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Assessment of quality of systematic reviews in dermatology using AMSTAR 2 Part 2 of 2. Validity and reliability testing of AMSTAR 2 (UP-PGH)

Rowena Natividad S. Flores-Genuino ; Maria Christina Filomena R. Batac ; Anne Julienne M. Genuino ; Ian Theodore G. Cabaluna

Journal of the Philippine Dermatological Society.2020;29(2):6-19.

BACKGROUND AMSTAR 2 enables a more detailed assessment of systematic reviews and includes non-randomised studies of healthcare interventions, compared to its earlier version, AMSTAR. We validated AMSTAR 2 in a group of systematic reviews in dermatology in the Philippines. METHODS We used a cohort of systematic reviews (SRs) in dermatology from the Philippine that were previously described in Part 1 of this 2-part series. The SRs included clinical trials on any intervention for the treatment or prevention of a dermatologic disease or for maintenance of healthy skin, hair or nails. Two reviewers independently extracted data and used AMSTAR 2 to appraise the methodological quality of each included SR. We determined construct validity by comparing the number of critical flaws between a set of non-Cochrane and matched Cochrane reviews, using Wilcoxon rank sum test. We tested for interrater reliability of the AMSTAR 2 tool using Gwet’s AC1 statistic. RESULTS: We included 20 non-Cochrane systematic reviews in dermatology by Philippine-based authors, and a set of 20 reviews from the Cochrane skin group, matched by year and randomly chosen. Construct validity testing showed a significantly greater number of AMSTAR 2 critical flaws (median 4.5 vs 0.0; z=3.64; P=0.000) and non-critical weaknesses (5 vs 2.0; z-score=3.10; P-value=0.001) by non-Cochrane reviews compared to a matched set of Cochrane skin group reviews. There was good interrater reliability (average Gwet’s AC1 statistic = 0.87) with the lowest agreement (0.62) for discussion of heterogeneity (item 14), and the highest agreement (0.97) for study selection criteria (item 3). CONCLUSION The AMSTAR 2 was a valid and reliable tool for assessing systematic reviews using a cohort of reviews by dermatology reviews, both non-Cochrane and Cochrane. Further validation of the AMSTAR 2 is needed to determine if it can be applied to a wide variety of systematic reviews.

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A double-blind, randomized controlled trial on the efficacy and safety of 4% niacinamide cream on the treatment of mild to moderate chronic plaque psoriasis at the University of Santo Tomas Hospital Out-Patient Department

Lauren Margaret T. Hao ; Eleanor L. Letran

Journal of the Philippine Dermatological Society.2020;29(2):20-34.

Background: Niacinamide is known for its anti-inflammatory effect and skin penetration capability. Currently, limited studies are available on its efficacy on psoriasis. Objective: This study aimed to determine the efficacy and safety of 4% niacinamide cream on mild to moderate psoriasis. Methods: 40 patients were randomly allocated to 4% niacinamide cream (N), or 0.1% triamcinolone acetonide cream (TAC) or 4% niacinamide cream and 0.1% triamcinolone acetonide cream (N-TAC) for 10 weeks treatment. A 50% improvement in psoriasis area severity index (PASI50) was considered as the primary endpoint of the study. Secondary outcome measures were physician global assessment (PGA), dermatology life quality index (DLQI), and adverse events. PASI and PGA were assessed biweekly. DLQI was assessed at the start and at the end of the study period. Results: PASI50 was achieved in 85% of patients in N-TAC, 75% of patients in TAC and 15% of patients in N. There was no statistical significant difference between groups TAC and N-TAC (p=0.645, Fisher’s exact test). A higher number of patients in N-TAC (31%) achieved PGA1 score or “almost clear” and reached PASI50 earlier (60% at week 4). A higher improvement in DLQI score was seen in N-TAC; however, mean DLQI improvement did not vary by treatment group (p=0.0770). No adverse event was reported for groups TAC and N-TAC while pruritus and erythema were noted in N. Conclusion: Monotherapy of 4% niacinamide cream was not effective in the treatment of mild to moderate psoriasis. The combination N-TAC showed a continuous and sustained improvement of lesions compared to monotherapy TAC.
triamcinolone acetonide ; niacinamide ; psoriasis

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Guidelines for the management of atopic dermatitis: A literature review and consensus statement of the Philippine Dermatological Society

Ma. Teresita Gabriel ; Hester Gail Lim ; Zharlah Gulmatico-Flores ; Gisella U. Adasa ; Ma. Angela M. Lavadia ; Lillian L. Villafuerte ; Blossom Tian Chan ; Ma. Angela T. Cumagun ; Carmela Augusta F. Dayrit-Castro ; Maria Victoria C. Dizon ; Angela Katrina Esguerra ; Niñ ; a Gabaton ; Cindy Jao Tan ; Marie Eleanore O. Nicolas ; Julie W. Pabico ; Maria Lourdes H. Palmero ; Noemie S. Ramos ; Cecilia R. Rosete ; Wilsie Salas Walinsundin ; Jennifer Aileen Ang-Tangtatco ; Donna Marie L. Sarrosa ; Ma. Purita Paz-Lao

Journal of the Philippine Dermatological Society.2020;29(2):35-58.

Introduction: Atopic dermatitis (AD) is a complex disease with an interplay of genetic and environmental factors. In the United States, AD affects 10.7% of children andyc 7.2% of adults. Similarly in the Philippines, the prevalence of AD is 12.7% in the under 18 population, and 2% in the over 18 population. While AD affects all ages, the burden of the disease is greater in the pediatric population. The pathogenesis of AD is multifactorial. Variations in genes responsible for epidermal barrier function, keratinocyte terminal differentiation, and the innate and adaptive immune responses have been linked to AD. A null mutation involving the filaggrin gene is the strongest known risk factor for AD. This mutation results in a loss of filaggrin (FLG) protein by at least 50%. Filaggrin breakdown products form part of the natural moisturizing factor (NMF) of the skin, which is essential in skin hydration. A decrease in NMF and an increase in transepidermal water loss (TEWL) are observed in AD patients with FLG mutation. The defective barrier in AD patients decreases skin defenses against irritation and allergen penetration. Exposure to certain environmental chemicals like formaldehyde may worsen this barrier. This may lead to increased skin permeability to aeroallergens that leads to dermatitis in sensitized patients. Barrier defects may also play a role in epicutaneous sensitization and the subsequent development of other atopic conditions, such as bronchial asthma and allergic rhinitis. The Philippine Dermatological Society (PDS) consensus on AD aims to provide a comprehensive guideline and evidence-based recommendations in the management of this condition, with consideration of cultural factors that are often encountered in the Philippine setting. These guidelines are intended to provide practitioners with an overview of the holistic approach in the management of AD, ameliorating the negative effects of the disease and improving overall quality of life.. Methodology: A group of 21 board-certified dermatologists from the Philippine Dermatological Society (PDS) convened to discuss aspects in the clinical management of AD. Database and literature search included the full-text articles of observational studies, randomized controlled clinical trials, and observational studies using the Cochrane library, PubMed, Hardin (for Philippine based studies) as well as data from the PDS health information system. The terms used in combinations from the literature included “atopic dermatitis”, “atopic eczema”, “emollients”, “topical corticosteroids”, “topical calcineurin inhibitors”, “anti-histamines” and “phototherapy”. A total of fifty (50) full text articles were reviewed and found applicable for the scope of the study. Articles were assessed using the modified Jadad scale, with score interpretations as follows: (5- excellent, 3- good, 1– poor). Consensus guidelines for AD from within and outside of the region were also reviewed, from the 2013 Asia-Pacific guidelines, 2014 Taiwanese Dermatological Association consensus, 2016 guidelines in the management of AD in Singapore, 2014 American Academy of Dermatology guidelines, and the 2020 Japanese guidelines for AD. From the literature review, proposed consensus statements were developed, and a Delphi survey was conducted over two separate virtual meetings. Individual dermatologists provided Likert Scoring (1- strongly disagree to 5- strongly agree) based on consensus statements. A consensus was deemed reached at mean scores of > 4.00, a near consensus at > 3.5, and no consensus at <3.5. Summary: AD is a chronic relapsing condition with a significant burden of disease, most commonly affecting the pediatric population. The PDS AD Consensus Guidelines summarizes the standards of therapy and the therapeutic ladder in the management of AD based on published clinical trials and literature review. While these modalities remain the cornerstone of therapy, an individualized approach is the key to the holistic management of an AD patient. Knowledge and awareness of frequently associated conditions, whether in the realm of food allergies, contact allergies, or secondary infections, is paramount. In addition to the standard therapeutic armamentarium, the physician must also consider cultural practices and be knowledgeable of alternative therapeutic options. Referral to a specialist is recommended for recalcitrant cases of AD, or when initiation of systemic immunosuppressive agents, phototherapy, or biologic agents is contemplated.

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A case report of a successfully treated Mycoplasma-Induced Rash and Mucositis (MIRM) in a 10-year-old Filipino

Angela Katrina M. Esguerra ; Elaine Melody T. Co

Journal of the Philippine Dermatological Society.2020;29(2):59-62.

Introduction: Erythema multiforme has been known as an infection or drug-associated mucocutaneous eruption characterized by target lesions. A clinical entity, known as Mycoplasma-induced rash and mucositis seen mostly in the pediatric population is emerging and may be associated with atypical pneumonia caused by Mycoplasma pneumoniae. This presents with features overlapping with erythema multiforme and SJS-TEN spectrum but with a different trigger, prognosis, and recurrence rate. Case summary: Target lesions in the clinical setting are usually characteristically associated with erythema multiforme, a mucocutaneous condition associated with an underlying infectious trigger. We present a case of a 10-year-old Filipino boy who was initially diagnosed with erythema multiforme major. Eventual testing for the etiology of the underlying infection, Mycoplasma pneumoniae, proved to be a useful diagnostic that gave a better grasp on the case’s mechanism, sequela, and prognosis. The patient was admitted for pneumonia and his presenting mucositis was severe. Cutaneously, he had atypical target and few target lesions on the trunk and extremities. He was diagnosed as a case of Mycoplasma-induced rash and mucositis (MIRM) and treated with antibiotics and systemic steroids for which he recovered fully in three weeks. MIRM should be separated from erythema multiforme, Stevens Johnsons syndrome and toxic epidermal necrolysis as it follows a different disease course. Conclusion: Mycoplasma-induced rash and mucositis is now considered a distinct entity despite it having overlapping features with erythema multiforme and SJS-TEN spectrum. It presents usually in the younger age group with absent to sparse atypical vesiculobullous or targetoid lesions, significant mucosal involvement, and confluent necrosis on histology. It is important to identify it as a trigger because of its more frequent and severe mucosal sequelae. Management includes symptomatic relief, antibiotic therapy with a macrolide in the presence of pneumonia and systemic steroids when mucositis is severe. Majority of patients achieve full recovery.
Erythema Multiforme ; Mycoplasma pneumoniae ; Mucositis ; Exanthema

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A case of bullous pemphigoid uniquely associated with dipeptidyl peptidase-4 (DPP-Inhibitor)

Gwendolyn Y. Wong ; Mary Joyce W. Chiong

Journal of the Philippine Dermatological Society.2020;29(2):63-66.

Introduction: Bullous pemphigoid (BP) is a chronic, autoimmune blistering disease occurring primarily in the elderly population. The pathogenesis of this condition has been strongly linked to the presence of circulating and tissue-bound autoantibodies against the basement membrane antigens BP180 and BP230. In most cases, the causative agent remains unidentified, but in a selected few, certain medications have been implicated in the pathogenesis of the disease. Dipeptidyl peptidase-4 inhibitors (-gliptins), in particular, which are used primarily in the treatment of diabetes mellitus, have been increasingly suspected to be a prime aggravating drug in the incidence of BP. Case summary: Bullous pemphigoid (BP) is a chronic autoimmune blistering disease mainly affecting the elderly population. While the pathogenesis has not yet been fully elucidated, it has been suggested that there is a correlation observed with certain groups of medications. Among drugs correlated with bullous pemphigoid, the group of dipeptidyl peptidase-4 inhibitors (-gliptins) used in the treatment of diabetes mellitus has been one of the most strongly associated. This is a case of a 64-year-old female on regular maintenance medications including linagliptin who developed generalized pruritus followed a week after by appearance of localized fluid-filled vesicles and bullae on the right lower leg. BP associated with dipeptidyl peptidase-4 inhibitors is characterized as “non-inflammatory” – lesions are localized and associated with less erythema compared to the classic presentation. Serum eosinophilia was absent, and serum autoantibody against BP180 was positive. Histopathologic and immunohistologic results revealed characteristics similar to classic bullous pemphigoid. The association of dipeptidyl peptidase-4 inhibitors to the development of BP was observed to have a long latency period between initiation of drug to onset of lesions. There was significant improvement after both withdrawal of the drug and standard steroids and doxycycline. Unlike other drug-induced BP, dipeptidyl peptidase-4 inhibitor-associated BP was found to have similar prognosis with the classic manifestation as the patient noted recurrence one month after remission despite withdrawal of inciting drug. Conclusion: There has been increasing incidence in DPP-4 inhibitor-associated BP. Though its clinical course is similar to classic BP, a non-inflammatory and more localized presentation would prompt suspicion of association with drug. The long latency in DPP-4 inhibitor and lesion onset suggests that rather than being simply an adverse reaction to treatment, DPP-4 inhibitor-associated BP should be viewed as a drug-associated or drug-aggravated disease. Determining the association of BP to DPP4-inhibitors is significant as the management for these patients not only entails standard management of BP but also withdrawal of the suspect drug, which in this case was found to significantly improve the patient’s lesions after one month. Unlike other drug-induced BP, however, DPP-4 inhibitor associated BP was found to have the same prognosis with classic BP as the patient noted recurrence one month after remission.
Dipeptidyl-Peptidase IV Inhibitors ; Pemphigoid, Bullous ; Pharmaceutical Preparations ; Dipeptidyl-Peptidase IV Inhibitors ; Hypoglycemic Agents

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Erythrokeratodermia variabilis et progressiva in a Filipino Girl: A case report

Maria Lourdes H. Palmero ; Franchesca Marie D. Ilagan

Journal of the Philippine Dermatological Society.2020;29(2):67-72.

Introduction: Erythrokeratodermia variabilis et progressiva (EKVP) is a rare, usually autosomal dominant disorder characterized by co-existence of erythematous to hyperpigmented scaly plaques and stationary or migratory patches symmetrically distributed on the face, buttocks and extremities. Case summary: This report describes an 8-month-old Filipino female infant who initially presented at 13 days old with erythematous scaly patches on the scalp, periorbital, perioral, and genital areas. These patches progressed to multiple erythematous plaques with well-defined erythematous to hyperpigmented border, some topped with hemorrhagic and yellowish crusts and scales on the scalp, face, neck, upper and lower extremities, genital and gluteal area. Histologic examination of the skin showed dense aggregates of neutrophils in the stratum corneum, parakeratosis, mild spongiosis, and irregular acanthosis. There were focal areas of hypogranulosis underneath the areas of parakeratosis; however, other areas showed normal granular cell layer. The dermis showed moderate superficial perivascular lymphohistiocytic cell infiltrates with melanophages. Histopathologic changes were nonspecific but may be consistent with EKVP. Patient was initially treated with IV antibiotics; however lesions continued to progress. She was then started on oral acitretin, resulting to improvement of lesions. Conclusion: A Filipino girl with erythrokeratodermia variabilis et progressiva is reported. The knowledge of this disease and its treatment will allow clinicians to promptly initiate treatment and monitor treatment side effects
Erythrokeratodermia variabilis ;

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Upper lip squamous cell carcinoma arising from discoid lupus erythematosus treated with standard wide excision

Janelle G Go ; Melanie Joy Doria-Ruiz ; Daisy King-Ismael

Journal of the Philippine Dermatological Society.2020;29(2):73-77.

Introduction: Squamous cell carcinoma (SCC) is a rare complication of long-standing discoid lupus erythematosus (DLE). The reported risk factors associated with the malignant transformation include chronic inflammation, scarring, immunosuppression, and the dysfunctional healing already evident in discoid lesions. If underdiagnosed and left untreated, this may lead to higher rates of recurrences, metastases and death. Objective: The main objective of this article is to report the diagnosis and management of a DLE-associated SCC on the upper lip of an elderly Filipino female. A short discussion on the pathogenesis and treatment of this disease entity is also presented.ugs/topical medications, family history and accompanying systemic symptoms were reviewed and analyzed. Case: A 78-year-old female, pawid maker, developed a rapidly growing verrucous tumor measuring 4.0 x 2.0 x 2.0 cm from a depigmented atrophic plaque located on the upper lip. Initial histopathologic findings were consistent with SCC and DLE. Considering the tumor size and the challenging anatomical location, the surgical oncology and plastic surgery team carried out a wide excision with 5 mm margin of the entire upper lip mass and surrounding plaque, followed by lip reconstruction. Biopsy findings of the excised mass were consistent with the initial findings. Three months post-operation, there was significant wound healing with no recurrences. Conclusion: Although the incidence is rare, SCC occurring in DLE is considered to be high-risk and should warrant early recognition and prompt treatment. In this paper, the authors also highlight the use of a standard wide excision in lieu of Mohs Microscopic Surgery as an alternative option where resources are limited.
surgical flaps ; Lupus Erythematosus, Discoid ; Carcinoma, Squamous Cell

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Subcutaneous zygomycosis due to Basidiobolus ranarum in a Filipino child responding to itraconazole: A case report

Maria Christina Corazon C. Gonzalez ; Eleanor L. Letran

Journal of the Philippine Dermatological Society.2020;29(2):78-82.

Introduction: Subcutaneous zygomycosis or basidiobolomycosis is caused by a saprophytic fungi Basidiobolus ranarum (B. ranarum). It presents clinically as a slowly growing painless subcutaneous nodule more commonly on the extremity, trunk and rarely on other parts of the body. Mode of infection has not been established but most likely follows traumatic implantation. We report a gradually evolving case of basidiobolomycosis in a 12-year-old immunocompetent Filipino male with no history of trauma who responded dramatically to itraconazole. Case summary: Subcutaneous zygomycosis is caused by Basidiobolus ranarum (B. ranarum) which is endemic in parts of Africa, India and other parts of Asia. We report an evolving case of a Filipino male child who presented with chronic and persistent subcutaneous nodules and plaques on the left extremity. Dense cell infiltrates consisting of lymphocytes, histiocytes and eosinophils were seen on histology with non-septated hyphal structures on Gomori’s methenamine silver stain. Fungal culture of the lesion yielded B. ranarum. Complete resolution of the lesions were observed after 6 months of itraconazole therapy alone. Conclusion: This case demonstrated the gradual progression of the disease, and that the lack of a history of trauma does not exclude its diagnosis. Subcutaneous zygomycosis should be highly suspected in chronic painless subcutaneous nodules with swelling, and its early recognition is crucial to prevent progression of the disease. In patients whom an infectious cause is suspected, appropriate cultures, special staining, and sometimes repeat biopsies of new cutaneous lesions may be helpful in determining or ruling out the associated disease. Furthermore, performing PAS stain alone to identify the presence or absence of a fungi is insufficient, rather, additional staining such as GMS should be done to heighten detection of fungal elements.
Child ; Dermatology ; Itraconazole ; Basidiobolus ranarum ; entomophthoromycosis ; Zygomycosis

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Tumor check through teledermatology: A critical appraisal

Elaine Melody Co ; Cynthia Ciriaco-Tan

Journal of the Philippine Dermatological Society.2020;29(2):83-32.

Original article: Kroemer S, Frühauf J, Campbell T, Massone C, Schwantzer G, Soyer H, Hofmann-Wellenhof R. Mobile teledermatology for skin tumour screening: diagnostic accuracy of clinical and dermoscopic image tele-evaluation using cellular phones. Br J Dermatol. 2011;164(5):973-979. Aim: The original article aimed to evaluate the diagnostic accuracy of clinical and dermoscopic image tele-evaluation for mobile skin tumor screening. Setting and population: The tumors examined in the study were selected prospectively from an outpatient clinic in Graz, Austria in a duration of 3 months. They are from men or women with benign and/or malignant skin tumors of either melanocytic or non-melanocytic origin. A total of 104 tumors from 80 patients using a mobile phone camera were gathered. The lesions were from the head and neck area, trunk, legs and feet and genital area. Study examination: A board-certified dermatologist with clinical expertise in teledermatology and dermoscopy reviewed the clinical and dermoscopic pictures with clinical information separately. The results from the review of the pictures were compared with those obtained by face-to-face examination and the gold standard face-to-face examination plus histopathology. Outcome: Tumors were classified under four categories: benign non-melanocytic, benign melanocytic, malignant non-melanocytic and malignant melanocytic. The table (Table 1) below shows the final diagnoses of the skin tumors examined per category. Results: Among these 104 lesions, 25 (24%) benign non-melanocytic, 15 (14%) benign melanocytic, 58 (56%) malignant non-melanocytic and six (6%) malignant melanocytic lesions were identified. Clinical and dermoscopic tele-evaluations showed high sensitivity and specificity. For malignant non-melanocytic tumors, sensitivity for both clinical and dermoscopic lesions is 97%; specificity for clinical and dermoscopic lesions are 91& and 94%, respectively. For classifying malignant melanocytic lesions, sensitivity for both clinical and dermoscopic lesions is 100% while specificity is 98% and 97%, respectively Conclusion: Clinical image tele-evaluation might be the method of choice for mobile tumor screening. Both clinical image tele-evaluation and teledermoscopy achieved excellent and equally high concordance rates with the gold standard.
dermatology ;

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Assessing quality of systematic reviews in dermatology from the Philippines using AMSTAR 2 Part 1: Methodologic quality of dermatological systematic reviews from the Philippines

Rowena Natividad S. Flores-Genuino ; Maria Christina Filomena R. Batac ; Anne Julienne M. Genuino ; Ian Theodore G. Cabaluna ;

Journal of the Philippine Dermatological Society.2020;29(1):6-19.

BACKGROUND: Quality systematic reviews (SRs) are essential in the practice of evidence-based dermatology. We assessed the methodologic quality of SRs in dermatology from the Philippines. METHODS: We searched databases (MEDLINE, CDSR, PROSPERO, HERDIN; from inception until June 30, 2019), and secondary sources. We included SRs, authored by Filipino primary authors, which included clinical trials on any intervention for the treatment or prevention of a dermatologic disease or for maintenance of healthy skin, hair or nails. Two reviewers independently extracted data and appraised the methodological quality of each included SR using the AMSTAR 2. The 16-item AMSTAR 2 has 7 critical items and 9 non-critical items. The number of critical items mainly determine the overall confidence in the results of the review. Descriptive analysis using means and standard deviation for continuous data, and frequency and percentage distribution for categorical data were employed. RESULTS: Twenty SRs were included in this review, and were mostly published in the 2010s. Majority of SRs had three authors, who belonged to a single institution, with at least one dermatologist. The most common topic was infections and both oral and topical interventions were used. Majority had 5 included studies in the SRs, with a median number of 425 participants. The median number of critical flaws in the included SRs was 4.5, and non-critical flaws, 5. Overall confidence was critically low in majority (19/20 ) of included reviews, with only one review rated as low. CONCLUSION: The methodologic quality of the dermatology SRs from the Philippines based on the AMSTAR 2 tool was poor with a rating of critically low in majority. There is a need to improve quality of conduct and reporting through dissemination of the reporting guidelines such as the PRISMA
Humans ; Nails ; Philippines ; Dermatologists ; Dermatology ; Data Management ; Data Collection ; Publications ; Maintenance ; Reference Standards

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