Nodular syphilis with a granulomatous inflammatory histopathologic pattern is an uncommon cutaneous presentation of secondary syphilis which could pose a diagnostic challenge for clinicians and pathologists alike.

A 33-year-old male diagnosed with HIV presented with a 5-week history of asymptomatic generalized erythematous papules and nodules with overlying scales, with involvement of the palms and soles. Histopathologic examination of a nodule from the forearm revealed non-caseating granulomas in a background of a mixed cell inflammatory infiltrate composed of lymphocytes, epithelioid and foamy histiocytes, plasma cells, neutrophils, and multinucleated giant cells. Warthin-Starry Stain revealed spirochetal organisms, while Fite-Faraco and Periodic Acid-Schiff stains were negative for acid-fast bacilli and fungal elements, respectively. Rapid plasma reagin (RPR) was reactive (1:256). Patient was given a single dose of benzathine penicillin G 2.4 million units intramuscularly, with noted complete resolution of skin lesions as well as an 8-fold decrease in RPR titers.

Nodular lesions are an uncommon cutaneous manifestation of secondary syphilis, and the associated histopathologic finding of granulomatous inflammatory pattern is also unusual, posing a diagnostic challenge. With the increasing prevalence of syphilis, especially among HIV patients, dermatologists, dermatopathologists, internists, and infectious disease specialists should be aware of such presentations of syphilis.

A 46-year-old male presented with an erythematous papule progressing into a vegetative plaque on the right cheek that resolved with cribriform scarring. Eight months after, a similar looking erythematous papule appeared on his left cheek. This papule rapidly progressed into a vegetative plaque within a week, and was associated with a pain score of 7 out of 10. Histopathology of the second lesion revealed suppurative dermatitis with diffuse dense infiltrates composed mostly of neutrophils. Cultures revealed few colonies of Enterobacter cloacae which was inconclusive. Pathergy test was negative. High dose systemic corticosteroids were started, with an observed rapid reduction of pain, inflammation, and ultimately resolution of the lesion with formation of cribriform scarring, confirming a case of vegetative pyoderma gangrenosum. It is important to note that not all inflamed and purulent lesions are infectiousneutrophilic dermatoses should always be considered.

Alopecia resulting from radiation exposure occurs 2-8 weeks after exposure. It can be temporary or permanent depending on the dose of exposure. Alopecia following fluoroscopy-guided procedures are increasing in frequency. We report the case of a 22-year-old female who underwent fluoroscopically-guided embolization of an arteriovenous malformation. Twelve days after embolization, significant hair shedding was noted, resulting in a large rectangular hairless patch with no erythema or pain on the irradiated site. Hair pull test was positive and the hair mount showed dystrophic anagen hairs. Hair tug test was negative. Trichoscopy showed yellow dots, black dots, vellus hairs, and flame hairs. Histopathologic examination showed an increase in catagen and telogen hairs. On review of the procedure, she received a total peak skin dose of 4.67 Gray from the procedure. The diagnosis of radiation-induced alopecia was made and topical minoxidil was started, resulting in complete hair growth after six months. Patients undergoing fluoroscopy-guided procedures should have adequate follow-up weeks to months post-procedure to monitor for skin and hair reactions. Physicians should also consider delayed radiation reactions in patients with a history of radiation exposure. Safety protocols must be in place, and measures should be done to minimize the dose delivered.

Type 1 reactions can occur in leprosy patients with oral corticosteroids being the drug of choice for treatment. However, in the setting of immunocompromised state (i.e., HIV), chronic steroid use poses significant risks, including opportunistic infections, highlighting the need for non-immunosuppressive alternatives. We report a case of Type 1 lepra reaction in a PLHIV patient with leprosy, previously on oral steroids, who was successfully treated with short-course high-dose clofazimine.

This is a case of an 18-year-old Filipino female with no known comorbidities, who presented with a three-year history of recurrent erythematous papules, vesicles, and nodules over her bilateral side of the chin. She was initially managed as a case of infected acne vulgaris, and was given oral antibiotics such as Cloxacillin, Rifampicin, and Clarithromycin, but with minimal improvement. She was then referred to Dermatology service for further evaluation. A 3-mm skin punch biopsy on an erythematous nodule on the left chin was done, and histopathologic findings were diffuse eosinophilic infiltrates, exhibiting flame figures admixed with few lymphocytes and neutrophils, consistent with Wells’ syndrome, otherwise known as eosinophilic cellulitis. Serology also revealed elevated IgE level at 949.2 IU/mL but normal eosinophil count. Patient was then given oral corticosteroid for eight weeks, resulting in complete resolution of lesions and no residual scarring.
Wells syndrome ; Cellulitis ; Eosinophilia

Introduction: Intralesional purified protein derivative (PPD) is an affordable therapeutic option that has been studied for cutaneous warts. However, the lack of good evidence precludes its widespread use. Objective: To determine the efficacy and safety of intralesional PPD in the treatment of cutaneous warts. Methods: A systematic search for controlled clinical trials comparing intralesional PPD and placebo or any conventional therapy was conducted using electronic databases. The included studies were assessed for risk of bias, and data such as clearance rate of target and distant lesions, recurrence rate, and adverse events were extracted. Analysis was done through RevMan v5.3. Results: Four controlled clinical trials composed of 205 patients were included. All of the studies compared intralesional PPD to placebo as comparator. Intralesional PPD had a significantly higher clearance rate of target wart (RR=0.43[0.22,0.84], P=0.01) and a significantly higher clearance rate of distant lesions (RR=0.59[0.41,0.85], P=0.005) as compared to placebo. However, there was no significant difference in the recurrence rate (RR=0 [-0.07,0.07], P=0.98). Adverse events reported were only considered minor. Conclusion Intralesional PPD is an effective and safe treatment option for cutaneous warts. However, more well-structured RCTs with longer follow-up period and those comparing it with conventional treatment are needed to further support its use.
Warts ; Meta-Analysis ; Tuberculin

A 29-year-old male with eleven-year history of hyperkeratotic papules and speckled pigmentation developed cutaneous squamous cell carcinoma. Arsenicosis was confirmed by elevated hair arsenic level, and histopathologic findings of arsenical keratosis and one lesion showing carcinoma-in-situ. Chronic arsenic exposure has been found to activate inflammatory and carcinogenic pathways leading to development of pre-malignant and malignant lesions. A multi-disciplinary approach involving healthcare specialists and environmentalists is crucial in source control and management of long-term complications.
Arsenic ; Arsenic Poisoning ; Carcinoma, Squamous Cell ; Carcinoma In Situ

OBJECTIVES: The study aimed to confirm the association between androgenetic alopecia (AGA) and Metabolic Syndrome (MetS). It also aimed to determine if early-onset AGA among males and AGA among females increases the risk of developing MetS, and if severity of AGA increases the odds of developing MetS.

METHODS: Observational studies from electronic databases were selected by the consensus of three independent review authors. The Newcastle-Ottawa Scale for assessing the quality of non-randomized studies in meta-analysis was used. Statistical analyses were accomplished using Review Manager software.

RESULTS: A total of 11 case-control studies, one prospective cohort study, and five cross-sectional studies were selected. In the meta-analysis of ten case-control studies and three cross-sectional studies (3840 participants), AGA was significantly correlated with MetS (OR 2.59, 95% CI 1.51 to 4.44; p<0.0005). Early-onset AGA among males (

CONCLUSION: Although the pathophysiology still remains under investigation, the present study points to an association between AGA and MetS. It can be used as a marker to identify patients who should be screened for MetS and managed accordingly.

BACKGROUND: Alopecia areata (AA) is an autoimmune hair disorder, with the clinical variants ophiasis and extensive variants AA totalis and universalis, having poor response to therapy. Oral steroids are used to treat the severe variants, requiring prolonged therapy, which leads to side effects while discontinuation leads to high relapse rate. Azathioprine is a steroid-sparing agent for the severe AA forms.

OBJECTIVE: To review the current evidence on the therapeutic efficacy and adverse effects of azathioprine for severe forms of alopecia areata

METHODS: Published articles utilizing azathioprine for alopecia areata were obtained until July 2018 from PubMed, MEDLINE, Cochrane Library, TRIP database, HERDIN, and Google Scholar.

RESULTS: Seven articles underwent a full-length review. Clinical variants include patchy, diffuse, steroid-resistant, reticulate, totalis, universalis, ophiasis, and sisaipho. Doses ranged from 2 to 2.5 mg/kg/day or weekly 5 mg/kg pulse therapy. Initial response ranged from 6 to 12 weeks, with almost complete resolution by 32 weeks. Response was sustained for 6 months upon discontinuation, with only 14% relapsing at 2.5 months. Adverse effects were gastrointestinal discomfort, elevated liver function tests, and myelosuppression.

CONCLUSION: There is emerging evidence on the efficacy and safety of azathioprine for the treatment of extensive forms of alopecia areata. Randomized-controlled trials are needed to evaluate its efficacy.

BACKGROUND: Alopecia areata is postulated to be an autoimmune disease of which vitamin D may play a role being found in the immune system and hair.

OBJECTIVE: To determine the association between serum 25-hydroxyvitamin D levels in patients with alopecia areata compared with healthy controls.

METHODS: Observational studies on association of vitamin D levels on alopecia areata compared to healthy controls were obtained from all published articles until July 2018 on MEDLINE, Cochrane Library, TRIP, HERDIN, and Google. Review Manager 5.3 was used for the meta-analysis.

RESULTS: The search strategy yielded 13 qualified articles for the full-length review and 11 studies, containing 916 patients, were included in the meta-analysis using the pooled random effects model. The pooled mean difference of the serum 25-hydroxyvitamin D levels between alopecia areata patients and healthy controls was -9.55 (95% CI, -10.51 to -8.59) with heterogeneity (I2=85%).

CONCLUSION: In conclusion, there were reduced levels of serum 25-hydroxyvitamin D levels in alopecia areata compared to healthy controls and vitamin D deficiency was more prevalent in alopecia areata compared to healthy controls. There was also a trend of lower vitamin D levels in the more severe forms of alopecia.