart data during a 5-month period in 2020; wherein the number of online consultations were observed to be the highest. We noted demographic and clinical features and compared some of these data to those obtained in the same period in 2019.

RESULTS: A total of 1,632 patients were seen via teledermatology in 2020 versus 7,219 face-to-face patients in 2019. Mean age for both groups were 26.59 and 36.89 respectively. Most patients in both years were from Davao. However, there was an increase in consults from other regions in 2020. Overall, the majority of cases for both periods were non-urgent inflammatory conditions.

CONCLUSION: This study showed that providing remote dermatologic care is now possible with the advent of technology even during a pandemic. Teledermatology may serve as an effective adjunct to traditional consultations.

KEYWORDS: telemedicine, dermatology, COVID-19, pandemic

Background: Common warts are a common malady among patients. Not only does it affect the person physically but also mentally and socially. Several treatment modalities are available; however, the major concerns are the treatment cost and adverse effect profile. Salicylic + lactic acid (SLA) solution is one of the standard treatment modalities owing to its strong keratolytic properties; however, its cost and adverse effects limit its use among patients. A cost-effective and safe alternative treatment is ideal to bring about a more favorable clinical outcome and better patient satisfaction. 100% tea tree oil (TTO) solution was used in this study due to its natural antiviral and anti-inflammatory properties. Objective: The study aimed to compare the safety and effectiveness of 100% TTO versus SLA solution in the treatment of common warts. Methods: A total of 17 patients with a total of 74 warts were included in the study. Each wart was assigned to either of the two treatment groups. the SLA group and the 100% TTO group. A treatment period of 6 weeks was used to assess the effectiveness of both treatment groups. Results: The study showed no significant difference between the SLA solution and 100% TTO in the treatment of common warts. The 100% tea tree group reported lesser adverse effects. Both treatment groups reported favorable treatment satisfaction. Conclusion 100% TTO is a potentially safe and cost-effective alternative in the treatment of common warts.
Lactic Acid ; Salicylic Acid ; Tea Tree Oil

Background: Extracts from several citrus plants have antimicrobial properties and have been used for certain infectious skin conditions. Objective: To compare the efficacy of 12.5% pomelo peel ointment and 2% mupirocin ointment in the management of localized impetigo contagiosa. Design: Randomized, double-blind, controlled trial. Setting: Dermatology Outpatient Clinic in Southern Philippines Medical Center, Davao City, from September 2012 to November 2012. Participants: 46 male and female patients, aged 2-15 years old, and clinically diagnosed with localized impetigo contagiosa. Interventions : Participants were randomized to receive either 12.5% pomelo peel ointment (PPO) or 2% mupirocin ointment (MO), thinly applied on impetigo lesions twice daily for 7 days. Main outcome measures: Clinical success defined as either ‘complete resolution of lesions’ or ‘dryness of the lesions without crusts, with intact skin, and with no to minimal local erythema’ at any time within 7 days from the start of intervention. Main results: The 23 patients in 12.5% PPO group had similar baseline demographic and clinical characteristics as the 23 patients in the 2% MO group. Within 7 days from the start of intervention, 15 of the 23 patients (65.22%) in the PPO group and 19 of the 23 patients (82.61%) in the MO group had clinical success (p=0.1792). Conclusion Pomelo peel ointment is as efficacious as mupirocin ointment in the management of localized impetigo contagiosa.
Anti-Infective Agents, Local ; Citrus ; Staphylococcus aureus

Acral lentiginous melanoma (ALM) is the rarest of the four subtypes of cutaneous melanoma.1 It accounts for only 2-8% of melanomas in caucasians.2 Only 52 cases of ALM have been recorded in the Philippine Dermatological Society Health Information System from 2011 to 2016.3 Histopathologic demonstration of cytologic atypia, presence of mitoses in the deep dermis, pagetoid spread of epidermal melanocytes and lack of maturation of nests with descent into the dermis are features diagnostic of melanoma.2 4 ALM is primarily managed through wide surgical excision. The most common sites for ALM are the soles, palms, and subungual areas.2 The rarity of ALM, the inconspicuousness of the locations of some lesions, and the difficulty in discerning ALM from benign lesions and traumatic changes usually delay the diagnosis and contribute to the poor prognosis of the disease.4 5 6 A 53-year-old male consulted us for an enlarging pigmented plaque on the sole of his left foot. The lesion started as a junctional nevus, which the patient had since birth. The nevus, originally measuring approximately 0.5 x 0.5 cm, started to increase in size one year prior to the consultation. One month before consultation, the patient noted a black nodule on the center of the lesion. A week before consultation, the lesion bled and became painful after manipulation by the patient. Dermatologic examination of the plantar aspect of the left foot revealed a 1.7 x 1.6 cm, dark brown-black, asymmetric plaque with cobblestone-like surface and a black indurated nodule on the center (Figure 1A). Dermoscopic findings of bluish white veil and irregular pigmentation with variable hypopigmented blotches are suggestive of acral melanoma (Figure 1B). Skin punch biopsy and immunohistochemical stains for S100, Melan A, HMB-45, and KI-67 confirmed the diagnosis of ALM (Figure 2, 3). We did a wide local excision of the lesion with a 2-cm margin from the tumor edge, with depth up to the suprafascial level (Figure 4A). The excisional defect was repaired with a split-thickness skin graft taken from the patient’s skin on the right thigh (Figure 6), which provided excellent aesthetic result. We also did a sentinel lymph node biopsy on the left inguinal area (Figure 5A,B). Frozen section biopsy showed solid nests of atypical melanocytes invading the surrounding fibrous stroma. Individual cells exhibit round to oval, deeply basophilic nuclei and abundant, clear to eosinophilic cytoplasm. Some areas showed prominent melanin pigmentation. Sections along lines of resection, lymphovascular channels, nerves and adipose tissues of the excised mass (Figure 4 B,C) and lymph nodes from sentinel biopsy were all devoid of malignant tumor cells. Histopathologic findings from frozen section biopsy and permanent section biopsy were both consistent with malignant melanoma with 3 mm Breslow thickness. The patient’s postoperative course, including wound healing, was uneventful (Figure 7). During the patient’s 12-month follow up period, we did not observe any signs of local or distant recurrence of the tumor.
Melanoma, Cutaneous Malignant ; Skin Transplantation

Acral lentiginous melanoma (ALM) is the rarest of the four subtypes of cutaneous melanoma.1 It accounts for only 2-8% of melanomas in caucasians.2 Only 52 cases of ALM have been recorded in the Philippine Dermatological Society Health Information System from 2011 to 2016.3 Histopathologic demonstration of cytologic atypia, presence of mitoses in the deep dermis, pagetoid spread of epidermal melanocytes and lack of maturation of nests with descent into the dermis are features diagnostic of melanoma.2 4 ALM is primarily managed through wide surgical excision. The most common sites for ALM are the soles, palms, and subungual areas.2 The rarity of ALM, the inconspicuousness of the locations of some lesions, and the difficulty in discerning ALM from benign lesions and traumatic changes usually delay the diagnosis and contribute to the poor prognosis of the disease.4 5 6 A 53-year-old male consulted us for an enlarging pigmented plaque on the sole of his left foot. The lesion started as a junctional nevus, which the patient had since birth. The nevus, originally measuring approximately 0.5 x 0.5 cm, started to increase in size one year prior to the consultation. One month before consultation, the patient noted a black nodule on the center of the lesion. A week before consultation, the lesion bled and became painful after manipulation by the patient. Dermatologic examination of the plantar aspect of the left foot revealed a 1.7 x 1.6 cm, dark brown-black, asymmetric plaque with cobblestone-like surface and a black indurated nodule on the center (Figure 1A). Dermoscopic findings of bluish white veil and irregular pigmentation with variable hypopigmented blotches are suggestive of acral melanoma (Figure 1B). Skin punch biopsy and immunohistochemical stains for S100, Melan A, HMB-45, and KI-67 confirmed the diagnosis of ALM (Figure 2, 3). We did a wide local excision of the lesion with a 2-cm margin from the tumor edge, with depth up to the suprafascial level (Figure 4A). The excisional defect was repaired with a split-thickness skin graft taken from the patient’s skin on the right thigh (Figure 6), which provided excellent aesthetic result. We also did a sentinel lymph node biopsy on the left inguinal area (Figure 5A,B). Frozen section biopsy showed solid nests of atypical melanocytes invading the surrounding fibrous stroma. Individual cells exhibit round to oval, deeply basophilic nuclei and abundant, clear to eosinophilic cytoplasm. Some areas showed prominent melanin pigmentation. Sections along lines of resection, lymphovascular channels, nerves and adipose tissues of the excised mass (Figure 4 B,C) and lymph nodes from sentinel biopsy were all devoid of malignant tumor cells. Histopathologic findings from frozen section biopsy and permanent section biopsy were both consistent with malignant melanoma with 3 mm Breslow thickness. The patient’s postoperative course, including wound healing, was uneventful (Figure 7). During the patient’s 12-month follow up period, we did not observe any signs of local or distant recurrence of the tumor.
Melanoma, Cutaneous Malignant ; Skin Transplantation

A 45-year-old female came to our clinic due to multiple pustules on her fingers. The lesions first appeared when she was 15 years old, starting as a few erythematous macules on her left thumb that eventually developed into painful pustules. The patient claimed that no relief was provided by analgesics and oral antibiotics. Over the next 11 years, the lesions on her left thumb gradually spread to all her fingers including those on her right hand, accompanied by the development of erosions, fissures, and scales, as well as intermittent joint pains and swelling. These symptoms remained unresponsive to multiple topical products, the names of which the patient could not recall. At 24 years old, the patient experienced onycholysis in the first to third digits of her left hand, which progressed to anonychia and eventually affected all the fingers in her left and right hands. When the patient was 38 years old, similar pustules, erosions, fissures, and scaling appeared on several toes. Due to increasing discomfort from lesions spreading to her toes, making it difficult to put on footwear, the patient sought consultation at our dermatology clinic. No symptoms related to pulmonary, gastrointestinal, and genitourinary systems were reported. The patient denied pain or immobility in other joints of her right hand, hair or scalp changes, and oral mucosal lesions. There was no family history of psoriasis, hypertension, peripheral arterial diseases, or other conditions with similar lesions. The patient denied any history of cigarette smoking, chronic alcohol intake, or illicit drug use. On physical examination, the patient appeared comfortable with no signs of distress. We observed multiple erythematous pustules, some coalescing into pus-filled lakes, and thick white hyperkeratotic plaques with scales located on the distal interphalangeal joints, extending to the tips of all digits on both hands. Similar pustules and plaques with scales were seen on the first metatarsophalangeal joint of the right foot and the first digit of the left foot, sparing only the patient’s palms and soles (Figure 1). Anonychia affected all fingers, and there was shortening of all digits on both hands. No hair changes, oral mucosal lesions, or lymphadenopathies noted. The rest of the physical examination findings were unremarkable. Based on the history and clinical findings, we initially assessed the patient as having a form of acropustulosis. Differential diagnoses included infections (e.g., herpetic whitlow, staphylococcal felon, candidal paronychia), which were ruled out due to finger involvement and lack of systemic symptoms. Malignant conditions (e.g., squamous cell carcinoma, acrometastasis) were excluded from the differential diagnoses due to the absence of other typical indicators like trauma, chronic paronychia, exposure to radiation or arsenic fumes, a history of cigarette smoking, or a primary tumor.1 2 Inflammatory conditions (e.g., dyshidrotic eczema, chronic hand contact dermatitis) were also ruled out due to the lack of prominent pruritus, burning sensation, and exposure to common irritants.3 4 Immune-mediated conditions (e.g., palmoplantar pustulosis, palmoplantar psoriasis) were considered but eventually ruled because the patient's lesions did not involve her palms and soles.4 At the time of our evaluation, the patient had normal results in hematology, lipid panel, and liver and kidney function tests. Radiography of the hands showed shortening of the distal phalanges on the first to third digits on both hands, good alignment of osseous structures, intact outlines and trabecular patterns, and normal joint spaces and soft tissue shadows. These findings are consistent with brachydactyly, frequently observed in cases of psoriasis manifesting with dactylitis. Gram stain of the pustules yielded negative results. Histopathology from a skin punch specimen taken from an erythematous plaque on the third digit of the left hand showed focal parakeratosis overlying a spongiotic epidermis with hypogranulosis and psoriasiform hyperplasia. The dermis showed superficial dermal edema and moderately dense perivascular inflammatory infiltrates composed predominantly of lymphocytes and some neutrophils (Figure 1). The final histopathologic impression was psoriasiform dermatitis, ruling out other possible differential diagnoses, including infectious, malignant, and inflammatory conditions. Given the histopathologic consistency with psoriasis, coupled with the clinical presentation of multiple pustules on the tips of the digits and nail changes, the clinicopathologic final diagnosis was acrodermatitis continua of Hallopeau. We initiated oral methotrexate at 10 mg/week for 3 weeks, followed by an increase to 15 mg/week for 7 weeks, reaching a cumulative dose of 135 mg. The patient also received oral folic acid 5 mg daily on days without methotrexate and topical clobetasol propionate 0.05% ointment applied twice daily with occlusion at night. We provided counseling and education about the chronic nature of her condition, emphasizing the need for follow-up every 3 to 6 months. Most pustules resolved, and no new lesions were observed during the tenth week of treatment. No adverse events were reported, and erythema and scaling were significantly lessened. Acrodermatitis continua of Hallopeau (ACH) is a rare form of localized pustular psoriasis characterized by recurrent chronic eruptions of sterile pustules, especially affecting the distal regions of the fingers and toes, and occasionally the nail beds.4 5 The pathophysiology remains poorly understood, but a few authors attribute it to mutations in the interleukin-36RN gene.6 7 8 Diagnosis of ACH can be established based on clinical features. Histopathologic examination and laboratory tests may be helpful in difficult cases, but they are not necessarily performed in all patients.4 6 9 ACH is associated with a wide range of differential diagnoses including infectious paronychia of viral, bacterial, or fungal etiology, dishydrotic eczema, and infected contact dermatitis.4 10 11 Rarely, osteitis and osteolysis of the phalanges may occur in persistent or severe cases.4 6 12 Due to its chronic and relapsing nature, long-term therapeutic control of ACH is necessary to prevent complications.<13 Cirone et al> ACH is recalcitrant to available therapies, with no clear management guidelines or drugs achieving lasting remission.5 Progression to severe disease with irreversible complications is common, and even with treatment, ACH often recurs, affecting patients' physical and psychological well-being.

Background: Skin metastases are rare yet crucial indicators of advanced disease. They can mimic various skin conditions, making them challenging to diagnose. Aims and Objectives: To investigate the incidence rate of biopsy-confirmed cutaneous metastasis and explore the clinical presentation, workup, and diagnostic techniques for skin metastases Materials and Methods: Local study involving comprehensive laboratory tests, pathological examination, and immunohistochemistry to identify primary tumors and confirm diagnoses. Results: Nodules were the most common manifestation of skin metastases, particularly in breast carcinoma. The chest wall and abdomen were frequent sites of involvement. Pathological examination and immunohistochemistry played a critical role in confirming diagnoses, revealing various histopathologic patterns. Immunohistochemical markers assisted in determining tumor origin but required careful interpretation. Monitoring tumor behavior over time provided insights into nature and origins. Conclusion Comprehensive workups including laboratory testing, pathology, and immunohistochemistry are essential for accurate diagnosis and management of skin metastases. Careful monitoring of tumor behavior can provide valuable information about its nature and origins.
Diagnosis