Mammary Paget’s disease (MPD) is a rare form of intraepithelial adenocarcinoma occurring in the apocrine gland-bearing areas in patients older than 50 years old. This clinical disease presents as erythematous, scaly plaque that usually affects the unilateral nipple or areola and is frequently misdiagnosed as inflammatory or infectious dermatitis. In this report, we are presented with a 54-year-old Filipino female who came in with a 3-year history of persistent pruritic erythematous moist plaque on the right nipple gradually spreading to the surrounding areola previously treated as a case of fungal infection. Mammography revealed BI-RADS 4C. Skin punch biopsy showed nuclear atypia with pale staining cytoplasm and were consistent with MPD. Immunohistochemical stains showed positive for epithelial membrane antigen and carcinoembryonic antigen. We reiterate the importance of early diagnosis for appropriate treatment to prevent unwanted sequelae.

Lues maligna, also known as malignant syphilis, is an uncommon variant of syphilis at the secondary stage – more commonly reported in immunocompromised patients or those with concomitant human immunodeficiency virus (HIV) infection. In this report, we present a case of a 28‑year‑old HIV‑negative male with a 9‑month history of multiple, well‑defined, irregularly‑shaped, erythematous papules, and small plaques evolving to ulcerated plaques and nodules with crusts, associated with pain, pruritus, and episodes of fever, arthralgia, and weight loss. Positive treponemal and nontreponemal tests, aided by histopathologic findings consistent with syphilis led to the diagnosis of lues maligna. Significant improvement of lesions was noted with 3 weekly doses of 2.4 million units of benzathine penicillin G. For patients presenting with painful and pruritic erythematous ulcerated plaques with crusts associated with systemic symptoms, and with a significant sexual history despite testing negative for HIV infection, a high index of suspicion for uncommon presentations of other sexually transmitted infections such as syphilis could aid in early diagnosis and subsequent treatment.

Introduction: Non-classical congenital adrenal hyperplasia (CAH) represents a group of inherited, autosomal recessive disor- ders that typically presents with androgenetic alopecia, but may present with alopecia universalis on rare occasions. Case report: We report a case of a 14-year-old Filipino female with non-classical congenital adrenal hyperplasia presenting with alopecia universalis, treated with a combination of Tretinoin and Minoxidil solution, low dose prednisone and an oral supplement containing zinc gluconate, nicotinamide, superoxide dismutase, vitamin E and selenium, with noted gradual hair regrowth and improvement in Dermatology Life Quality Index (DLQI). Conclusion Alopecia universalis in a patient diagnosed with non-classical congenital adrenal hyperplasia is a rare and atypical manifestation, with no case reports available to describe its occurrence. Due to its rarity, there is no standard treatment for pa- tients with this condition. However, the combination of tretinoin and minoxidil solution, low dose prednisone and an oral supple- ment containing zinc gluconate, nicotinamide, superoxide dismutase, vitamin E and selenium shows promising results.
Minoxidil ; Tretinoin

Introduction: Rosai-Dorfman disease is a rare disease that manifests with painless cervical lymphadenopathy, fever, anemia, an elevated erythrocyte sedimentation rate (ESR), and hypergammaglobulinemia. Extranodal lesions occur in 1/3 of patients, and the skin is involved in more than 10% of cases. Purely cutaneous disease is uncommon and only about more than 100 cases have been reported. Cutaneous Rosai-Dorfman Disease (CRDD) appears to be a distinct entity with different age and race predilection from cases with lymph node involvement. Case report: This is a case of a 40-year-old Filipino female who presented with multiple erythematous papules and plaques with pustules on the cheeks. Skin punch biopsy showed a dense dermal infiltrate of polygonal histiocytes with abundant cytoplasm and vesicular nuclei. Emperipolesis was also present. The histiocytes were highlighted by the immunohistochemical stains S-100 and CD68 and was CD1a negative. Complete blood count and ESR were normal. Cervical lymphadenopathy was absent. Findings were consistent with Cutaneous Rosai-Dorfman disease. The patient was started on methotrexate at 15mg/week with folic acid supplementation. Mild soap, benzoyl peroxide 5% gel and tretinoin 0.05% cream once daily were maintained during the treatment course. There was significant decrease in erythema and size of existing lesions after 2 months. The patient was referred to a hematologist for monitoring of possible future systemic involvement. Conclusion Because of its rarity, clinicopathological correlation is always mandatory to establish a diagnosis of CRDD. Immu- nohistochemical stains are required to differentiate this entity form other forms of Langerhans cell histiocytosis. Multidisci- plinary referral is required to rule out concomitant systemic involvement.
Lymphadenopathy

Introduction: Hansen’s disease or leprosy is a chronic infectious disease caused by Mycobacterium leprae associated with inflammation that may damage the skin and peripheral nerves. In countries where leprosy is still endemic, an increasing preva- lence of human immunodeficiency virus (HIV) can be seen, hence increasing the possibility of HIV-leprosy co-infection. Hansen’s disease, if not treated promptly, can cause scars and deformities associated with leprosy reaction. Immunosuppressive drugs like corticosteroids used in the treatment of leprosy reaction may put the patient at risk of opportunistic infections. Case report: This is a case of a 27-year-old Filipino male with HIV-leprosy co-infection, who manifested with erythema nodosum leprosum reaction, treated with tapering dose of oral corticosteroids and multidrug therapy (MDT) for multibacillary leprosy showing good response to treatment after 5 months without recurrence of reaction. The use of chronic oral corticosteroids, despite its immunosuppressive effects, has been beneficial in the management of reactions in this patient with HIV-leprosy co-infection. Conclusion Considering that both Hansen’s disease and HIV directly affects T helper CD4+ lymphocytes in its pathogenesis, there seems to be little to no alteration in the course of patients with HIV-leprosy co-infection. Hence, treatment of HIV-leprosy co-infection does not differ from that of a seronegative leprosy patient. This case highlights the occurrence of erythema nodo- sum leprosum reaction in HIV-leprosy co-infection and the need for immunosuppressive drugs to control reaction and prevent nerve damage. Close monitoring is imperative to weigh the risk-benefit ratio of medications given to patients with HIV-leprosy co-infection.
HIV

Introduction: Acquired immunodeficiency syndrome-Kaposi sarcoma (AIDS-KS) has unique clinical characteristics, often dis- seminated on presentation, a rapidly progressive course, and often fatal outcome. Describing the epidemiology and clinical characteristics of AIDS-KS in the Philippines may lead to early recognition, diagnosis, and management of this condition, which are the keys to preventing significant complications. Case Series: AIDS-KS in 11 Filipino MSM patients with a mean age of 36.55 years (SD 11.54) was described. Violaceous plaques and nodules were present for an average of 5.1 months prior to diagnosis confirmed by biopsy. Histopathologic findings from all pa- tients were consistent with KS. The median CD4+ count of patients was 44 cells/microliter (range, 4 to 181). Six patients presented with opportunistic infections (OI)/AIDS-related conditions (ARC). The most common OIs observed were pulmonary tuberculosis, oropharyngeal candidiasis, and Pneumocystis jiroveci pneumonia. Nine patients improved with highly active antiretroviral therapy (HAART). One patient required modification on his HAART regimen, which was shifted to 2 NRTI and ritonavir-boosted protease inhibitor, and one patient died due to AIDS-related complications. Conclusion This series of 11 cases of AIDS-KS showed similar demographic, clinical and histopathologic characteristics to pre- viously published studies. Findings suggest the need for earlier recognition and diagnosis. While HAART afforded clinical improve- ment in a majority of patients, other treatment options such as chemotherapy should be considered for appropriate patients.
Sarcoma, Kaposi ; Antiretroviral Therapy, Highly Active

BACKGROUND: Several trials on relapse rates on duration of multibacillary regimens have varying results. OBJECTIVE: To compare the relapse rate among smear-positive Leprosy patients receiving 12 blister packs of multibacillary drug therapy and 24 blister packs of multibacillary drug therapy. METHOD: A review of records of smear positive Leprosy patients seen from 2002 to 2006 was done. Demographic, clinical and therapeutic data were collected. Bacteriologic index was determined from Leprosy Laboratory records. RESULT: A total of 391 patients were found to have complete records for review and analysis. Relapse rate was 11.9%(28) for patients who received 12 blister packs and 1.91%(3) for patients who received 24 blister packs and the difference was found to be statistically significant (p<0.01). Distribution of relapse was statistically significant according to age (p<0.01), bacteriologic index (p<0.01) and clinical spectrum (p<0.01). CONCLUSION: Relapse rates shown among smear positive leprosy patients receiving 12 blister packs vs. those receiving 24 blister packs was statistically higher which differs from previously published studies. Significant predictors were clinical spectrum, bacteriologic index of >3.5, and >4 and number of blister packs.
Leprostatic Agents ; Drug Therapy, Combination ; Leprosy ; Recurrence ; Chronic Disease

Introduction: Impetigo herpetiformis is a rare pustular disorder that affects pregnant women. It is also otherwise termed as “pustular psoriasis of pregnancy”, owing to the fact that the pustules are sterile and are not associated with a viral etiology. The classic lesions are erythematous patches or plaques with margins studded with subcorneal pustules spreading centrifugally. A cardinal feature of this disorder is the rapid resolution of lesions after delivery. Case Summary: This is a case report of a 33-year-old female, gravida 3, para 2 (2-0-0-2) at 36 weeks age of gestation who presented with one week history of multiple well defined irregularly shaped erythematous annular patches and plaques with marginal pustules on the trunk and extremities. The lesions began on the trunk spreading centrifugally, sparing the face, palms, soles and mucus membrane. Biopsy showed scale crust in the stratum corneum, the epidermis showed acanthosis, spongiosis and neutrophilic microabscesses with focal vacuolar alteration and small sub-epidermal nests on the basal cell layer. The dermis revealed dilated blood vessels and mild superficial perivascular lymphocytic infiltrates. Patient was given Prednisone and Cetirizine with noted resolution of lesions. Conclusion: Recurrences of impetigo herpetiformis in subsequent pregnancies are common with earlier onset in gestation and are characteristically more severe. The complications are placental insufficiency, stillbirth or neonatal death. Early detection is of utmost importance. Management must be multidisciplinary involving a dermatologist, obstetrician and pediatrician.
Pregnancy ; Female ; Impetigo ; Psoriasis ; Skin Diseases, Vesiculobullous ; Exanthema

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.

BACKGROUND: Melasma is an acquired hyperpigmentary disorder occurring in the sun-exposed areas of the face and neck. There is little information on its prevalence, epidemiology and clinical characteristics in the Philippines. OBJECTIVE: To determine the prevalence, epidemiology and clinical characteristics of melasma in Philippine dermatology patients METHODS: This was a multicenter, cross-sectional study conducted from July to December 2013. The investigators determined the prevalence of melasma in 12,068 dermatology patients from 6 government hospitals and private centers in Metro Manila, Philippines. The melasma patients, aged 18 years and above were examined and given self-administered questionnaires to determine the epidemiological and clinical characteristics of their melasma. RESULTS: Of the 12,068 dermatology patients who were seen at the selected hospitals and private centers, 153 (1.26%) were clinically diagnosed with melasma. Majority of the melasma patients were Filipinos (73.20%), aged 41-50 years old (37.91%), with an average age of 42.40 + 9.68 years, and Fitzpatrick skin types III and IV (29.41% and 57.52%, respectively). Melasma was more prevalent in females (81.70%), wherein majority had a prior history of pregnancy (76.8% of the females). Oral contraceptive use was also reported in 37.6% of the female patients and 63.83% of those who have used OCP, have used it for only 1 year or less. Majority had no thyroid disease (75.16%) and daily sun exposure was limited to 1 hr or less for most patients (43.14%). Their melasma was mostly malar in distribution (60.13%), epidermal (61.44%), and mild (51.63%) to moderate (27.45%) in severity. The average mMASI score was 4.63 + 3.32. CONCLUSION Prevalence of melasma was low among the Philippine dermatology patients sampled. Majority of the melasma patients were Filipinos, aged 41-50 years old, with Fitzpatrick skin type IV, limited sun exposure and no thyroid disease. They were mostly females, with a prior history of pregnancy. Their melasma was mostly malar, epidermal, and mild in severity. These descriptive data can serve as baseline information for further studies on melasma in the Philippines.
Philippines