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Published by jpds.editor, 2021-05-18 01:12:01

JPDS MAY 2021_18MAY2021

JPDS MAY 2021_18MAY2021

JPDS CASE REPORT
Journal of the Philippine
Dermatological Society

CBDC induced by drug is less common in the pediatric popu- Figure 3. Subepidermal split with neutrophilic and eosinophilic infiltrates in the blister cavity.
lation.6 Drugs involved may elicit an autoimmune response,
where they may act as haptens, causing a break in the self-tol- Figure 4. Strong linear IgA deposit (+2) along the basement membrane zone.
erance of native antigens. Possible antigens to the disease are
two proteins (97-kD and 285-kD) found in both the lamina lu- antibiotics.7 Though the optimal therapeutic option in drug-
cida and sublamina densa. Moreover, drug-specific T cells and induced CBDC is the discontinuation of the suspected drug,
cytokines increase IgA antibody synthesis that deposit along less than 50% of cases have spontaneous resolution upon
the basement membrane zone in CBDC.7 Studies have also sug-
gested that infection may serve as the triggering or aggravating
event, as this serves as cofactors of the immunologic response
of drug-induced LABD or CBDC.8 The drug-induced variant is
difficult to distinguish from the idiopathic subtype, as in both
cases, autoantibodies are directed to the same heterogeneous
group of proteins.9

Vancomycin is the most common drug involved in drug-
induced LABD, followed by phenytoin and trimethoprim/
sulfamethoxazole.5,9 In contrast to pencillin-derived medications
reported to induce LABD, ixoxazolyl penicillins such as oxacillin
and cloxacillin which were used in the case have been reported
as effective treatment options for LABD.2 There are limited
published case reports on drug-induced LABD secondary to
cephalosporins, much less drug-induced CBDC. While there is
one published report of drug-induced LABD due to cefuroxime,8
no such report has been made implicating cefaclor among adults.
More specifically, and to the best of our knowledge, there are
no published cases of drug-induced CBDC secondary to either
cefaclor or cefuroxime. In the case presented, either cefuroxime
or cefaclor may be the culprit drug as both were administered
and withdrawn in close proximity.5

Currently, the typical features of a drug-induced subtype
are yet to be elucidated. Nonetheless, the most important
characteristic of a drug-induced CBDC is the temporal sequence
of drug administration and onset of symptoms.9 Algorithms
have been developed to strengthen causality between the
suspected drug and the adverse event such as the Naranjo
score.9,10 Using this algorithm, the patient was able to garner two
points that fall under the probability score of “possible adverse
drug reaction,” namely there had been previous reports of the
reaction in the drug, specifically cefuroxime8 (one point), and
event appeared after the suspected drug was given (two points).
Since the patient had an infection that might have triggered the
disease, a point is deducted from the score, giving us the total
of two points.

Challenge-dechallenge-rechallenge protocol remains to be
the gold standard for confirming the diagnosis of a drug-induced
event.9 Such rechallenge may result to severe recurrence
and longer disease course, hence only a few cases have been
confirmed by this procedure.5,9 For ethical reasons, rechallenge
was not done in the patient.

Idiopathic CBDC is usually self-limiting and remits in
months or years.2 First line of treatment include dapsone
supplemented with medications such as corticosteroids and

J Phil Dermatol Soc · May 2021 · ISSN 2094-201X 43

CASE REPORT JPDS
Journal of the Philippine
Dermatological Society

withdrawal.5 Additional therapy for drug-induced cases may and bullae several days after finishing a course of cefuroxime,
be needed to avoid the amplification of the disease, resulting in and cefaclor for sepsis. As both drugs were given, and withdrawn
a self-maintaining immune response.5,9 In the case presented, in a period of close proximity from each other and to the onset of
gradual remission was observed eight weeks into treatment symptoms, it is difficult to determine the definite culprit drug that
with dapsone, prednisolone, cloxacillin, topical betamethasone caused the drug-induced CBDC. Gradual response was noted with
dipropionate, and mupirocin ointment. dapsone and prednisolone. In contrast to idiopathic CBDC which
is a self-limited disease, spontaneous resolution upon withdrawal
CONCLUSION of the suspected drug in drug-induced cases is variable. Systemic
therapy such as dapsone may be necessary for treatment.
We report a case of a two-year-old male presenting with vesicles,

REFERENCES

1. Wojnarowska F, Marsden R, Bhogal B, Black M. Chronic bullous disease of childhood, childhood cicatricial pemphigoid, and linear IgA disease
of adults. J Am Acad Dermatol. 1988;19(5):792-805. doi: 10.1016/s0190-9622(88)70236-4.

2. Fortuna G, Marinkovich MP. Linear immunoglobulin A bullous dermatosis. Clin Dermatol. 2012;30(1):38-50. doi:10.1016/j.clindermatol.2011.03.008.
3. Philippine Dermatological Society Health Information System (PDS HIS), accessed 2019.
4. Patrício P, Ferreira C, Gomes MM, Filipe P. Autoimmune Bullous Dermatoses: A Review. Ann N Y Acad Sci. 2009;1173(1):203-210. doi:10.1111/j.1749-

6632.2009.04737.x.
5. Fortuna G, Salas-Alanis JC, Guidetti E, Marinkovich MP. A critical reappraisal of the current data on drug-induced linear immunoglobulin A

bullous dermatosis: A real and separate nosological entity? J Am Acad Dermatol. 2012;66(6):988-994. doi:10.1016/j.jaad.2011.09.018.
6. Lings K, Bygum A. Linear IgA Bullous Dermatosis: A Retrospective Study of 23 Patients in Denmark. Acta Derm Venereol. 2015;95(4):466-471.
7. Guide, SV, Marinkovich, MP. Linear IgA bullous dermatosis. Clin Dermatol. 2001;19(6):719–727.
8. Pastuszczak M, Lipko-Godlewska S, Jaworek AK, Wojas-Pelc A. Drug-induced linear IgA bullous dermatosis after discontinuation of cefuroxime

axetil treatment. J Dermat Case Rep. 2012;6(4).
9. Lammer J, Hein R, Roenneberg S, Biedermann T, Volz T. Drug-induced Linear IgA Bullous Dermatosis: A Case Report and Review of the Literature.

Acta Derm Venereol. 2019;99(6):508-515.
10. Naranjo CA, Busto U, Sellers EM, Sandor P, Ruiz I, Roberts EA et al. A method for estimating the probability of adverse drug reactions. Clin

Pharmacol Ther. 1981;30(2):239-245.

44 J Phil Dermatol Soc · May 2021 · ISSN 2094-201X

JPDS CASE REPORT
Journal of the Philippine
Dermatological Society

Lupus panniculitis in an ANA-negative systemic lupus
erythematosus patient: A case report

Ma. Corazon A. Iniego-Rodas, MD, DPDS,1 Maria Franchesca Quinio, MD, FPDS, DDSP-PDS,1
Charlene Ang-Tiu, MD, FPDS1

ABSTRACT

INTRODUCTION Lupus panniculitis (LP) is an unusual type of cutaneous lupus erythematosus (CLE) wherein the cutaneous inflam-
matory reaction involves primarily the deeper dermis and subcutaneous fat. It is characterized by the appearance of recurrent,
mostly asymptomatic, firm, nodules or plaques, involving the face, upper limbs, and buttocks.

CASE REPORT In our case, a 30-year-old female presented with a non-tender, non-movable nodule on the left breast, 6 weeks
prior to her admission. She had fever, chills, and joint pains. The patient later developed hyperpigmented plaques on the infra-
clavicular area, and left flank extending to the abdomen. Urinalysis showed proteinuria, and RBC cast. She also had leukopenia,
and anemia on CBC. Chest computerized tomography (CT) scan revealed a heterogeneously enhancing soft tissue mass in the
base of the neck at the right infraclavicular region with malignant features. ANA titer was normal, while skin biopsy on two sites
and direct immunofluorescence studies were compatible with lupus panniculitis. She was managed as a case of systemic lupus
erythematosus (SLE) using a combination of hydroxychloroquine, and oral corticosteroids, which afforded temporary relief of
symptoms. The patient however was lost to follow-up and opted for alternative medicine, and subsequently succumbed to the
complications of SLE.

CONCLUSION This case highlights the importance of a carefully made assessment after an accurate clinicopathological cor-
relation was done. This case also emphasizes that although LP if associated with SLE may signify a milder condition, judicious
monitoring and follow-up must still be undertaken since management is based on the disease activity.

KEYWORDS Chronic cutaneous lupus erythematosus, lupus panniculitis, lupus mastitis

1Department of Dermatology, INTRODUCTION CASE REPORT
East Avenue Medical Center,
Quezon City, Philippines Lupus panniculitis (LP) is a clinical variant of cu- This is a case of a 30-year-old female who present-
taneous lupus erythematosus (CLE). It may pres- ed with a firm, approximately 2x3 cm, non-ten-
Corresponding author ent as exclusive cutaneous condition, or it may der, non-movable nodule over the left breast, six
Ma. Corazon A. Iniego-Rodas, coexist with discoid lupus erythematosus (DLE), weeks prior to admission, without any accompa-
MD, DPDS or systemic lupus erythematosus (SLE). Although nying symptoms. She then developed irregularly
LP is more frequent in women, it may affect both shaped, hyperpigmented, indurated plaques on
Conflict of interest genders and the median age of presentation is 41 the infraclavicular area and left flank. At that
None years old.1 The condition consists of a tender, in- time, the patient experienced high-grade fever
durated, subcutaneous nodules or plaques with and chills. Consult was done, and the assessment
Source of funding or without surface changes. Surface changes was soft tissue infection. She was prescribed with
None may include erythema, atrophy, hyper or hy- sultamicillin 750mg/tablet,1 tablet twice a day for
popigmentation, hyperkeratosis, telangiectasia, 7 days, which provided no relief of her symptoms.
ulceration, necrosis, or follicular plugging. Typ-
ical sites involved are the proximal extremities, Four weeks prior to admission, the patient
buttocks, trunk, scalp, and face. The condition noted the development of a hyperpigmented
runs a chronic and relapsing course and lesions plaque overlying the nodule. Because of this,
tend to resolve with lipoatrophic depressions.1,2 A consult with another physician was done and an
rarer variant is called lupus mastitis, defined as ultrasound of the left breast revealed soft tissue
the extension of LP to the mammary gland.3 swelling. Ciprofloxacin 500mg/capsule, twice a
day, and amycin 300mg/capsule, twice a day, for

J Phil Dermatol Soc · May 2021 · ISSN 2094-201X 45

CASE REPORT JPDS
Journal of the Philippine
AB Dermatological Society

AB

Figure 1. A. Showing the round, well-demarcated, hyperpigmented to dusky plaque on the C
right infraclavicular area and the left breast. B. Showing the irregularly shaped, ill to well-
defined hyperpigmented plaque on the left flank extending to the lower left abdomen.

10 days were given but these did not provide resolution of her Figure 2. Skin punch biopsy on the flank. A. Scanning view. B. LPO: Lesion on the flank
symptoms. showed lymphocytic infiltrates with occassional plasma cells extending into the lobules of
the subcutaneous fat, the blue tinge indicates presence of mucin. C. HPO: necrosis of the
In the interim, the patient still experienced intermittent fat towards the base of the section in the subcutaneous fat, and nuclear dust within the
high-grade fever and increase in the size of the lesions. infiltrate. These findings were consistent with lupus panniculitis.

Patient was admitted under the Internal Medicine Depart- AB
ment and was referred to the Dermatology service. On physical
examination, there were well-demarcated, hyperpigmented, Figure 3. Skin punch biopsy on the clavicular area. A. Scanning view. B. HPO view
plaques on the right infraclavicular and left breast. At the time showing basal layer vacuolization, follicular plugging, mild to moderately dense superficial
of examination, there were no palpable breast nodules, or axil- and deep perivascular and peri-appendageal lymphocytic infiltrates admixed with few
lary lymphadenopathies. There was also an irregularly shaped, plasma cells.
hyperpigmented plaque on the left flank, extending to the lower
abdomen (Figure 1). Complete blood count (CBC) revealed leu- respond well with the initial treatment. Direct immunofluores-
kopenia and anemia, while the antinucleur antibody (ANA) test cence revealed presence of granular basement membrane zone
was within normal limits. Both erythrocyte sedimentation rate deposition of IgG, C3, IgM and fibrin, consistent with a connec-
(ESR) and C-reactive protein (CRP) were elevated, while urinal-
ysis revealed proteinuria (+++) and red blood cell (RBC) casts.
Computed tomography (CT) scan of the chest showed soft tissue
tumor on the right infraclavicular region with malignant fea-
tures. The patient was also referred to the Surgery Department
for the evaluation of the breast lesion. However, during the time
of examination, there was no palpable breast mass, hence the
surgeons opted to wait for the result of the skin biopsies.

Skin biopsies from the dusky plaque on the right supra-
clavicular area, and left flank were obtained and both sections
revealed basal layer vacuolization, mild to moderately dense su-
perficial and deep perivascular and peri-appendageal lympho-
cytic infiltrates admixed with few plasma cells (Figures 2 and
3). In addition, the lesion on the flank showed lymphocytic in-
filtrates with occasional plasma cells extending into the subcu-
taneous lobules wherein hyaline necrosis of the fat and nuclear
dust within the infiltrates were noted. (Figure 2B and 2C) These
findings were consistent with LP. The Surgery Department was
notified of the result of the skin biopsies and decided to defer
the biopsy on the left breast. They noted however that they will
proceed with the contemplated procedure if the patient will not

46 J Phil Dermatol Soc · May 2021 · ISSN 2094-201X

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Dermatological Society

tive tissue disease. Further work up showed normal C3 and An- complex cases such as SLE. They are at the forefront of doing
ti-Ds DNA levels, while Anti-Sm and direct coomb’s test were not a thorough investigation about lupus-specific mucocutaneous
done. findings, as these findings are part of both the ACR and SLICC
diagnostic criteria for SLE. Because of the complexity of SLE,
On review of system, patient reported absence of weight a multi-disciplinary approach is necessary to provide the best
loss, non-scarring alopecia, malar rash, oral ulcerations, and management.
photosensitivity. She however reported occasional joint pains
involving both her elbows and knees. The diagnostic procedure of choice for CLE is skin biopsy.
The two most important histopathologic criteria for diagnosis of
Considering the clinical features including fever, joint LP are the presence of lymphocytic infiltrate involving fat lob-
pains, the discoid rash proven to be LP, urinalysis findings ules and hyaline necrosis of the fat lobule.1 Direct immunofluo-
of proteinuria and RBC casts, and CBC findings of anemia rescence is also a valuable tool and shows deposits of IgG, IgM
and leukopenia, the patient fulfilled the American College and C3 at the dermoepidermal junction.6,7 These are all consis-
of Rheumatologists (ACR) criteria for SLE. However, due to tent with the direct immunoflurescence findings of our patient.
the negative ANA, normal C3 and anti-Ds DNA; and other
immunologic markers not provided, it is difficult to classify her Since this patient presented with a lesion on the breast
using the Systemic Lupus International Collaborating Clinics initially perceived as a nodule, it is important to note that a rarer
Classification (SLICC) Criteria for SLE. subtype of LP called lupus mastitis (LM) exists. It is the extension
of the lupus panniculitis on the mammary gland, and presents
The patient was managed as a case of SLE with LP and was clinically as a mass, or may present with cutaneous involvement
given hydroxychloroquine 200mg/tablet OD with clearance such as thickening and discoloration, as observed in our patient.
from Ophthalmology service. She was also given prednisone Just like LP, LM, may present before, during, or after a diagnosis
30mg/day (0.5mkd) and Vitamin D + calcium once a day. She of SLE is made. The diagnosis of LM may be established by doing
was asked to apply clobetasol propionate 0.05% ointment twice skin biopsy, core needle biopsy, fine needle aspiration, or open
daily on the indurated plaques. She was also advised rigorous surgical biopsy. Major histopathologic criteria includes hyaline
sun protection measures and regular follow-up with her physi- fat necrosis, lymphocytic infiltration with lymphoid nodules
cians. The patient was signed out as discharged improved and surrounding the necrosis, periseptal or lobular panniculitis,
stable. However, she was lost to follow-up, and physicians were and microcalcifications.8 Moreover, in some case reports,
informed that she opted to seek alternative medicine which re- imaging modalities such as mammography and magnetic
sulted to the patient succumbing to the complications of SLE. resonance imaging (MRI) helped in verifying the diagnosis.3,8 In
the literature review done by Voizard et al, there was no distinct
DISCUSSION investigation algorithm established. On mammography, LM
often presents as an ill-defined mass, or either a focal or diffuse
LP is an uncommon subset of CLE. It can occur as a single mani- asymmetry. Other mammographic findings include large
festation of the disease, or it may be associated with DLE or SLE. dystrophic calcifications and axillary lymph node enlargement
The condition, LP, may emerge at the same time, before, or after that may be suggestive of a neoplastic process. 3 While a biopsy
the appearance of other signs and symptoms of DLE or SLE.1 is necessary to rule out carcinoma, the procedure can possibly
exacerbate the inflammatory process. Cho et al in their report
The frequency of association of LP with SLE varies therefore recommended that a trial pharmacological treatment
depending on the series. Arai and Katsuoka noted in their study be given first to avoid diagnostic biopsy or surgery.8
that 40% were associated with SLE, while reports by Mastens
et al and Massone et al showed only 10% and 22.2% association First-line treatment for both LP and LM is hydroxychloro-
respectively.4,5 Fraga et al observed that the coexistence of LP quine, and effects may take up to 3 months.1,3,4 Systemic cortico-
with SLE signified a marker for a less severe variant of SLE.1 steroids may be combined with the anti-malarial drug during
the initial therapy of patients presenting with extensive in-
ANA is often negative in cases of LP alone.1 A retrospective flammatio.4 For patients with LM, surgical intervention is the
study by Ng et al noted only 27% of the cases of LP revealed a last option if pharmacological treatment fails to improve the
positive ANA; and it was emphasized that the presence of ANA symptoms.8 In patients with systemic involvement, associated
positivity in a patient with LP signifies a high likelihood of adverse side effects of chronic steroid use is of paramount con-
systemic involvement. However, this finding is not universal as sideration. As such, glucocorticoids are believed to be a bridge
other studies did not find any association.2 A study by Tarazi et therapy. To minimize SLE-associated organ damage, the goal is
al highlighted that although a positive ANA is a sensitive marker to control active inflammation, reduce steroid dose, and eventu-
in identifying patients with SLE, ANA may not always be present ally use long term immunosuppressives such as mycophenolate
in patients with significant disease. The study also discovered mofetil, azathioprine, and methotrexate.1
that ANA status can change over time, thus if ANA positivity
will be required for a diagnosis of SLE, some cases might be
missed.5 This case also highlights the role of dermatologists in

J Phil Dermatol Soc · May 2021 · ISSN 2094-201X 47

CASE REPORT JPDS
Journal of the Philippine
Dermatological Society

CONCLUSION that it presented with a number of diagnostic dilemmas. There-
fore, a multi-specialty approach, and proper clinicopathologic
Lupus panniculitis is a rare variant of CLE. A rare subtype of LP correlation are needed to arrive at an appropriate diagnosis
is LM that may present clinically as breast mass, and on imaging and management plan. Lastly, since SLE is characterized by a
as a carcinoma. The frequency of association of LM and LP with chronic course of remissions and flares, vigilant surveillance of
SLE is variable, both may emerge simultaneously, after, or prior disease progression is recommended as long-term treatment is
to the onset of SLE. This case highlights how complex lupus is designed depending on the disease activity.

REFERENCES

1. Fraga, J. and García-Díez, A. (2008). Lupus Erythematosus Panniculitis. Dermatologic Clinics, 26(4), pp.453-463. DOI: 10.1016/j.det.2008.06.002.
2. Ng PP, Tan SH, Tan T. Lupus erythematosus panniculitis: a clinicopathologic study. Int J Dermatol 2002; 41:488–90. DOI: 10.1046/j.1365-

4362.2002.01510.x.
3. Voizard, B., Lalonde, L., Sanchez, L., Richard-Chesnay, J., David, J., Labelle, M., El Khoury, M. and Trop, I. (2017). Lupus mastitis as a first

manifestation of systemic disease: About two cases with a review of the literature. European Journal of Radiology, 92, pp.124-131. DOI:
10.1016/j.ejrad.2017.04.023.
4. Martens PB, Moder KG, Ahmed I. Lupus panniculitis: clinical perspectives from a case series. J Rheumatol 1999;26:68–72.
5. Massone C, Kodama K, Salmhofer W, Abe R, Shimizu H, Parodi A,etal. Lupus erythematosus panniculitis (lupus profundus): clinical,
histopathological, and molecular analysis of nine cases. J Cutan Pathol 2005;32:396–404. DOI: 10.1111/j.0303-6987.2005.00351.x.
6. Kündig, T., Trüeb, R. and Krasovec, M. (1997). Lupus profundus / Panniculitis. Dermatology, 195(1), pp.99-101. DOI: 10.1159/000245706.
7. Tuffanelli DL. Lupus erythematosus panniculitis (profundus):clinical and immunologic studies. Arch Dermatol 1971;103:231–42. DOI: 10.1001/
archderm.1971.04000150001001.
8. C.C.M. Cho, W.C.W. Chu, A.P.Y. Tang, Lupus panniculitis of the breast − Mammographic and sonographic features of a rare manifestation of
systemic lupus, J. HK. Coll. Radiol. 11 (1) (2007) 41–43.

48 J Phil Dermatol Soc · May 2021 · ISSN 2094-201X

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Journal of the Philippine
Dermatological Society

Angiosarcoma of the scalp in a 79-year-old male: A
case report

Erika Kim R. Chan, MD,1 Charlene Marie U. Ang-Tiu, MD, FPDS,1
Mary Elizabeth S. Danga, MD, FPDS,1 Michael Jeff B. Fontano, MD, DPBS2

ABSTRACT

INTRODUCTION Angiosarcoma is a rare head and neck sarcoma of vascular endothelial cell origin. We report a case of angiosar-
coma in an elderly male, and the multidisciplinary approach employed in his treatment.

CASE REPORT A 79-year-old male presented with a 4-month history of a rapidly enlarging black, soft, immovable tumor surround-
ed by bruise-like patches over the right temporoparietal scalp. There was associated pruritus and bleeding when scratched.
Dermoscopy showed bluish black crusts over the tumor, and surrounding violaceous patches. Wedge biopsy revealed a dermis
with irregular vascular spaces infiltrating dermis, lined by atypical endothelial cells. Immunohistochemistry of the atypical in-
filtrative cells was positive for CD31. These findings were consistent with angiosarcoma. The patient underwent wide excision
with a rotational flap and split thickness skin graft. Postoperatively, the patient was referred to Oncology for adjuvant radiation
therapy.

CONCLUSION Even with treatment, the prognosis of angiosarcoma remains poor due to its aggressive nature, with a 5-year sur-
vival rate ranging from 10-54%. However, early detection of the disease may increase patient survival rates. This rare case shows
the importance of maintaining a high level of suspicion for lesions that have an atypical presentation to prevent delays in man-
agement and improve patient outcomes.

KEYWORDS Angiosarcoma, scalp, oncology, neoplasm

1Department of Dermatology, INTRODUCTION employed for his treatment.
Rizal Medical Center, Pasig City,
Philippines Angiosarcoma is a rare, malignant tumor of CASE REPORT
2Department of Surgery - Section vascular endothelial cell origin.1,2 It has an
of Head and Neck, Rizal Medical incidence of approximately 0.01/100,000 per year, This is a case of a 79-year old male presenting with
Center, Pasig City, Philippines and comprises <2% of soft tissue sarcomas and 5% a 4-month history of a rapidly enlarging brown to
of malignant skin tumors.1,3,4 It can occur in any black plaque surrounded by bruise-like patches
Corresponding author site, although the most common locations for the over his right temporoparietal scalp. There was
Erika Kim R. Chan , MD primary tumor are the skin of the head and neck associated pruritus and bleeding when scratched.
region.3-5 There are 3 clinical variants – primary He was a known hypertensive, maintained on
Conflict of interest cutaneous angiosarcoma, lymphangiosarcoma amlodipine and losartan. The patient initially
None or Stewart-Treves syndrome, and post-irradiation sought consult with General Surgery, and
angiosarcoma.1,3,6 ultrasound was requested; the results showed
Source of funding a cutaneous growth with increased vascularity
None Primary cutaneous angiosarcoma is dif- confined to the basal region. A diagnosis of basal
ficult to diagnose clinically due to its variable cell carcinoma was considered. The patient was
presentation. The lesion may present as singular then referred to the Dermatology service for
or multifocal, appearing as bruise-like patches, further evaluation.
plaques or nodules that may bleed or ulcerate.1,7 On cutaneous examination, there was a solitary,
Prognosis is poor, and treatment is difficult due well-defined, black, soft, immovable tumor with
to the aggressive nature of the neoplasia, and a a violaceous base measuring 3.5 x 2.8 x 2.1 cm
lack of standardized protocol for the manage- over the right temporoparietal scalp (Figure 1).
ment of the disease.3,6,7 Dermoscopy findings were nonspecific, showing
bluish black and hemorrhagic crusts. There were
We report a case of angiosarcoma in an
elderly male, and the multidisciplinary approach

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Dermatological Society

Figure 1. Solitary, well-defined, black, soft, immovable tumor with a violaceous base over intracranial metastasis. Contrast enhanced chest CT scan was
the right temporoparietal scalp. also done, which revealed multiple, non-calcified pulmonary
nodules, suspicious for pulmonary metastasis.
AB
The patient was referred back to General Surgery – Head
Figure 2. A. Hematoxylin and eosin stain revealed irregular vascular spaces infiltrating and Neck service for surgical evaluation and management.
the dermis, lined by atypical endothelial cells. B. Immunohistochemistry revealed atypical Palliative wide excision of the scalp lesion was done. A 2 cm
infiltrative cells positive for CD31. margin from the violaceous base was marked using Gentian
violet prior to surgical incision. The mass resected was hard
no palpable periparotid, perifacial, buccinator, and cervical and slightly movable, measuring approximately 5 x 4 cm.
lymphadenopathies. Frozen section examination of resection margins showed tumor
deposits at the basal margins. The periosteum was also removed
A wedge biopsy of the tumor was done, and histopathology as an additional basal margin, which eventually revealed
revealed irregular vascular spaces infiltrating the dermis, lined negative for tumor deposits. The Plastics and Reconstructive
by atypical endothelial cells (Figure 2a). Immunohistochemis- Surgery service closed the surgical defect using full thickness
try of the atypical infiltrative cells was positive for CD31 (Figure scalp rotational flap with split thickness skin grafting. A flap
2b). These findings were consistent with a diagnosis of Angio- was developed from the medial aspect of the defect and the
sarcoma. anterior scalp. The flap was then rotated to cover the defect. A
superficial partial thickness skin graft was harvested from the
To evaluate the extent of the tumor, a cranial computed to- left thigh, and was placed into a 1:1.5 mesher. The skin graft was
mography (CT) scan was done. The imaging revealed a 3.7 x 3.1 x then placed on the defect on the anterior scalp (Figure 3).
5.3 cm, well-defined, lobulated, heterogenous mass on the right
parietal extra-calvarial region, exhibiting minimal heteroge- Microscopic section showed a malignant tumor constituted
nous enhancement with no associated calvarial erosions and by epithelioid or fusiform cells with rudimentary vascular
differentiation. Pleomorphism, mitosis, and tissue infiltration
we re pre se nt. Surgical margins of re se ction we re de void of tumor
involvement. This case was signed out as Scalp Angiosarcoma
stage IV (T2N0M1).

The patient was compliant with follow up at the outpatient
department, with note of viable flap and skin graft on subse-
quent weeks postoperatively. The patient was referred to the
Oncology service for co management. He underwent 25 cycles
of radiation therapy. He was started on palliative chemotherapy
with Paclitaxel, though he was only able to complete 2 cycles.
Eight months post-surgery, the patient was admitted due to dys-
pnea. He eventually expired due to acute respiratory failure sec-
ondary to poor ventilatory drive.

DISCUSSION

Angiosarcoma is difficult to diagnose and treat, not only because
of its aggressive nature, but also due to its rarity. Most published
studies are case reports and retrospective analyses. There are
no clinical or randomized trials to standardize diagnostic and
therapeutic management.2,4

Clinical diagnosis is difficult due to the variable presen-
tation of angiosarcoma. Presenting signs may be ill-defined,
bruise-like macules or patches that progress to more indurated
plaques or nodules. Most lesions are painless, though there may
be bleeding and ulceration.6,7 Similarly, our patient presented
with a painless, brown to black plaque that rapidly progressed
to a tumor with a violaceous base, and a tendency to bleed. Mis-
diagnosis on first consult is fairly common due to the nonspecif-
ic clinical picture, and the low suspicion for the disease.5

Definitive diagnosis of angiosarcoma can be made through

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ABCD

EF

Figure 3. A. Diagram of the procedure B-D. intraoperative images of the procedure. E-F. Day 5 postoperative images of the surgical site.

histopathologic examination.5 Angiosarcoma extensively collagen.1,6,8 Nuclear atypia is always present. Mitotic figures
involve the dermis, with a possible invasion of deeper structures are variable, though a high mitotic rate may be associated
such as fascia, and subcutaneous tissue.7 For this reason, a with a poor prognosis.6,8 These histopathologic findings were
wedge biopsy may be the better technique for collecting sample consistent with our patient’s biopsy.
as it can provide the dermatopathologist a deeper view of the
specimen. A punch biopsy may provide inadequate tissue, and Specific markers for angiosarcoma include factor VIII
an excision biopsy may be difficult due to the tumor’s location antigen, CD34, and CD31. Of the three, CD31 is the most sensitive
and the challenge of achieving negative margins. and specific endothelial marker that stains positive in more
than 90% of angiosarcomas.6 In this case, the specimen stained
Angiosarcoma is characterized by irregular, anastomosing positive for CD31, confirming a diagnosis of angiosarcoma.
vascular channels lined by endothelial cells that dissect through
The rarity of the disease and its clinical variability

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CASE REPORT JPDS
Journal of the Philippine
Dermatological Society

may contribute to a delay in diagnosis, which averages to 5.1 Post-operatively, the patient was referred to Oncology for
months.5,7 Due to this delay, multiple lesions, extensive local adjuvant radiation therapy and chemotherapy. Studies show
growth, or metastasis may already occur prior to detection that this may improve local control and survival rates.2,4,7 Subse-
of the disease.7 The most frequent sites of metastases include quent follow-up should be done every 3-6 months for the first 2-3
the lung, and lymph nodes.3,7 Though the patient was initially years, then every 6-12 months thereafter. Complete history and
asymptomatic, pulmonary metastasis was considered due to the physical examination must be done to assess for recurrence.9
multiple nodules seen in his chest CT scan. Another challenge
encountered was the delay in complete diagnostic work-up due The prognosis for patients with scalp angiosarcoma is
to financial constraints. poor, with a 5-year survival rate ranging from 10%-54%.2,3,7
Factors associated with poor outcomes include tumors > 2 in or
The current treatment of choice remains to be wide local 5 cm, patients >70 years old at presentation, deep location of the
excision even though it is difficult to achieve negative margins tumor, and presence of necrosis.3,4,7 Our patient presented 2 of
due to its multifocal growth tendency.1,3,4,7 There are no stan- these factors, specifically the tumor size, and advanced age.
dardized recommendations as to what constitutes as adequate
margins, though a margin <1 cm is associated with poor surviv- CONCLUSION
al.10 Mohs micrographic surgery was not considered due to the
tumor’s tendency for multifocal growth, the difficulty of achiev- Angiosarcoma is a rare, malignant tumor that poses a diagnostic
ing negative margins,4 and pulmonary metastases. Our patient’s challenge for clinicians. It is important to maintain a high index
cranial CT scan revealed that the mass was extra-calvarial, with of suspicion for lesions that have an atypical presentation in
no calvarial erosions. Given the advanced age of the patient and order to prevent delays in diagnosis. The sarcoma may present
the suspicious findings of possible distant metastases, the surgi- as ill-defined, bruise-like macules or patches that progress to
cal treatment included a more conservative wide local excision, more indurate d plaque s or nodule s with ble e ding and ulce ration.
ensuring negative pathologic margins to include only the full Early diagnosis could be associate d with a smalle r tumor size and
thickness of the scalp layer and not the skull bone. This was to absence of metastasis on presentation of the disease, possibly
ensure prevention of early local recurrence of the tumor on the increasing the survival rate for patients.3 Though limited,
surgical defect, as more radical resection will not give any fur- current observations show the benefit of a multidisciplinary
ther benefit to the patient in terms of overall survival. approach, including dermatopathology, surgery, and oncology
in the management of patients with angiosarcoma.

REFERENCES

1. Wolff K, Goldsmith L, Katz S, Gilchrest B, Paller AS, Leffell D. Fitzpatrick’s Dermatology in General Medicine, 8th Edition. New York: McGraw-Hill,
2011.

2. Patel SH, Hayden RE, Hinni ML, Wong WW, Foote RL, Milani S, Wu Q, Ko SJ, Halyard MY. Angiosarcoma of the scalp and face: the Mayo Clinic
experience. JAMA Otolaryngol Head Neck Surg. 2015 Apr;141(4):335-40. doi: 10.1001/jamaoto.2014.3584. PMID: 25634014. Available from: https://
pubmed.ncbi.nlm.nih.gov/25634014/.

3. Rampinelli H, Ramos-e-Silva M, Quintella D, C, Fernandes N, C: Cutaneous Angiosarcoma. Case Rep Dermatol 2018;10:55-60. doi: 10.1159/000485073.
Available from: https://www.karger.com/Article/Pdf/485073.

4. Buehler D, Rice SR, Moody JS, Rush P, Hafez GR, Attia S, Longley BJ, Kozak KR. Angiosarcoma outcomes and prognostic factors: a 25-year single
institution experience. Am J Clin Oncol. 2014 Oct;37(5):473-9. doi: 10.1097/COC.0b013e31827e4e7b. PMID: 23428947; PMCID: PMC3664266. Available
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3664266/.

5. Wang H, Shi J, Liu H, Chen Y, Wang Y, Wang W, Zhang L. Clinical and diagnostic features of angiosarcoma with pulmonary metastases: A
retrospective observational study. Medicine (Baltimore). 2017 Sep;96(36):e8033. doi: 10.1097/MD.0000000000008033. PMID: 28885371; PMCID:
PMC6392612. Available from: https://pubmed.ncbi.nlm.nih.gov/28885371/.

6. Selim A, Khachemoune A, Lockshin NA. Angiosarcoma: a case report and review of the literature. Cutis. 2005 Nov;76(5):313-7. PMID: 16422466.
Available from: https://pubmed.ncbi.nlm.nih.gov/16422466/.

7. Pawlik TM, Paulino AF, McGinn CJ, Baker LH, Cohen DS, Morris JS, Rees R, Sondak VK. Cutaneous angiosarcoma of the scalp: a multidisciplinary
approach. Cancer. 2003 Oct 15;98(8):1716-26. doi: 10.1002/cncr.11667. PMID: 14534889. Available from: https://pubmed.ncbi.nlm.nih.gov/14534889/.

8. Wu J, Li X, Liu X. Epithelioid angiosarcoma: a clinicopathological study of 16 Chinese cases. Int J Clin Exp Pathol. 2015 Apr 1;8(4):3901-9. PMID:
26097574; PMCID: PMC4466961. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4466961/.

9. Von Mehren M, Kane JM, Bui MM, Choy E, Connelly M, Dry S, Ganjoo KN, George S, Gonzalez RJ, Heslin MJ, Homsi J, Keedy V, Kelly CM, Kim E, Liebner
D, McCarter M, McGarry SV, Meyer C, Pappo AS, Parkes AM, Paz IB, Petersen IA, Poppe M, Riedel RF, Rubin B, Schuetze S, Shabason J, Sicklick JK,
Spraker MB, Zimel M, Bergman MA, George GV. NCCN Guidelines Insights: Soft Tissue Sarcoma, Version 1.2021. J Natl Compr Canc Netw. 2020 Dec
2;18(12):1604-1612. doi: 10.6004/jnccn.2020.0058. PMID: 33285515. Available from: https://pubmed.ncbi.nlm.nih.gov/3328551.

10. Fujisawa Y, Yoshino K, Fujimura T, Nakamura Y, Okiyama N, Ishitsuka Y, Watanabe R, Fujimoto M. Cutaneous Angiosarcoma: The Possibility of New
Treatment Options Especially for Patients with Large Primary Tumor. Front Oncol. 2018 Mar 2;8:46. doi: 10.3389/fonc.2018.00046. PMID: 29552543;
PMCID: PMC5840142. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC58.

52 J Phil Dermatol Soc · May 2021 · ISSN 2094-201X

JPDS CASE REPORT
Journal of the Philippine
Dermatological Society

Cutaneous Rosai-Dorfman disease in a 40-year-old
female: A case report

Joland A. San Juan, MD,1 Juan Antonio D. Cervantes, MD,1 Johannes F. Dayrit, MD, FPDS, FDSP,1
Ricky H. Hipolito, MD, FPDS,1 Ma. Teresita G. Gabriel, MD, FPDS1

ABSTRACT

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.

KEYWORDS Cutaneous Rosai-Dorfman Disease, Non-langerhans cell histiocytosis, lymphadenopathy

1Department of Dermatology, INTRODUCTION and is frequently seen in Caucasians, Asians, and
Research Institute for Tropical older individuals.2 This case report is focused on
Medicine, Mintinlupa City, Rosai-Dorfman Disease (RDD) is a rare disorder the clinical and histologic features of cutaneous
Philippines belonging to the group of non-langerhans cell RDD with management leading to a cosmetically
histiocytosis (NLH). First described in 1969, RDD acceptable result.
Corresponding author also known as sinus histiocytosis with massive
Joland A. San Juan, MD lymphadenopathy, is a benign and self-limited CASE REPORT
disease characterized by fever, anemia, elevated
Conflict of interest erythrocyte sedimentation rate (ESR), hyperga- We present a case of a 40-year-old female who
None mmaglobulinemia, and lymphadenopathy. The sought consult at a tertiary hospital for a 3-month
etiology of RDD is unknown; however, it was history of multiple erythematous papules on the
Source of funding frequently observed after an infection with Ep- cheeks. The patient sought prior consult with a
None stein-Barr virus, human herpes-virus 6, or par- dermatologist, and was prescribed unrecalled
vovirus.1 oral antibiotics and topical medications without
improvement of lesions.
Cutaneous RDD is rare and has been in-
creasingly recognized as a distinct entity. In Upon consult with us, lesions were noted to
contrast to systemic RDD, cutaneous RDD has a increase in size and number, some coalescing
more benign clinical course with normal labora- to form multiple erythematous papules, and
tory findings. Epidemiologically, cutaneous RDD plaques with pustules on the cheeks. The patient
has been identified to have a different age and ra- did not present with systemic symptoms such as
cial predilection. It has a female preponderance, fever, and lymphadenopathy.

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CASE REPORT B JPDS
Journal of the Philippine
A Dermatological Society

C

Figure 1. Multiple views of patient presenting with multiple, erythematous plaques with papules and pustules on the cheek.

were within normal limits. A 3-mm skin punch biopsy was tak-
en from a lesion on the right cheek. Histopathologic examina-
tion using Hematoxylin and Eosin stain revealed parakeratosis
of the stratum corneum, spongiosis of the epidermis with focal
areas of ulceration, dense dermal infiltrates of polygonal histio-
cytes with abundant cytoplasm, and vesicular nuclei. Emperip-
olesis was present. The S-100 and CD68 immunohistochemical
stains highlighted histiocytes, and CD1a was negative (Figure 3).

Clinicopathologic findings confirmed the diagnosis of
cutaneous RDD. The patient was started on methotrexate at
15mg/week, and folic acid supplementation at 5mg/day on days

AB

Figure 2. Dermoscopy of the lesions revealed milky white globules (blue arrows), and CD
small curvilinear vessels on a red-orange background (red arrows).
Figure 3. A. Section showing parakeratosis of the stratum corneum, spongiosis of
Past medical and family history were unremarkable. the epidermis with focal areas of ulceration. Dermis reveals mild edema and a dense
Menstrual history was likewise unremarkable with no history mixed inflammatory infiltrate consisting of plasma cells, lymphocytes, and histiocytes
of any gynecologic or hormonal disorders. Similar lesions were (Hematoxylin and Eosin Stain. Original Magnification, 100x). B. Emperipolesis (red arrow)
not described in the family and workplace. The patient is a non- (Hematoxylin and Eosin Stain. Original Magnification, 1000x). C. Histiocytes highlighted
smoker and an occasional alcoholic beverage drinker. by S100, x100. D. Histiocytes highlighted by CD68, x400.

On cutaneous examination, we describe multiple, well-
defined, irregularly shaped, erythematous plaques with papules
and pustules on the cheeks (Figure 1). The lesions were limited
to the face and were not seen on other areas of the body. There
were no lymphadenopathies present. Dermoscopy of the lesions
revealed milky white globules and small curvilinear vessels on
a red-orange background (Figure 2).

Complete blood count and ESR were requested and results

54 J Phil Dermatol Soc · May 2021 · ISSN 2094-201X

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Journal of the Philippine
Dermatological Society

when methotrexate was not given. Mild soap, benzoyl peroxide AB
5% gel once daily in the morning, and tretinoin 0.05% cream
once daily in the evening were maintained during the treatment Figure 4. Side-by-side comparison of the patient’s lesions before (A) and after (B)
course. There was flattening of the lesions with significant treatment showing decrease in erythema, number, and size of lesions.
decrease in erythema, resolution of pustules, residual post-
inflammatory hyperpigmentation and minimal scarring after have limited studies in terms of efficacy.5,7 Improvement with
two months of treatment (Figure 4). Clinical improvement was methotrexate as monotherapy in the management of cutaneous
accompanied by a marked positive impact on the patient’s quality RDD is inconsistent, resulting to non-response, partial, or
of life and self-image. The patient was referred to a hematologist complete response.8 Methotrexate in combination with other
for monitoring of possible future systemic involvement. agents, including prednisone, 6-thioguanine, 6-mercaptopurine
and leucovorin have been utilized in both systemic and
DISCUSSION cutaneous RDD resulting to either partial or complete
response.8,9 Anti-inflammatory, bactericidal, and keratolytic
Cutaneous RDD is increasingly being recognized as a distinct effect of benzoyl peroxide have been demonstrated, and its use
disease from systemic RDD with different clinical presentation, on inflammatory type of rosacea, folliculitis, decubitus ulcer,
age of onset, gender and racial predilection.1,2 In 1990, a compre- progressive macular hypomelanosis, and pitted keratolysis
hensive review of case reports has been done. Among the 423 pa- have been reported.10 Systemic retinoids have also been used
tients diagnosed with RDD, 13 patients presented with cutaneous in the treatment of RDD; however, there are no published
lesions without lymph node involvement.3 Subsequently, a com- reports on the use of topical retinoids or benzoyl peroxide 5%
prehensive review of case reports has been done in 2006 where gel in combination with methotrexate in the management of
72 cases of cutaneous RDD were identified. Cutaneous RDD ap- cutaneous RDD.5,7 Due to cutaneous RDD’s rarity, standard
pears to favor older patients with mean age of 43.5 – 45 years old, treatment has yet to be established.
Caucasians, Asians, and females with a 2:1 female to male ratio.2,4
Cutaneous lesions vary from <1cm to 30cm, some appear singly CONCLUSION
or as multiple papules, pustules, plaques, and nodules located on
the trunk (40%), head and neck (31%), and extremities (29%).2 The Clinicopathological correlation and immunohistochemical
clinical variability of cutaneous RDD limits its clinical diagnosis stains are required to establish the diagnosis of cutaneous
in which several presentations may mimic different diseases in- RDD, and differentiate it from other forms of Langerhans cell
cluding histiocytosis, sarcoidosis and cutaneous infectious dis- histiocytosis. Treatment with immunomodulating agents such
eases.5 as methotrexate in combination with benzoyl peroxide 5% gel
and tretinoin 0.05% cream shows promising results. It brought
Clinicopathological correlation is always mandatory to about a cosmetically acceptable outcome leading to marked
establish a diagnosis of cutaneous RDD. Histopathology typically improvement in the patient’s quality of life. Multidisciplinary
reveals dermal polygonal histiocytic infiltrates with emperipolesis referral is required in order to rule out concomitant systemic
which is the hallmark of cutaneous RDD. Immunohistochemical involvement.
staining demonstrates S100 positive, CD68 positive and CD1a
negative.1,2,5,6

As it is self-limited, close observation of the lesions remains
to be the cornerstone of management of cutaneous RDD.
However, in cases wherein lesions result to substantial physical
deformity and compression of vital structures, surgical excision
is warranted. Topical and systemic corticosteroids, thalidomide,
radiotherapy, and alkylating antineoplastic agents including
cyclosporine and methotrexate have been used although

REFERENCES

1. Kang, S., Amagai M., Bruckner AL., Enk AH., Margolis DJ., McMichael AJ., Orringer JS. Fitzpatrick’s Dermatology 9th edition. McGraw-Hill
Education; 2018 p. 2031.

2. Frater, J. L., Maddox, J. S., Obadiah, J. M., & Hurley, M. Y. Cutaneous Rosai-Dorfman Disease: Comprehensive Review of Cases Reported in the
Medical Literature since 1990 and Presentation of an Illustrative Case. Journal of Cutaneous Medicine and Surgery. 2006; 10(6), 281–290. DOI:
10.2310/7750.2006.00067.

3. Foucar E, Rosai J, Dorfman R. Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease): review of the entity. Semin Diagn

J Phil Dermatol Soc · May 2021 · ISSN 2094-201X 55

CASE REPORT JPDS
Journal of the Philippine
Dermatological Society

Pathol 1990;7:19–73.
4. Brenn, T., Calonje, E., Granter, S. R., Leonard, N., Grayson, W., Fletcher, C. D. M., & McKee, P.H. Cutaneous Rosai-Dorfman Disease Is a Distinct

Clinical Entity. The American Journal of Dermatopathology. 2002, 24(5), 385–391. DOI: 10.1097/01.DAD.0000026462.55673.41.
5. J.L. Bolognia, J.L. Jorizzo, J.V. Schaffer Dermatology. 3rd Edition. Elsevier Saunders, Philadelphia (2012), pp. 1441-1443.
6. G. Kroumpouzos, M.F. Demierre Cutaneous Rosai-Dorfman disease: histopathological presentation as inflammatory pseudotumor. A

literature review Acta Dermato-Venereol. 2002, 82 (4), pp. 292- 296. DOI: 10.1080/000155502320323289.
7. Pulsoni A, Anghel G, Falcucci P, Matera R, Pescarmona E, Ribersani M, et. al. Treatment of sinus histiocytosis with massive lymphadenopathy

(Rosai-Dorfman disease): report of a case and literature review. Am J Hematol. 2002; 69(1):67-71. DOI: 10.1002/ajh.10008.
8. Nasseri E, Belisle A, Funaro D. Rosai-Dorfman disease treated with methotrexate and low-dose prednisone: case report and review of the

literature. J Cutan Med Surg. 2012;16(4):281-285. DOI: 10.1177/120347541201600411.
9. Sun NZ, Galvin J, Cooper KD. Cutaneous Rosai-Dorfman Disease Successfully Treated With Low-Dose Methotrexate. JAMA Dermatol.

2014;150(7):787–788. DOI:10.1001/jamadermatol.2013.8679.
10. Matin T, Goodman MB. Benzoyl Peroxide. [Updated 2020 Nov 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

Available from: https://www.ncbi.nlm.nih.gov/books/NBK537220/.

56 J Phil Dermatol Soc · May 2021 · ISSN 2094-201X



JPDS POSITION PAPER
Journal of the Philippine
Dermatological Society

COVID-19 vaccination and dermatologic patients on
immunotherapy and biologic therapies

A Position Paper from the Philippine Dermatological Society

Clarisse G. Mendoza, MD, FPDS,1 Bryan Edgar K. Guevara, MD, FPDS,2
Cybill Dianne C. Uy, MD, FPDS

PDS Immunodermatology Subspecialty Core Group

KEY POINTS

• Immunocompromised patients have a higher risk of developing severe and life-threatening COVID-19 infection
compared to the general population.

• The five Philippine FDA-authorized for emergency use COVID-19 vaccines are all non-live vaccines. These vaccines
may provide benefits for dermatologic patients with immunosuppressed states or who are taking immunomodulating
medications, upon appropriate advice and counseling.

• COVID-19 vaccination should not replace transmission prevention measures, such as proper mask wearing, frequent
disinfection, and physical distancing.

1Department of Dermatology, I. INTRODUCTION
Research Institute for Tropical
Medicine, Mintinlupa City, SARS-CoV-2, the virus causing COVID-19, has infected more than 140 million people and has caused
Philippines more than three million deaths worldwide since it was first detected in 2019.1 Patients with diabetes
2Department of Dermatology, mellitus, chronic obstructive pulmonary disease, cardiovascular disease, hypertension, malignancies,
Southern Philippines Medical and other immunocompromised states could develop severe and life-threatening infections.2
Center, Davao City, Philippines
Numerous dermatologic conditions result from immune dysfunction or necessitate chronic and
Corresponding author prolonged treatment with agents that may cause drug-induced immunosuppression. Patients with pso-
Clarisse G. Mendoza, MD, FPDS riasis, eczemas, connective tissue diseases, and blistering disorders are often maintained on drugs
such as topical and systemic corticosteroids, methotrexate, rituximab, azathioprine, mycophenolate
Conflict of interest mofetil and mycophenolic acid, cyclosporine, intravenous immunoglobulin (IVIG), and other biologic
None agents. This subset of potentially vulnerable patients require specialized care and advice.

Source of funding With the introduction of COVID-19 vaccines worldwide due to the ongoing pandemic, we still do
None not have enough evidence to definitively guide us in the recommendation, administration, and manage-
ment of complications arising from vaccine rollouts for dermatologic patients. As of this writing, the
Philippine Food and Drug Administration (FDA) has issued emergency use authorization (EUA) for five
vaccines, namely Pfizer-BioNTech COVID-19 Vaccine (BNT162b2), AstraZeneca/Oxford ChAdOx1-S[re-
combinant], Sinovac Biotech CoronaVac, Sputnik V Gam-COVID-Vac COVID-19 Vaccine and Moderna.3

In this position paper, we aim to provide guidance for dermatologists and other healthcare work-
ers involved in the care of these patients based on the best available data we have at the time. Should we
have more relevant data in the coming months, we will update this statement.

II. IMMUNOSUPPRESSIVE AGENTS, IMMUNOMODULATORS & DERMATOLOGIC
CONDITIONS REQUIRING THESE AGENTS

Immunosuppressants used in dermatology are categorized according to the risk for COVID-19,
depending on the immunity of the individual.

Dermatologic conditions that require immunosuppressives include atopic dermatitis, psoriasis,

57 J Phil Dermatol Soc · May 2021 · ISSN 2094-201X

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Dermatological Society

autoimmune blistering diseases, and connective tissue diseases. These patients have a higher risk of developing
infections due to their underlying immunologic condition, the immunosuppressive drugs that they are on, and the
comorbidities that they may have.

Table 1. Risk stratification for COVID-19 with commonly used immunomodulators in dermatology.4

Low risk Sulfasalazine, Apremilast, Hydroxychloroquine

Intermediate risk Methotrexate, Azathioprine

High risk Cyclophosphamide, Cyclosporine, Leflunomide, Mycophenolate Mofetil, Prednisolone, Biologics

III. SARS-CoV-2 VACCINES

There are different types of vaccines according to its components and how it stimulates the immune response. These
include live attenuated vaccines, inactivated vaccines, subunit vaccines, and nucleic acid vaccines.5

1. Live attenuated
a. Uses weakened (or attenuated) virus or bacteria.
b. Due to the similarity to a natural infection that they help prevent, they create a strong and long-lasting
immune response. After the first or second dose of most live vaccines, it can give a lifetime of protection.
c. Examples: MMR combined vaccine, rotavirus, smallpox & chickenpox vaccines

2. Inactivated
a. Uses the killed version of the microbe that causes a disease.
b. These do not provide immunity that is as strong as live vaccines. One may need several doses over a pe-
riod of time (booster shots) in order to get ongoing immunity against diseases.
c. Examples: Flu shot, hepatitis, polio & rabies vaccines

3. Subunit
a. Subunit, recombinant, polysaccharide, and conjugate vaccines use specific pieces of the microbe, such
as its protein, sugar, or capsid.
b. Because these vaccines use only specific pieces of the microbe, they give a very strong immune response
that is targeted to key parts of the microbe.
c. Examples: HPV, hepatitis B, shingles, pneumococcal & meningococcal vaccines

4. Nucleic acid
a. Makes proteins in order to trigger an immune response.
b. Benefits include shorter manufacturing times and, because they do not contain a live virus, no risk of
causing disease in the person getting vaccinated.
c. Example: COVID-19 vaccines

IV. POSITION OF THE GROUP REGARDING VACCINATION WHILE ON AN
IMMUNOMODULATING OR IMMUNOSUPPRESSIVE THERAPY (INCLUDING BIOLOGICS)

A. On the type of vaccine to be administered
Live attenuated vaccines should not be given concomitantly with immunosuppressive and biologic therapy.
The administration of non-live vaccines may be done to such patients.
According to the National Psoriasis Foundation COVID-19 Task Force, systemic medications (and
biologics) for psoriasis and psoriatic arthritis are not contraindicated with the mRNA-based COVID-19

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POSITION PAPER JPDS
Journal of the Philippine
Dermatological Society

Table 2. SARS-CoV-2 vaccines available or currently in development as of this writing.6

Manufacturer Type Dosage Storage Efficacy against Overall efficacy Philippine
severe COVID-19 approval
Pfizer-BioNTech mRNA 2 doses -80 to -60 °C 52%
(US) (6 months) 88.9% after 1st dose EUA
after 1st dose

94.6%
after 2nd dose

AstraZeneca/Oxford Viral vector 2 doses 2-8 °C 100% 64.1% EUA
(UK) (genetically (6 months) 21 days after after 1st dose EUA
modified virus) 1st dose
Sinovac 2-8 °C 70.14%
(China)** (Lifespan: after 2nd dose
unknown)
Inactivated virus 2 doses Brazil:
50.38% (mild) and 78% (mild to severe)

Indonesia: 65%

Turkey: 91.25% (Dec 2020)

Moderna mRNA 2 doses -25 to -15 °C 100% 92.1% EUA
(US) (7months) after 2nd dose after 1st dose

Novavax, Inc. Protein subunit 2 doses 2-8 °C -- 94.1% --
(US) (6 months) after 2nd dose

89.3%
after 2 doses (UK)

Johnson & Johnson Viral vector 1 dose 2-8 °C (3 months) 85% 60% --
(US) after 28 days (South Africa)

57-72%
(at 28 days)

100%
after 49 days

Sinopharm 1/2 Inactivated virus 2 doses 2-8 °C -- 79-86% --
(China) (Lifespan: (unpublished) EUA
unknown)
--
Gamaleya National Research Center Viral vector 2 doses -18 °C 100% 87.6%
for Epidemiology and Microbiology (Liquid form) after 1st dose after 1st dose
(Russia)
2-8 °C 91.1%
(freeze dried) for after 2nd dose
up to 6 months

CureVac / mRNA 2 doses 2-8 °C Unknown (Phase 3 Trial ongoing)
GlaxoSmithKline (3 months)
(Germany)

EUA: Emergency Use Authorization by the Philippine FDA.
**18-59 years old healthy population, and not recommended for healthcare workers with direct exposure to COVID-19 patients.

vaccines. The Task Force also recommends that those who receive the mRNA-based COVID-19 vaccines
continue their biologic and oral therapies for psoriasis and psoriatic arthritis as scheduled.7

The vaccines approved by the Philippine FDA do not contain live or replicating subunits of SARS-CoV-2,
and may therefore be used. However, as there are currently scarce data on the safety of these vaccines
in special populations, patients must be properly counseled regarding the unknown safety profile in
immunocompromised groups, as well as the potential for reduced immune responses.

B. Effect of immunomodulators/immunosuppressants on the efficacy of vaccines
The effect of these therapies on the efficacy of COVID-19 vaccines is unknown. The following show the effect

59 J Phil Dermatol Soc · May 2021 · ISSN 2094-201X

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Journal of the Philippine
Dermatological Society

of these systemic therapies on different vaccines currently present in the market:
• Methotrexate lowers the humoral response to seasonal flu and pneumococcal vaccines, thus temporary

discontinuation for 2 weeks after immunization to improve immunogenicity is advised.8,9
• TNF-inhibitors and tofacitinib do not significantly affect the humoral response to flu vaccine, but reduce

immune response to pneumococcal vaccine.10-12
• Ustekinumab13, secukinumab14,15 & ixekizumab16 do not interfere with the immune response to both

influenza or pneumococcal vaccines.
• No data for cyclosporine, anti-IL-23 biologics, aprelimast, or acitretin on the efficacy of any approved

vaccine.7
The immunogenicity of non-live vaccines appear to be preserved during the use of biologic agents,
whereas methotrexate may significantly impair humoral response to vaccines.
In high-risk situations wherein the potential risk of infection is considered to outweigh the risk related
to the administration of live vaccines, vaccination could be considered according to an infectious disease
specialist.17

C. On the timing of vaccination
Non-live vaccines are preferred to be given when the patient’s dermatologic condition is stable, and may
be given concomitantly with immunomodulatory or immunosuppressive therapies. If feasible, it is
recommended to vaccinate before planned immunosuppression. Vaccines are most effective when the level
of immunosuppression is low.
As recommended by the American College of Rheumatology (ACR), the timing considerations for
immunomodulatory therapy and COVID-19 vaccination are as follows.

Table 3. ACR recommendations for timing of vaccination and immunotherapy.18

Medication Timing Level of task force
consensus
Hydroxychloroquine; IVIG; Prednisone <20mg/day No modification to either immunomodulatory therapy or vaccination Strong-moderate
Moderate
Mycophenolate; Azathioprine; Cyclophosphamide (oral); TNFi; No modification to either immunomodulatory therapy or vaccination
IL-17i; IL-12/23i; IL-23i; Prednisone > 20mg/day Moderate

Methotrexate Hold MTX 1 week after each vaccine dose, for those with well-con- Moderate
trolled disease; no modifications to vaccine timing
Moderate
Cyclophosphamide IV Time administration so that it will occur approximately 1 week after
each vaccine dose, when feasible

Rituximab Assuming that patient's COVID-19 risk is low or is able to be mitigated
by preventive health measures (e.g., self-isolation), schedule vaccina-
tion so that the vaccine series is initiated approximately 4 weeks prior
to next scheduled rituximab cycle; after vaccination, delay RTX 2-4
weeks after 2nd vaccine dose, if disease activity allows

TNFi: Tumor necrosis factor inhibitors; MTX: Methotrexate; RTX: Rituximab

The European Task Force on Atopic Dermatitis suggested that clinicians may consider pausing the
immunosuppressant during vaccination to possibly improve chances or appropriate vaccination response.23
• 1 week after for cyclosporine
• 2 weeks after for methotrexate and azathioprine

Alternatively, the lowest dose possible may be used:23
• 2.5 mg/kg/day cyclosporine
• 1 mg/kg/day azathioprine
• 7.5 mg/week methotrexate

Measurement of antibodies against SARS-CoV-2 may be requested to assess successful immunization.23

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D. On the risk of allergy
There is no evidence that autoimmune conditions are at any greater risk of vaccine allergy than the general
population. The Center for Disease Control and Prevention (CDC) recommendations state that COVID-19
vaccination is not contraindicated for patients who are receiving immunomodulatory and immunosuppressive
agents for as long as they do not have any history of severe allergic reactions to any of the components of
the COVID-19 vaccine, such as Polyethylene Glycol (PEG) and polysorbate. These patients should first be
evaluated by an allergologist to determine the safety of the vaccine.19-22

E. Post-vaccination monitoring
The Philippine Society of Allergy, Asthma, and Immunology (PSAAI) recommends observing patients who
have been vaccinated for at least 30 minutes after the procedure.21 There is limited data regarding how safe
and effective the vaccines are in preventing transmission among patients with autoimmune conditions. It is
still advised that all safety preventive measures be followed post-vaccination.

V. CONCLUSION

It is therefore recommended that all patients on an immunomodulatory or immunosuppressive agent for any
dermatologic condition be vaccinated by any of the Philippine FDA-authorized for emergency use COVID-19 vaccines
to prevent infection. Patients must be evaluated on an individualized approach, with the benefits and risks clearly
stated and understood. It is also imperative that vaccinated patients are reminded that vaccination cannot and must
not replace transmission prevention measures in all patients and their immediate contacts. Proper mask wearing,
frequent disinfection, and physical distancing must still be practiced at all times.

REFERENCES

1. Coronavirus disease (COVID-19) Pandemic: Numbers at a glance. https://www.who.int/emergencies/diseases/novel-coronavirus-2019.
Retrieved 19 April 2021.

2. Ejaz H, Alsrhani A, Zafar A, Javed H, Junaid K. COVID-19 and comorbidities: Deleterious impact on infected patients. J Infect Public Heal journa.
2020;13(January):1833-1839. doi: 10.1016/j.jiph.2020.07.014.

3. List of FDA-issued EUA. https://www.fda.gov.ph/list-of-fda-issued-emergency-use-authorization/. Retrieved 19 April 2021.
4. Schwartz RA, et al. COVID-19 and immunosuppressive therapy in dermatology. Dermatologic Therapy. July 2020;e14140. doi: 10.1111/dth.14140
5. Vaccine Types. https://www.vaccines.gov/basics/types. Retrieved 3 March 2021.
6. Creech CB, Walker SC, Samuels RJ. SARS-CoV-2 Vaccines. JAMA. Published online February 26, 2021. doi:10.1001/jama.2021.3199.
7. Gelfand J, et al. National Psoriasis Foundation COVID-19 Task Force guidance for management of psoriatic disease during the pandemic:

Version 2: Advances in psoriatic disease management, COVID-19 vaccines, and COVID-19 treatments. J Am Acad Dermatol. Published online
February 27, 2021. doi:10.1016/j.jaad.2020.12.058.
8. Park JK, Lee YJ, Shin K, et al. Impact of temporary methotrexate discontinuation for 2 weeks on immunogenicity of seasonal influenza vaccination
in patients with rheumatoid arthritis: a randomised clinical trial. Ann Rheum Dis. 2018;77:898-904. DOI: 10.1136/annrheumdis-2018-213222.
9. Subesinghe S, Bechman K, Rutherford AI, Goldblatt D, Galloway JB. A systematic review and meta-analysis of anti-rheumatic drugs and
vaccine immunogenicity in rheumatoid arthritis. J Rheumatol. 2018;45:733-744. DOI: 10.3899/jrheum.170710.
10. Fiorino G, Peyrin-Biroulet L, Naccarato P, et al. Effects of immunosuppression on immune response to pneumococcal vaccine in inflammatory
bowel disease: a prospective study. Inflamm Bowel Dis. 2012;18:1042-1047. DOI: 10.1002/ibd.21800.
11. Kaine JL, Kivitz AJ, Birbara C, Luo AY. Immune responses following administration of influenza and pneumococcal vaccines to patients with
rheumatoid arthritis receiving adalimumab. J Rheumatol. 2007;34:272-279. PMID: 17304653.
12. Winthrop KL, Silverfield J, Racewicz A, et al. The effect of tofacitinib on pneumococcal and influenza vaccine responses in rheumatoid
arthritis. Ann Rheum Dis. 2016;75:687-695. DOI: 10.1136/annrheumdis-2014-207191.
13. Doornekamp L, Goetgebuer RL, Schmitz KS, et al. High immunogenicity to influenza vaccination in Crohn’s disease patients treated with
ustekinumab. Vaccines (Basel). 2020;8:455. DOI: 10.3390/vaccines8030455.
14. Furer V, Zisman D, Kaufman I, et al. Immunogenicity and safety of vaccination against seasonal influenza vaccine in patients with psoriatic
arthritis treated with secukinumab. Vaccine. 2020;38:847-851. DOI: 10.1016/j.vaccine.2019.10.081.
15. Richi P, Martın MD, de Ory F, et al. Secukinumab does not impair the immunogenic response to the influenza vaccine in patients. RMD Open.
2019;5:e001018. DOI: 10.1136/rmdopen-2019-001018.
16. Gomez EV, Bishop JL, Jackson K, Muram TM, Phillips D. Response to tetanus and pneumococcal vaccination following administration of
ixekizumab in healthy participants. BioDrugs. 2017;31:545-554.

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17. Chiricozzi, A., Gisondi, P., Bellinato, F., and Girolomoni, G. Immune Response to Vaccination in Patients with Psoriasis Treated with Systemic
Therapies. Vaccines 2020, 8, 769. doi: 10.3390/vaccines8040769.

18. ACR COVID-19 Task Force. COVID-19 Vaccine Clinical Guidance Summary for Patients with Rheumatic and Musculoskeletal Diseases. https://
www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/1138. Retrieved 5 March 2021.

19. European Academy of Dermatology and Venereology COVID-19 Task Force. Guidance for Autoimmune Blistering Diseases during the COVID-19
pandemic. Updated 14 Jan 2021. https://eadv.org/covid-19/task-force. Retrieved 2 March 2021.

20. American Academy of Dermatology COVID-19 Vaccine administration guidance. https://www.aad.org/member/practice/coronavirus/
vaccines. Retrieved 2 March 2021.

21. de Leon JC, et al. PSAAI Guidelines on the Prevention, Diagnosis and Management of Immediate Severe Allergic Reactions to COVID-19
Vaccines. Published 9 February 2021. Retrieved 3 March 2021.

22. Allergy, Immunodeficiency, Autoimmunity and COVID-19 Vaccination Position Statement given by the ASCIA 2 March 2021. Retrieved 2 March
2021.

23. Thyssen JP, et al. European Task Force on Atopic Dermatitis (ETFAD): position on vaccination of adult patients with atopic dermatitis against
COVID-19 (SARS-CoV-2) being treated with systemic medication and biologics. http://eprints.whiterose.ac.uk/171529/.

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COVID-19 vaccination and patients with a history of
facial soft tissue fillers and botulinum toxin injection

A Position Paper of the Philippine Dermatological Society (PDS)
Dermatologic Surgery Subspecialty Core Group in cooperation with

the Philippine Dermatological Society

Krisinda Clare C. Dim-Jamora, MD,1,2,3 Zharlah Gulmatico-Flores, MD,4 Stephen Lacson, MD,1
Ma.Cricelda Rescober-Valencia, MD,4 Francesca Sy-Alvarado, MD,5 Irene Gaile Robredo-Vitas, MD,6

Maria Cecilia Ingente-Tablante, MD,7 Teresita Ferrariz, MD,8 Agnes Thaebtharm, MD4

INTENT

• To provide information for physicians and patients on the safe use of COVID-19 vaccination on patients with facial soft
tissue fillers and botulinum toxin injection based on currently available data.

1Department of Dermatology, Facial aesthetic injectables using soft tissue fillers and neurotoxins have been used for decades as part
Makati Medical Center, Makati of the armamentarium to enhance, restore, and attenuate aging skin.
City, Philippines
2Dermatology Service, The Summary of guidelines addressing COVID-19 Vaccine side effects related to facial soft tissue fillers
Medical City, Pasig City, and botulinum toxin injection:
Philippines
3Skin and Cancer Foundation, • The American Society for Dermatologic Surgery (ASDS) states that patients injected with soft
Inc., Pasig City, Philippines tissue fillers should be encouraged to receive vaccines regardless of their kind. The ASDS
4Department of Dermatology, says that this also applies to those who have received vaccines, and the patients should not be
Jose R. Reyes Memorial Medical discouraged from having injectable soft tissue fillers. The rare cases of adverse events were
Center, Manila, Philippines either self-limited or resolved with oral corticosteroids and injectable hyaluronidase.1
5Skin Solutions Dermatology
& Laser Center, Bacolod City, • The International Society for Dermatologic Surgery (ISDS) states that based on a global
Philippines survey, a majority (94.9%) did not experience any adverse reaction on the soft tissue filler site
6DermHQ, Makati City, after the COVID-19 vaccination.2
Philippines
7Davao Doctor’s Hospital, Davao • The American Society of Plastic Surgery (ASPS) states that patients with a history of soft
City, Philippines tissue fillers should not be discouraged from receiving the COVID-19 vaccination. Case
8Gwapaha Medical Spa, General reports of those who had facial swelling were self-limited and resolved thru the intake of oral
Santos City, Philippines corticosteroids and antihistamines.3

Corresponding author • The American College of Allergy, Asthma, and Immunology (ACAAI) states that swelling at/
Krisinda Clare C. Dim-Jamora, or near the soft tissue filler injection site after COVID-19 vaccination is temporary and self-
MD, FPDS resolving through oral corticosteroid use. The ACAAI finds no contraindication to COVID-19
vaccination for those patients who have received soft tissue fillers, and who may receive these
Conflict of interest fillers in the future.4
None
• The Aesthetic Society, whose members are certified by the American Board of Plastic Surgery
Source of funding (USA) or by the Royal College of Physicians and Surgeons of Canada, reports that patients
None with a history of soft tissue fillers should proceed with their COVID-19 vaccination.5

• Physicians should educate their patients regarding the possibility of delayed hypersensitivity
reaction to soft tissue fillers following any influenza-like illness.6

• A PubMed search with the search terms “COVID-19 vaccine and botulinum toxin/
onabotulinum toxin/incobotulinum toxin/abobotulinum toxin” did not show any available

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literature on the effects of COVID-19 vaccination on patients with botulinum toxin injection.

Position of The Philippine Dermatological Society Dermatologic Surgery Subspecialty Core Group:
a. Based on current information, patients with a history of soft tissue fillers and botulinum toxin injections

may safely proceed with COVID-19 vaccination once available.
b. Based on current information, patients with a history of COVID-19 vaccination may have soft tissue filler and

botulinum toxin injection.
c. Soft tissue fillers and neurotoxin injections should be administered by Board-Certified PDS Dermatologists

knowledgeable and experienced in safe injection practices and can manage any associated complications
arising from their use.

The Philippine Dermatological Society Dermatologic Surgery Subspecialty Core Group monitors and evalu-
ates data and scientific literature regarding this issue. We continue to update our Philippine Dermatological Society
members when new data is available.

REFERENCES

1. Avram M, Bertucci V, Cox SE, Jones D, Mariwalla K. American Society for Dermatologic Surgery Guidance Regarding SARS-CoV-2 mRNA Vaccine
Side Effects in Dermal Filler Patients December 29, 2020. Accessed January 19, 2021. https://www. asds.net/Portals/0/PDF/secure/ASDS-SARS-
CoV-2-Vaccine-Guidance.pdf.

2. Gotkin R; Gout U; Sattler S; Piansay-Soriano ES, Wanitphakdeedechka R, et al. Global Recommendations on COVID-19 Vaccines and Soft Tissue
Filler Reactions: A Survey-Based Investigation in Cooperation With the International Society for Dermatologic and Aesthetic Surgery (ISDS).
Journal of Drugs in Dermatology. 2021; Vol 20 Issue 4: 217-221. doi:10.36849/JDD.2021.6041.

3. ASPS Guidance Concerning FDA Reported Adverse Events in Patients with Dermal Fillers Receiving the SARS-CoV-2 mRNA Vaccine. https://
www.plasticsurgery.org/for-medical-professionals/covid19-member-resources/covid19-vaccine-dermal-fillers.

4. Guidance now includes information on the adenovirus vector Johnson & Johnson vaccine11-Mar-2021 10:30 AM EST, American College of
Allergy, Asthma and Immunology (ACAAI). https://www.newswise.com/coronavirus/acaai-updates-guidance-on-risk-of-allergic-reactions-
to-covid-19-vaccines/?article_id=747642.

5. The Aesthetics Society: Facial Fillers and COVID-19 Vaccine. https://www.surgery.org/professionals/covid-19/facial-fillers-and-covid-19-
vaccine.

6. Mohammed G Turkmani, Koenraad De Boulle, Wolfgang G Philipp-Dormston. Delayed hypersensitivity reaction to hyaluronic acid dermal filler
following influenza-like illness Clin Cosmet Investig Dermatol. 2019; 12: 277–283. doi: 10.2147/CCID.S198081.

J Phil Dermatol Soc · May 2021 · ISSN 2094-201X 64

The JPDS aims to provide recent advances in the diagnosis,
management and treatment of skin diseases and share research output

from the 12 dermatology-training institutions.

Conceptualized and launched in September 1992, the journal was
envisioned as the society members’ venue to publish and showcase

scientific works related to dermatology and research.

The journal is an open access, peer-reviewed bi-annual
publication, and is currently indexed in the Western Pacific Rim Index

Medicus (WPRIM) and HERDIN.

For more information, please visit https://journal.pds.org.ph/.




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