JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society
and examiner-assigned SPT. Majority of the pure Filipino partici- initial dosage of NB-UVB for their patients.
pants had an MED range of 600-800mJ/cm2; while those with East
Asian ancestry had a range of 400-800mJ/cm2. This suggests that CONCLUSION
determining the patient’s ancestry and their SPT during their ini-
tial visit can also be a good basis on determining the patient's initial Majority of the participants have a median MED value of 800 mJ/
NBUVB dosage, as it has always been done using the latter variable. cm2. Based on this MED value, the initial dosage of NBUVB at
50-70% of the MED would translate to an initial dose of 400-560
The participants who joined the study also had only very mJ/cm2. As there is no current definite guideline for the start-
minimal reports of pruritus, pain and burning sensation to the ing dose of NBUVB for Filipino skin, we can consider a higher
MED testing suggesting that in an ideal setting, determining the starting dose for Filipino patients compared to the conservative
patient’s MED should always be considered. approach most clinicians use. This can lead to a faster onset
of efficacy, improvement, and eventually decreased number of
The limitation of this study is that it was conducted in a selected treatment sessions that translates to less expense, improved
population in a tertiary hospital, which makes the results not rep- quality of life, and patient satisfaction. Having said this, the
resentative of the entire Filipino population. Also, given the range authors of the study recommend future studies to determine
of MED values on pure Filipinos, a standardized initial dose cannot if a higher initial NBUVB dosage can lead to faster clearance
be obtained. But considering the lack of study on MED values using of skin lesions in Filipino patients with photo-responsive der-
NBUVB on Filipino skin, the results are still worthy of recognition matoses.
in its attempt to serve as a guide for clinicians in determining the
REFERENCES
1. Cafardi J, Pollack B, Elmets C. Phototherapy. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K. Fitzpatrick’s Dermatology in
General Medicine. 8th ed. New York, NY: McGraw-Hill Companies Inc; 2012: p. 2841-2850.
2. Heckman CJ, Chandler R, Kloss JD, Benson A, Rooney D, Munshi T, et al. Minimal erythema dose (MED) testing. J Vis Exp 2013; 75: 50175. DOI:
10.3791/50175
3. Verallo-Rowell VM., Meneses M., Nunez J., Laureta R. Phototyping and multi-heritage skin of Asian-Filipinos in the Philippines. Skin in the
Tropics: Sunscreens and Hyperpigmentations. Anvil Publishing Inc. 2001 pp.143-155
4. Reddy K, Lenzy M, Brown K, Gilchrest B. Racial considerations: Skin of color. In: Goldsmith LA, Katz SI, Gilchrest BA, Paller AS, Leffell DJ, Wolff K.
Fitzpatrick’s Dermatology in General Medicine. 8th ed. New York, NY: McGraw-Hill Companies Inc; 2012: p. 91-103.
5. Pai GS. MED estimation for narrow band UV-B on type IV and type V skin in India. Indian J Dermatol Venereol Leprol 2001;67: 251-2. PMID: 17664763.
6. HOUVA4® User Manual, National Biologics Corporation, Ohio. 2012.
7. Fitzpatrick TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol 1988; 124: 869-71. DOI: 10.1001/archderm.124.6.869.
8. Zanolli M, Feldman SR. Phototherapy Treatment Protocols. 3rd ed. Boca Raton, FL: Taylor & Francis; 2016.
9. Elmets CA, Lim HW, Stoff B, Connor C, Cordoro KM, Lebwohl M, et al. Joint American Academy of Dermatology-National Psoriasis Foundation
guidelines of care for the management and treatment of psoriasis with phototherapy. J Am Acad Dermatol. 2019 Sep;81(3):775-804. doi:
10.1016/j.jaad.2019.04.042. Epub 2019 Jul 25. Erratum in: J Am Acad Dermatol. 2020 Mar;82(3):780. PMID: 31351884.
10. Lee H, Chu H, Oh SH. Investigation of suitable starting doses of narrowband UVB in Asian vitiligo patients: a pilot study. J Eur Acad Dermatol
Venereol. 2017 May;31(5):894-897. doi: 10.1111/jdv.13933. Epub 2016 Sep 12. PMID: 27549434.
J Phil Dermatol Soc · November 2021 · ISSN 2094-201X 46
JPDS ORIGINAL ARTICLE
Journal of the Philippine
Dermatological Society
Translation and validation of a scale on the health
care providers’ Attitudes Towards Persons Living With
Leprosy (AT-PLWL)
Maicka Keirsten O. Agon, MD,1 Abelaine Venida-Tablizo, MD, FPDS1
ABSTRACT
INTRODUCTION Leprosy is a chronic, progressive, and complex disease. One of the factors contributing to the quality of case
detection and treatment compliance is the attitudes of health care providers towards leprosy patients. Assessment of the
attitudes of HCP towards leprosy patients is crucial because this is where leprosy patients base their care-seeking behaviors;
hence, the creation of this scale.
OBJECTIVES To create and validate a functionally equivalent Filipino translation of the HCP AT-PLWL scale.
METHODS A validity study was conducted into two phases. In Phase I, the AT-PLWL scale was translated (forward-back method)
into Filipino, which underwent a cognitive debriefing (face validity) and pre-testing to 30 health care providers. In Phase 2, the
reconciled forward translation underwent face and content validity and was pilot-tested to 100 health care providers. Reliability,
both internal consistency and test-retest, were assessed via calculating Cronbach’s α and intra-class correlation coefficient,
respectively.
RESULTS Content and face validity showed that all items in the scale were relevant. Cronbach’s α showed an adequate internal
consistency of greater than 0.7 while the intra-class correlation coefficient of responses was greater than 0.80, indicating good
correlation.
CONCLUSION Overall, the final translated Filipino version of AT-PLWL scale is valid and reliable; hence, could serve as a tool to
evaluate HCP’s attitudes.
KEYWORDS Leprosy scale, health care providers, attitude scale
1Department of Dermatology, INTRODUCTION attitude, along with knowledge and practices,
Rizal Medical Center, Pasig are necessary to know among HCPs with regard
Boulevard, Pasig City Leprosy (also known as Hansen’s disease) is a to leprosy so that required knowledge and skills
Corresponding author chronic, progressive, and debilitating disease can be imparted.5
Maicka Keirsten O. Agon, MD caused by Mycobacterium leprae. The disease
Conflict of interest mainly affects the skin, the peripheral nerves, Health care providers play an important
None eyes, and the mucosa of the upper respiratory role in the management of cases because they di-
Source of funding tract.1,2 Although there had been an advent of rectly handle and counsel leprosy patients. Aside
None multidrug therapy (MDT) during the 1980s, with from their job, their role is very crucial as the
the World Health Organization (WHO) providing quality of case detection and treatment compli-
47 free MDT globally, still leprosy continues to be a ance relies on their kind of attitude towards lep-
significant problem and stigma is still rampant.2-4 rosy. A positive health environment is beneficial
for patients because this is where they base their
In the literature, few studies were found as- health-seeking behaviors and compliance. This
sessing the knowledge, attitude, and practices of is where assessment of HCPs’ attitudes comes in.
health care providers (HCPs) towards persons af-
fected by leprosy.5-11 Based on the reviews done by The first half of the methodology of the orig-
Srinivas, et al. (2018), majority of the scales were inal tool/instrument by Srinivas et al. (2018) is
more representative of knowledge and practice via a scale development process which consists
rather than attitude; hence, this gave rise for a of qualitative semi-structured interviews and
need to create a scale on HCP attitudes.12 More- focus group discussion for item generation pur-
over, Ahmad et al. (2010) stated that the levels of poses and scaling exercise.12 The second part of
J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society
the methodology is face and content validity of the tool. Con- Cognitive debriefing and pre-testing
tent validity of the scale was done and assessed by experts in the The pre-final forward translation was pre-tested for face valid-
field of leprosy by reviewing whether the items were relevant ity on 30 bilingual HCPs using purposive or convenience sam-
and representative of the theoretical domains of affect, behav- pling. This is based on power of 80% and prevalence of power of
ior, and cognitive components of attitude. Eleven items were 5% using the formula below.18
discarded from the initial pool of 38 items due to poor agree-
ment among experts regarding its relevance.12 Moreover, con- *n = sample size, p = prevalence of problem
tent validity was enhanced through a process of triangulation,
of which included reviews of existing scales measuring HCP at- A sample size of 30 would achieve an equitably high power
titudes towards various disabilities and qualitative interviews around 80% to detect a problem that occurs in 5% of the popula-
with different categories of HCPs.12 tion, and to detect a repeat occurrence of a problem that affects
10% of the respondents. This suggests that 30 participants are a
This study focuses on assessing the attitudes of HCPs to- reasonable default sample size or starting point for pre-tests of
wards patients affected with leprosy as a contribution in the questionnaires. In the pilot testing, 100 qualified subjects will
public health program or patient care by providing insights re- be used for the final version of the translated questionnaire.15
garding their attitudes and consequently serving as a guide in This is based on guidelines for the respondent-to-item ratio
planning appropriate programs and interventions in promoting equal to 5:1.15,19
positive attitudes of HCPs as well as promoting inclusion of per-
sons with leprosy.13 The consent, together with the explanation of the study,
and both English and Filipino versions of the questionnaire
The objectives of this study is to create a functionally were distributed to the participants either in person or via
equivalent Filipino translation of the HCP AT-PLWL scale, and online forms. Individual assessment and feedback were docu-
to validate the Filipino version of the HCP AT-PLWL scale. mented.15
METHODS Results were discussed and edited by the investigators and
4 back and forward translators via online meeting. A modified
This validity study was conducted into two phases: 1) transla- forward translation (Filipino version) of the HCP AT-PLWL scale
tion, and 2) validation and reliability tests of the Filipino version was produced for validation (phase 2).15
of the scale.
PHASE 2
PHASE I Validation of scale
Preparation A panel of experts on leprosy (composed of 3 experts) were invit-
The process flow of the methods used in the study is shown in ed and gathered via online meeting to review and assess the face
Appendix 3. Permission was obtained via electronic mail from and content validity of the translated scale.
the original developers/ authors to translate and validate the
HCP AT-PLWL scale into the Filipino language. Face validity was evaluated by the experts and their com-
ments and suggestions were documented. Content validity was
Translation measured and analyzed using the item-level content validity in-
The original English version of the HCP AT-PLWL scale was dex score (i-CVI). Each expert rated each of the items in terms
translated into a Filipino version using the forward-backward of its relevance to the underlying construct.20 A 4-point rating
method.14,15 The scale was translated into Filipino by two in- scale was used: 1- not relevant, 2- somewhat relevant, 3- quite
dependent translators (forward translation), who are native relevant, and 4- highly relevant.20,21 This would depend on the
speakers and experts in the Filipino language, with experience number of judges/experts assessing the items. The i-CVI should
in translation and cultural adaptation measures, at the same be 1.00 if there are five or fewer judges. On the other hand, if
time proficient in both English and Filipino. The two forward there are six or more judges, i-CVIs should not be lower than
translators and the investigators discussed and reconciled on a 0.78.20,21 If the item value falls below the set scores, then the item
single forward translation via an online meeting.15,16 will be subjected to discussion. According to Lynn (1986), five
or fewer experts should agree on the content validity for their
For the back translation, another two independent trans- rating to be considered a reasonable representation of the uni-
lators, with the same qualifications but not involved in the for- verse of possible ratings. After the discussion and consensus on
ward translation process, translated the synthesized forward
translation back into English. A review of back translation was
done by the investigators and problems and discrepancies were
discussed with the back translators and the Filipino translation
was further refined and used in the next step.15,17
J Phil Dermatol Soc · November 2021 · ISSN 2094-201X 48
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ARTICLE Journal of the Philippine
Dermatological Society
the final scale to be used, revisions were made according to the Table 1. Socio-demographic characteristics of the HCPs. Results
suggestions and consensus of the experts.20,21 Characteristics 41.3 ± 13.1
34 (34.0)
Sampling, pilot testing, and data gathering Age, years 22 (22.0)
The modified and translated HCP AT-PLWL scale was administered 21 to 30 14 (14.0)
to a minimum of 100 HCP participants in centers/institutions with- 31 to 40 17 (17.0)
in Metro Manila via purposive or convenience sampling. A re-test 41 to 50 13 (13.0)
was done with an interval of about 1 week to assess scale reliability. 51 to 60
The study, along with the consent forms, was conducted online or 61 to 70 89 (89.0)
in person due to feasibility and time constraint. 11 (11.0)
Gender
DATA MANAGEMENT AND ANALYSIS Female 47 (47.0)
Data was tabulated and encoded in Microsoft Excel and Word. Male 34 (34.0)
Internal consistency reliability was calculated using the Cron- 19 (19.0)
bach α coefficient. Cronbach’s α of 0 indicates no internal con- Type of health care provider
sistency while 1 reflects perfect internal consistency. A Cron- Barangay health worker 18 (18.0)
bach’s α value greater than 0.6-0.7 is indicative of good internal Physician 11 (11.0)
consistency. In practice, Cronbach’s α of at least 0.70 has been Nurse 9 (9.0)
suggested to indicate adequate internal consistency. 8 (8.0)
Institution 10 (10.0)
The test re-test reliability was measured via calculating the RMC 8 (8.0)
intra-class correlation coefficient (ICC) of the responses that were EAMC 8 (8.0)
obtained at two different time points. Values at 0.60 are considered RITM 7 (7.0)
marginal, 0.70 is acceptable, and above 0.80 has a good correlation. Other hospitals or research institutes 7 (7.0)
Health center - West Rembo 6 (6.0)
ETHICAL CONSIDERATIONS Health center - Ugong 5 (5.0)
Permission was granted from the original developers/authors Health center - East Rembo 3 (3.0)
to translate the HCP AT-PLWL scale into Filipino. The study Health center - Pineda
was carried out after securing ethical clearance from the Rizal Health center - Cembo
Medical Center IRB. Written/Online informed consent was ob- Health center - Barangay Kapitolyo
tained, and all information gathered was kept confidential. All Health center - Caniogan
files will be destroyed and deleted after 5 years. Health center - South Cembo
RESULTS Results: mean ± standard deviation or frequency (%)
A total of 120 HCPs were invited to join the phase 2 of the study; scale. Face validity was assessed by HCPs and experts during
however, only 100 respondents completed the consent forms the pre-testing and validation phase, respectively (Table 2).
and took the re-test. The 20 HCPs were dropped from the study
because they failed to answer the re-test. For all the items, the experts all agreed to change the term
“ketong” to “leprosy” since this is a more appropriate universal
The average age of respondents was 41.3 years old rang- term. The term “ketong” can be a term related to stigma. For
ing from 21 to 70 years old with most participants from 21 to item number 2, both HCP and experts opted to change the literal
40 years old (56%). The participants were 89% females and 11% translation of “maruming trabaho” to “nakakatakot o nakakadi-
males. The HCPs were 47% barangay health workers, 34% physi- ring trabaho”, which is what we wanted the readers to under-
cians, and 19% nurses. As for the institutions/centers, majority stand. For item number 3, there was a contest whether to change
who agreed to be part of the study were from Rizal Medical Cen- the term “magkakaroon” to “namamana” or “nahawa” but the
ter (18%) and health centers combined (54%), followed by East experts all agreed to still stick with “magkakaroon” because it
Avenue Medical Center (11%), Research Institute of Tropical is a wider term for both “nahawa” and “namana”. For item num-
Medicine (9%), and from other institutions (8%) – Jose N. Rodri- bers 5, 8, and 24, both HCP and experts agreed to change “ulser
guez Memorial Hospital and Sanitarium (DJNRMHS), Ospital ng sa balat” to “sugat sa balat” since lay people may not understand
Maynila Medical Center (OMMC), University of the East Ramon what an “ulser” is. For item number 6, the phrase “ospital ng
Magsaysay Memorial Medical Center (UERMMMCI), and Jose R. may leprosy” was changed to “ospital na gumagamot sa taong
Reyes Memorial Medical Center (JRRMMC) (Table 1). may leprosy” to be better understood by the readers. There was
also a conflict in which term to use – disability (“kapansanan”)
Three experts in the field of leprosy were invited to assess
the content and face validity of the translated HCP AT-PLWL
49 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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Table 2. Test on the face validity of the translated AT-PLWL scale from both experts and HCP participants.
Item # Major comments among experts Major comments among HCPs
No modifications required
1 Sa palagay ko ang leprosy ay isang sumpa at parusa. Change “ketong” to leprosy
I think leprosy is a curse and a punishment. Remove “sa palagay ko” Consider "sa mga pasyenteng…" versus "ng mga pasyenteng"
May not omit the phrase Instead of giving a literal translation of "maruming trabaho",
perhaps its better to translate it as how you want the reader to
2 Maruming trabaho ang pangangalaga sa mga pasyenteng Change “maruming” to “nakakatakot” understand (eg nakakapagod).
may ketong. Change “ketong” to leprosy
Nursing of leprosy patients is a dirty job. “Nakakadiri” or “nakakatakot” Namamana o dahil kasama siya sa bahay?
“Pinangdidirihan na trabaho ang pagalaga sa pasyenteng Nahawa o namana?
mayroong leprosy.” Translation in Tagalog could be well understood but direct
“Nakakatakot/nakakadiring trabaho ang pagalaga sa pasy- translation is not precise.
enteng merong leprosy” Rearrange statement to: "Ang mga anak ng pasyenteng may
ketong ay magkakaroon din ng ketong"
3 Magkakaroon din ng ketong ang mga anak ng pasyenteng Namamana Only if those who are afflicted with HD do not get the correct
may ketong. Change “ketong” to leprosy treatment, anyone in the household with prolonged contact
Children of leprosy patients invariably become lepers. Stick with “magkakaroon”, it is a wide term for nahawa at and low immune system can also have it.
namana No modifications required
4 Dapat mamuhay nang nakahiwalay sa iba ang mga taong Change “ketong” to leprosy Perhaps use: "mga sugat sa balat"
may ketong. Lay people may not understand what an "ulser" is. Better to
People with leprosy should live apart from other people. add a description, such as "ulser or sugat na may dugo o
nana na hindi gumagaling"
5 Nandidiri ako kapag nakakakita ng pasyenteng may leprosy Better to change “ulser” to “sugat sa balat” for all healthcare "Ospital ng may ketong" sounds like the hospital has leprosy
na may ulser sa balat. workers to understand. instead of a hospital catering to.
There is a sense of revulsion when seeing a leprosy patient Change “ketong” to leprosy "Karamihan sa mga nagtatrabaho sa ospital na gumagamot
with ulcers. sa taong may ketong ay kadalasang nahahawa sa sakit na
ito."
6 Karamihan sa mga nagtatrabaho sa ospital ng may ketong ay Change “ketong” to leprosy No modifications required
kadalasang nahahawa sa sakit na ito.
Most workers in leprosy hospitals usually contract the disease. Prefer "mga sugat sa balat"
7 Sa ospital, iniiwasan kong hawakan ang sinumang may Change “ketong” to leprosy No modifications required
ketong hangga’t maaari.
At the hospital, I prefer to avoid touching someone with No modifications required
leprosy if possible.
No modifications required
8 Dapat ihiwalay ang mga pasyenteng may ketong na may Better to change “ulser” to “sugat sa balat” for all healthcare
No modifications required
depormasyon sa katawan at ulser sa balat. workers to understand.
No modifications required
Leprosy patients with ulcers and deformities must be isolated. Disability - cannot function
Deformity – physical (agree in using depormasyon)
9 Mga depormasyon sa katawan ang hindi matatakasang Change “ketong” to leprosy
epekto ng ketong. Disability - cannot function
Deformities are an inescapable consequence of leprosy. Deformity – physical (agree in using depormasyon)
10 Nag-aalala akong mahawa mula sa mga pasyenteng may Change “ketong” to leprosy
ketong kapag ginagamot ko sila.
I am concerned with getting infection from patients with lepro-
sy when I treat them.
11 Ang pinakakaraniwang indikasyon ng ketong ay mga depor- Disability - cannot function
madong bahagi ng kamay at paa. Deformity – physical (agree in using depormasyon)
The commonest presentation of leprosy is deformed limbs. Change “ketong” to leprosy
12 Mas gusto kong sa isang hiwalay na klinika ginagawa ang Change “ketong” to leprosy
paglilinis at pagbebenda sa mga sugat ng ketong.
I prefer dressing for leprosy wounds are carried out in a
separate clinic.
13 Dapat ipaalam sa mga kawani at tagapangalagang pangkalu- Change “ketong” to leprosy
sugan kapag may magpapagamot na pasyenteng may ketong.
Staff and health care providers should be notified when a
patient with leprosy comes for treatment.
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14 Walang inaasahang propesyon kaugnay ng pangangalagang “Walang inaasahang paglago ng propesyon” "Walang ibang mapupuntahan sa propesyon ang mga nars na
pangkalusugan sa ospital ng may ketong. nagtratrabaho sa hospital na may ketong."
There are no career prospects as far as nursing practice in General precaution for hospital workers "Lalo akong mag-iingat (katulad ng pagsusuot ng guwantes sa
leprosy hospital is concerned. Change “ketong” to leprosy kamay at mask sa bibig) kapag NAGagamot ng pasyenteng
may ketong."
15 Lalo akong mag-iingat (katulad ng pagsusuot ng guwantes Change “ketong” to leprosy No modifications required
sa kamay at mask sa bibig) kapag nagagamot ng pasyenteng Change “ketong” to leprosy No modifications required
may ketong.
I would take special care (like wearing gloves and masks) Change “ketong” to leprosy No modifications required
when treating a patient with leprosy.
Change “ketong” to leprosy No modifications required
16 Posibleng mahawa ako kung gagamutin ko ang mga pasy-
enteng may ketong. Change “ketong” to leprosy No modifications required
It is possible for me to have leprosy if I treat leprosy patients. Change “ketong” to leprosy No modifications required
Change “ketong” to leprosy No modifications required
17 Hindi kadalasang nakadidiri ang paglilinis at pagbebenda sa
pasyenteng may ketong. Change “ketong” to leprosy No modifications required
Dressing for a leprosy patient is not disgusting most of the
times. Better to change “Ulser” to “sugat sa balat” for all healthcare Again, ulcers - maybe "sugat sa balat"
workers to understand.
18 Ang pagtatrabaho sa ospital ng may ketong ay isa sa pinaka- Change “ketong” to leprosy Change "pamamahala" to "pag-aasikaso"
magandang paraan ng pagiging makatao. Change “ketong” to leprosy
Working in a leprosy hospital is one of the best ways of exhib- No modifications required
iting humanitarian nature. Change “ketong” to leprosy No modifications required
Change “ketong” to leprosy
19 Kung ang aking kapamilya ay may ketong, hindi ako mahihi-
yang sabihin ito sa aking mga kaibigan.
If someone in my family has leprosy I wound not mind talking
about it to my friends.
20 Nakararamdam ako ng kasiyahan kapag ginagamot ko ang
mga pasyenteng may ketong.
I get a sense of satisfaction when I treat patients with leprosy.
21 Magpapakita ako ng suporta sa isang taong may ketong.
I would be supportive of a person who has leprosy.
22 Posibleng gamutin ang ketong tulad ng alin mang sakit sa
pangkalahatang serbisyong pangkalusugan.
It is possible to manage leprosy like any other disease in the
general health service.
23 Mas mabuting gamutin ang mga pasyenteng may ketong
sa mga pangkalahatang ospital kaysa sa mga ‘espesyal’ na
ospital ng may ketong.
It would be better to treat leprosy patients in general hospitals
instead of 'special' leprosy hospitals.
24 Wala akong problemang gamutin ang mga pasyenteng may
ketong na may depormasyon sa katawan o ulser sa balat.
I have no problem in treating leprosy patients with deformities
or ulcers.
25 Handa akong tumulong sa pagsusuri/pamamahala sa mga
kaso ng ketong sa aking pasilidad pangkalusugan.
I am willing to be involved in diagnosing/managing leprosy
cases at my health care facility.
26 Hindi ako nag-aalalang magtrabaho sa isang ospital na para
lang sa may ketong.
I don't mind working in an all leprosy hospital.
27 Nagagamot ang ketong.
Leprosy is curable.
and deformity (“depormasyon”). All experts and authors agreed into a final translated scale. All comments and suggestions were re-
to maintain “depormasyon” as this pertains to the physical as- vised into a final translated scale seen in Appendix 4. Based on the
pect while disability refers to malfunctioning. For item num- i-CVI, all of the items scored were 1.00 and were all accepted and
ber 14, “paglago” was added to the phrase “walang inaasahang maintained in the scale (Table 3).
propesyon”. For item number 25, “pamamahala” was changed
to “pag-aasikaso” since this is a better translation term for man- The items were grouped and averaged based on the ABC
aging leprosy cases. All comments and suggestions were revised model of attitudes – affective component with 10 items (Nos.
2, 4, 5, 8, 10, 17, 18, 19, 20, 21), behavioral with 8 items (Nos. 7,
51 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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Table 3. Test on the face validity of the translated AT-PLWL scale from both experts and HCP participants.
Item Relevance Rating (Frequency %)
Item Not Somewhat Quite Highly i-CVI Decision
Relevant relevant Relevant Relevant
2 1.00 Accepted
1 3 4 1.00 Accepted
1.00 Accepted
1 Sa palagay ko ang leprosy ay isang sumpa at parusa. 0 0 1 (33) 2 (66) 1.00 Accepted
I think leprosy is a curse and a punishment. 1.00 Accepted
1.00 Accepted
2 Maruming trabaho ang pangangalaga sa mga pasyenteng may ketong. 0 0 0 3 (100) 1.00 Accepted
Nursing of leprosy patients is a dirty job. 0 0 0 3 (100) 1.00 Accepted
1.00 Accepted
3 Magkakaroon din ng ketong ang mga anak ng pasyenteng may ketong. 1.00 Accepted
Children of leprosy patients invariably become lepers. 1.00 Accepted
1.00 Accepted
4 Dapat mamuhay nang nakahiwalay sa iba ang mga taong may ketong. 0 0 0 3 (100)
People with leprosy should live apart from other people. 1.00 Accepted
5 Nandidiri ako kapag nakakakita ng pasyenteng may leprosy na may ulser sa balat. 0 0 0 3 (100) 1.00 Accepted
There is a sense of revulsion when seeing a leprosy patient with ulcers. 1.00 Accepted
6 Karamihan sa mga nagtatrabaho sa ospital ng may ketong ay kadalasang nahahawa sa sakit na ito. 0 0 0 3 (100) 1.00 Accepted
1.00 Accepted
Most workers in leprosy hospitals usually contract the disease. 1.00 Accepted
1.00 Accepted
7 Sa ospital, iniiwasan kong hawakan ang sinumang may ketong hangga’t maaari. 0 0 0 3 (100) 1.00 Accepted
At the hospital, I prefer to avoid touching someone with leprosy if possible. 1.00 Accepted
1.00 Accepted
8 Dapat ihiwalay ang mga pasyenteng may ketong na may depormasyon sa katawan at ulser sa balat. 0 0 0 3 (100) 1.00 Accepted
Leprosy patients with ulcers and deformities must be isolated.
9 Mga depormasyon sa katawan ang hindi matatakasang epekto ng ketong. 0 0 0 3 (100)
Deformities are an inescapable consequence of leprosy.
10 Nag-aalala akong mahawa mula sa mga pasyenteng may ketong kapag ginagamot ko sila. 0 0 0 3 (100)
I am concerned with getting infection from patients with leprosy when I treat them.
11 Ang pinakakaraniwang indikasyon ng ketong ay mga depormadong bahagi ng kamay at paa. 0 0 0 3 (100)
The commonest presentation of leprosy is deformed limbs.
12 Mas gusto kong sa isang hiwalay na klinika ginagawa ang paglilinis at pagbebenda sa mga sugat ng 0 0 0 3 (100)
ketong.
I prefer dressing for leprosy wounds are carried out in a separate clinic.
13 Dapat ipaalam sa mga kawani at tagapangalagang pangkalusugan kapag may magpapagamot na 0 0 0 3 (100)
pasyenteng may ketong.
Staff and health care providers should be notified when a patient with leprosy comes for treatment.
14 Walang inaasahang propesyon kaugnay ng pangangalagang pangkalusugan sa ospital ng may ketong. 0 0 0 3 (100)
There are no career prospects as far as nursing practice in leprosy hospital is concerned.
15 Lalo akong mag-iingat (katulad ng pagsusuot ng guwantes sa kamay at mask sa bibig) kapag gumaga- 0 0 2 (66) 1 (33)
mot ng pasyenteng may ketong.
I would take special care (like wearing gloves and masks) when treating a patient with leprosy.
16 Posibleng mahawa ako kung gagamutin ko ang mga pasyenteng may ketong. 0 0 0 3 (100)
It is possible for me to have leprosy if I treat leprosy patients.
17 Hindi kadalasang nakadidiri ang paglilinis at pagbebenda sa pasyenteng may ketong. 0 0 0 3 (100)
Dressing for a leprosy patient is not disgusting most of the times.
18 Ang pagtatrabaho sa ospital ng may ketong ay isa sa pinakamagandang paraan ng pagiging makatao. 0 0 0 3 (100)
Working in a leprosy hospital is one of the best ways of exhibiting humanitarian nature.
19 Kung ang aking kapamilya ay may ketong, hindi ako mahihiyang sabihin ito sa aking mga kaibigan. 0 0 0 3 (100)
If someone in my family has leprosy I wound not mind talking about it to my friends.
20 Nakararamdam ako ng kasiyahan kapag ginagamot ko ang mga pasyenteng may ketong. 0 0 0 3 (100)
I get a sense of satisfaction when I treat patients with leprosy.
21 Magpapakita ako ng suporta sa isang taong may ketong. 0 0 0 3 (100)
I would be supportive of a person who has leprosy.
22 Posibleng gamutin ang ketong tulad ng alin mang sakit sa pangkalahatang serbisyong pangkalusugan. 0 0 0 3 (100)
It is possible to manage leprosy like any other disease in the general health service.
23 Mas mabuting gamutin ang mga pasyenteng may ketong sa mga pangkalahatang ospital kaysa sa mga 0 0 0 3 (100)
‘espesyal’ na ospital ng may ketong.
It would be better to treat leprosy patients in general hospitals instead of 'special' leprosy hospitals.
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24 Wala akong problemang gamutin ang mga pasyenteng may ketong na may depormasyon sa katawan 0 0 0 3 (100) 1.00 Accepted
o ulser sa balat.
I have no problem in treating leprosy patients with deformities or ulcers.
25 Handa akong tumulong sa pagsusuri/pamamahala sa mga kaso ng ketong sa aking pasilidad pangkalu- 0 0 0 3 (100) 1.00 Accepted
sugan.
I am willing to be involved in diagnosing/managing leprosy cases at my health care facility.
26 Hindi ako nag-aalalang magtrabaho sa isang ospital na para lang sa may ketong. 0 0 0 3 (100) 1.00 Accepted
I don't mind working in an all leprosy hospital.
27 Nagagamot ang ketong. 0 0 0 3 (100) 1.00 Accepted
Leprosy is curable.
Overall 0 0 0 3 (100) 1.00 Accepted
Table 4. Summary of Internal consistency analysis (Test-retest reliability). gender, and type of health care provider. Although the study
was carried out mainly with the objective to translate and vali-
Indicators ICC (95% Confidence Interval) date the original AT-PLWL scale, the authors decided to include
additional information gathered during the study process about
Affective (10 items) 0.895 (0.848 to 0.928) the attitudes of HCPs towards persons living with leprosy.
Behavioral (8 items) 0.927 (0.893 to 0.950) A positive attitude pertains to all positive response to >60%
of the questions (>16 out of the 27 questions); 40-60% (12-16 out of
Cognitive (9 items) 0.911 (0.870 to 0.939) the 27 questions) for intermediate attitude; and <40% (<12 out of
the 27 questions) for a negative attitude towards PLWL.22
Overall (27 items) 0.935 (0.904 to 0.956)
For the age group, a p-value of 0.002 (lower than 0.05)
Table 5. Summary of Internal consistency analysis. Cronbach’s α means that there is an association between age groups and at-
Indicators 0.795 titude. Majority of the age group between 21 to 30 years old had
0.781 a positive attitude towards leprosy while age groups of 31 to 40,
Affective (10 items, first) 0.780 41 to 50, and 61 to 70 had few respondents who have negative
Affective (10 items, second) 0.766 attitude towards leprosy.
Behavioral (8 items, first) 0.817
Behavioral (8 items, second) 0.761 For the gender, a p-value of 0.863 shows that there is the same
Cognitive (9 items, first) profile for males and females. Both resulted in having a positive at-
Cognitive (9 items, second) titude towards leprosy whether male or female; hence, there is no
significant association between gender and attitude.
12, 13, 15, 23, 24, 25, 26), and cognitive component with 9 items
(Nos. 1, 3, 6, 9, 11, 14, 16, 22, 27). Items 1 to 16 were all negative For the type of health care provider, a p-value of 0.018 con-
statements; hence, in the data analysis, the negative item results notes that there is an association between the type of health
(item numbers 1 to 16) were switched or converted into positive care provider and attitude towards leprosy. Although major-
statements/attitudes so that overall there would be a homoge- ity had positive attitude overall, amongst the barangay health
nized result of 1 (strongly agree) to 2 (agree), which pertains to workers, 10.6% had negative attitude, 23.4% had intermediate
a good/positive attitude. Affective, behavioral, and cognitive attitude, and 66% had positive attitude toward leprosy patients.
scores were computed as the sum of scores after conversion Among the nurses, 5.3% had negative attitude, 26.3% had inter-
based on the groupings of items. The total score was computed mediate attitude, and 68.4% had positive attitude toward lepro-
to represent the ICC of the whole scale. sy patients. Among the physicians, 2.9% had negative attitude,
2.9% had intermediate attitude, and 94.1% had positive attitude
Overall, the ICC result of the scale is 0.935, which connotes toward leprosy patients (Table 6).
that the test and re-test reliability of the scale has good correla-
tion with the components – affective (0.895), behavioral (0.927), DISCUSSION
and cognitive (0.911) - having good correlation respectively (Ta-
ble 4). The summary of the ICC result per item can be seen in Overall, the results revealed good validity and reliability. A tool
Table 5. is considered reliable if it is consistent and stable.17 Reliabil-
ity for this scale was assessed in two ways. First, the internal
As seen in Table 6, all components (affective, behavioral, consistency test was measured via calculating the Cronbach's α
and cognitive) resulted in at least 0.70 value of Cronbach’s α, in- coefficient. This is to measure if the same general construct pro-
dicating an adequate internal consistency. The answers to the duces similar scores using the translated tool; hence, assessing
translated scale were also tabulated based on the age groups, the degree of consistency and homogeneity between the items.
In this study, the Cronbach's α for all the components (affective,
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Table 6. Attitude scores grouped based on the socio-demographic profile of the HCPs.
Characteristics Negative Intermediate Positive P-value
0.002
Age group, years 4 (11.8) 30 (88.2) 0.863
3 (13.6) 18 (81.8) 0.018
21 to 30 0 (0.0) 2 (14.3) 9 (64.3)
4 (23.5) 13 (76.5)
31 to 40 1 (4.5) 4 (30.8) 6 (46.2)
41 to 50 3 (21.4) 15 (16.9) 68 (76.4)
2 (18.2) 8 (72.7)
51 to 60 0 (0.0)
11 (23.4) 31 (66.0)
61 to 70 3 (23.1) 5 (26.3) 13 (68.4)
1 (2.9) 32 (94.1)
Gender
Female 6 (6.7)
Male 1 (9.1)
Type of health care
Barangay Health Worker 5 (10.6)
Nurse 1 (5.3)
Physician 1 (2.9)
behavioral, and cognitive) are greater than 0.7, which is indica- why this scale is translated. The investigators aim to gauge the
tive of a good internal consistency. In other words, there is ade- attitudes of HCPs who are frontliners in early case detection and
quate consistency and homogeneity between the items, whether management of leprosy. This then would serve as a tool for fu-
they are connoting a positive or negative attitude. ture interventions geared against changing negative attitudes.
Second is the test re-test reliability which was assessed using In the literature, most studies on HCPs were done in India,
the intra-class correlation coefficient (ICC) of responses at two dif- Botswana, Nigeria, Sri Lanka, Guyana, etc. – all countries with
ferent time points. All ICCs of the items were all above 0.80, indicat- leprosy data and pockets of cases in far-flung areas. All stud-
ing a good correlation between the tests. This means that the items ies focused on knowledge, attitudes, and/or practices of HCPs
answered were relatively consistent across participants. towards leprosy. According to Srinivas et al. (2018), they found
that majority of the items in the different scales were more
In addition, overall, another finding in this study showed representative of knowledge and practice rather than attitude;
that the majority (76%) of the HCPs displayed a positive attitude hence, this served as their justification for developing a new
towards leprosy patients, 17% with intermediate attitude, and scale.12 The questionnaires/scales on the HCPs’ knowledge, at-
7% with negative attitude. However, there could be associations titudes, and/or practices have varying results. Recent studies by
when broken down based on different demographic profiles Ahmad et al. (2010) and Ewhrudjakpo (2017) revealed average to
– age, gender, and type of health care provider. Based on the good knowledge, positive behavior and attitude of HCPs towards
results, the youngest age group (21 to 30 years old), which com- leprosy, with most of the population consisting of medical offi-
prised of majority of the respondents, had the highest percent- cers, consistent with the results of this study.5,6 However, some
age of positive attitude results towards leprosy patients with no studies like that of Wijeratne and Ostbye (2017) conducted in Sri
negative attitude results in this age group. In contrast, the older Lanka revealed negative results to knowledge, attitudes, and
age groups (41 to 50, 61 to 70) had a small percentage of nega- practices among HCPs towards leprosy.7 Although most partici-
tive attitude results. This may be attributed to the fact that the pants could identify lesions and suspicious signs of leprosy, still,
younger generations have better means of access to information a huge percentage believed leprosy is still easily transmitted by
because of the developments in technology, providing a quick touch and 34% were still scared of leprosy.7 Older studies by Ku-
and efficient tool in accessing information. maresan and Maganu (1994) revealed poor knowledge amongst
99 HCPs, which was believed to influence attitude consequent-
For the type of health care provider, in terms of the hav- ly.8 Although a study by Briden and Maguire (2003) revealed a
ing a negative attitude towards leprosy patients, the barangay relatively good knowledge of leprosy, still, certain facts about
health worker group had more numbers compared to the other leprosy were not widely known.9 Half of the respondents did not
groups. Among the barangay health workers, 10.6% have nega- know that leprosy is curable and that leprosy can still be easily
tive attitudes, although a majority of them have positive (66%) transmitted by tough.9 Still, despite varying results over time,
and intermediate attitudes (23.4%). This negative attitude of ba- misconceptions still exist amongst countries.
rangay health workers towards leprosy patients may be due to
the lack of information or misinformation, which is the reason
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Dermatological Society
LIMITATIONS AND RECOMMENDATIONS search must be done to be able to translate this to other dialects
The translated tool has a good content validity using i-CVI and culturally adapt to ethnic groups across the country.
with a reasonable representation based on its relevance and CONCLUSION
applicability. Although this scale was successfully translated,
validated, and deemed reliable, still this scale is a pilot study The final translated Filipino version of the AT-PLWL scale is
with 100 participants in a limited area. To be able to come up similar to the original scale and could be used to evaluate HCPs’
with a good estimate of HCP attitudes, this has to be performed attitudes. The translated scale was deemed valid and reliable as
in a wider population and more areas. Also, although the Phil- shown and explained in the results and discussion. This scale
ippines national dialect is Tagalog, there are other regions with may serve as a tool to assess changes in HCP's attitudes follow-
different dialects with natives that could not understand Taga- ing interventions/activities geared against changing negative
log. Hence, for this scale to reach on national level, further re- attitudes.
ACKNOWLEDGMENTS
The authors would like to thank Dr. Srinivas et al., the original developer for the AT-PLWL scale, for giving us the opportunity to translate and
validate this scale; and Mr. Roy Alvin Malenab, our statistician, for helping us since the start of the study.
Moreover, we would also like to acknowledge Dr. Julie Mart C. Rubite, Dr. Arturo C. Cunanan, and Dr. Ma. Luisa A. Venida for accepting our invitation
to be included in the panel of experts. Their expertise and contributions in the validation of the scale are greatly appreciated. Also, we are
grateful for our department research heads, Dr. Czarina P. Chavez and Jacqueline D. Melendres, for their unwaivering support all throughout the
duration of this study.
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Medicine, 2:2, 115-120, DOI: 10.1080/09735070.2008.11886321.
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9. Briden, A, Maguire, E. An assessment of knowledge and attitudes towards leprosy/Hansen’s disease amongst healthcare workers in Guyana.
Leprosy Review. 74; 2; 154-162; DOI: 10.47276/lr.74.2.154.
10. Rao PV, Rao SL, Vijayakrishnan B, Chaudhary AB, Peril S, Reddy BP, et al. Knowledge, attitude and practices about leprosy among medical
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12. Srinivas G, Kumar S, Mohanraj R, Sekkizhar G, Muthuvel T, Lal V, et al. Development and validation of a scale to assess attitudes of health
care providers towards persons affected by leprosy in southern India. PLoS Negl Trop Dis. 2018 Sep 25;12(9):e0006808. doi: 10.1371/journal.
pntd.0006808. PMID: 30252851; PMCID: PMC6177202.
13. Rafferty J. Curing the stigma of leprosy. Lepr Rev. 2005 Jun;76(2):119-26. PMID: 16038245.
14. Rubio, CJ, Agulto MD. Translation and Validation of a Filipino version of the Glaucoma Quality of Life Questionnaire. Philippine Journal of
Ophthalmology.. Vol 36. No 2. Available at www.herdin.ph.
15. Tsang S, Royse CF, Terkawi AS. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi
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19. Gorsuch, Richard L. 1983. Factor Analysis, 2nd Edition. 425. http://www.amazon.com/Factor-Analysis-Edition-Richard-Gorsuch/p/089859202X
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21. Yu, GL & Rosales, R. Filipino Version of Penn Facial Pain Scale: Phase 1 Validation Study. Journal of Cancer Research and Therapeutics. Vol 11.
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22. Abeje T, Gobena E, Kebede E, Hailu T, Hassen I, Lema T, et al. Performance of general health workers in leprosy control activities at public
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Dermatological Society
HIV and leprosy in a 27-year-old Filipino male:
A case report
Kristen Therese A. Whaley, MD,1 Ma. Teresita G. Gabriel, MD, FPDS,1
Emmanuel Jacinth C. Atienza, MD1
ABSTRACT
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.
KEYWORDS Leprosy reaction, Hansen’s disease, Human immunodeficiency virus
1Department of Dermatology, INTRODUCTION February 2018, who was already receiving efavirenz
Research Institute for Tropical 600mg/emtricitabine 200mg/tenofovir 300mg for
Medicine, Research Drive, Co-infection with HIV has been a challenge in 75 weeks, with an improved CD4 count of 406 af-
Alabang, Muntinlupa City managing many infectious diseases, particularly ter 6 months of HAART (baseline CD4 count 124)
mycobacterial diseases. Most patients reported and a viral load of <34 copies/mL consulted at
Corresponding author to have HIV-leprosy co-infection had paucibacil- our institution. He initially presented with a few
Kristen Therese A. Whaley, MD lary leprosy, with exacerbation of lesions during hypopigmented, hypoesthetic plaques on the el-
a course of immune reconstitution inflammato- bows 11 months prior to consulting. Lesions in-
Conflict of interest ry syndrome (IRIS) associated with initiation of creased in size and number, evolving into multi-
None highly active antiretroviral treatment (HAART). ple erythematous papules, plaques, and nodules
Rarely, multibacillary lepromatous leprosy ex- on the face, ears, and extremities associated
Source of funding ists in the setting of HIV.1 with hypoesthesia. The patient was previously
None seen by a physician and was given betametha-
There is limited data on the course of lepro- sone valerate ointment and prednisone 20mg/
sy in HIV co-infected patients, hence this case re- day for 1 week with minimal improvement. The
port aims to describe the manifestations of lepro- persistence of lesions prompted consult at our
matous leprosy in an HIV co-infected patient and institution. Past medical history showed late la-
the satisfactory prognosis with the use of chronic tent syphilis treated with benzathine penicillin
corticosteroids in the management of leprosy re- G 2.4M units intramuscular injection for 3 doses
actions in the immunocompromised. in 2018. Family history was unremarkable. He is
currently in a monogamous sexual relationship
CASE REPORT
A 27-year-old male, diagnosed case of HIV since
59 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
CASE REPORT JPDS
Journal of the Philippine
A Dermatological Society
BC
Figure 1. A to C. Patient on first consultation presenting with multiple, well-defined, erythematous papules, plaques and nodules on the face, ears, and extremities.
with a male partner and works as a call center agent. AB
On physical examination, there were multiple, well-de-
Figure 2. A. Epidermis showed mild thinning and a subepidermal clear grenz zone (H&E,
fined, round to irregularly-shaped erythematous papules, 10x). B. A nodular, granulomatous inflammatory infiltrate composed of foamy histiocytes
plaques, and nodules that range in size from a few millimeters and lymphocytes is observed on the dermis (H&E, 40x).
up to 2 to 3 centimeters in diameter on the face, ears, and ex-
tremities (Figure 1). There were no palpable peripheral nerves. low-up with a noted elevation of old lesions and appearance of
Caloric testing revealed 0% sensation on cold and hot tem- new plaques and nodules with sizes ranging from a few centime-
peratures, and 50% sensory deficit on soft touch and pinprick ters up to 6 centimeters in diameter, on the face, arms and bilat-
on lesional skin. A 4-mm skin punch biopsy stained with H&E eral anterior legs. This was accompanied by fever, arthralgia,
revealed mild thinning of the epidermis, subepidermal grenz and myalgia. Partial clawing of the right hand was also noted
zone, and a dense, nodular, granulomatous inflammatory infil- (Figure 3). A diagnosis of Hansen’s disease lepromatous leprosy,
trate of foamy histiocytes, and many lymphocytes, surrounding in reaction, was made and the patient was resumed on 4th cy-
adnexal structures and extending to the deep dermis (Figure cle of MDT-MB blister pack and was given prednisone 40mg/day
2). Histopathological diagnosis was Hansen’s disease, leproma- for 2 weeks, with gradual tapering in decrements of 10mg/day
tous leprosy. A slit skin smear revealed a Bacillary Index (BI) of every 2 weeks until the oral corticosteroid is discontinued. The
1.83+ with all M. leprae bacilli in solid form. Chest radiograph, patient has been compliant with medications and had complet-
complete blood count, urinalysis, G6PD assay, kidney, and liver
function tests, as well as the rest of the metabolic parameters
were normal. The patient was then started on multidrug thera-
py-multibacillary regimen (MDT-MB) blister pack every 28 days.
However, after the 3rd cycle, due to unavailability of MDT blister
pack, the patient was switched to second-line drugs rifampicin
600mg/tab once a month, ofloxacin 400mg/tab once daily, and
clarithromycin 500mg/tab once daily, but had poor adherence
and subsequently lost to follow-up.
Five months after initiating MDT-MB, with good compli-
ance with HAART for 107 weeks, the patient came in for a fol-
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Journal of the Philippine
Dermatological Society C
A
Figure 3. A to C. Patient in leprosy reaction showing multiple, well-defined, erythematous to hyperpigmented papules, plaques and nodules on the face, ears, neck, upper and lower extremities.
ABC
Figure 4. A to C. Patient after completion of 7 cycles of MDT-MB blister pack and 10 weeks of tapered dose of prednisone, with no recurrence of reaction, showing multiple, well-defined,
erythematous to hyperpigmented patches, plaques and nodules on the face, neck, palms, upper and lower extremities.
ed 7 cycles of MDT-MB blister pack with no noted recurrence of HIV does not significantly affect the pathogenesis of neural or
reaction (Figure 4). Our plan is to complete 12 cycles of MDT-MB skin lesions.2,3 It is however possible that all types of leprosy can
blister packs for our patient. occur in co-infected patients, with the predominance of pauci-
bacillary cases in most published reports. In a study by Deps et
DISCUSSION al., HIV patients with low CD4+ count had borderline tubercu-
loid lesions with well-formed granuloma and normal numbers
HIV and Hansen’s disease are diseases that affect cell-mediated of CD4 cells.4 On the other hand, patients with lepromatous
immunity. It was initially expected that the decrease in CD4+ leprosy had loose inflammatory infiltrates comprised of macro-
cells seen in HIV patients would result in an increase in suscep- phages and a small number of CD8+ lymphocytes.1,2
tibility to leprosy, just as in mycobacterium tuberculosis. But stud-
ies have found that both diseases exist independently, and that Several reports have suggested that initiation of HAART
61 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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has been associated with the occurrence of reversal reaction occurrence of type 2 ENL reaction was seen in the borderline
and IRIS-associated reversal reaction, with the diagnosis of lep- lepromatous leprosy patients, and in patients who were severely
rosy increasingly being reported in this new clinical syndrome. immunosuppressed for a prolonged period. They have treated
IRIS is the paradoxical worsening in clinical status after start- reactions in leprosy-HIV co-infected patients with the use of
ing HAART, attributable to an increase in production and re- systemic corticosteroids using the same dose as patients with-
distribution of CD4+ cells, and increased immune responses to out HIV, with a preference for prednisone at 1mg/kg for Type 1
other opportunistic pathogens due to inhibition of regulatory reactions, acute neuritis and some cases of Type 2 ENL reactions
T cell function in suppressing pro-inflammatory cytokines re- with report of satisfactory improvement. Majority of patients in
sponsible for the focal and systemic signs of inflammation.1,3,5 this study received 50mg/day of prednisone in accordance to
Lockwood and Lambert proposed a defining criteria for the cor- weight, with gradual tapering every 15-20 days, decreasing to
rect identification of leprosy IRIS, which includes the following: a dose of 20mg, then 5mg until drug is fully withdrawn. Results
(1) leprosy and/or leprosy reaction presenting within six months showed that most patients had a single episode of reactional
of starting HAART; (2) an advanced HIV infection; (3) low CD4+ states within 2 years of follow up, with reaction episodes of mod-
count (<200 cells/mm3) before initiating HAART; (4) CD4+ count erate intensity and more severe complications in patients pre-
increasing after starting HAART.1,2 Our patient presented with senting with type 2 ENL reactions. All co-infected patients were
an advanced HIV infection, with baseline CD4+ count of 124 im- also found to have shorter periods of leprosy reaction, averag-
proved to 406 after 6 months of starting HAART. Although the ing at 2 months as compared to seronegative patients.1 This was
patient did not meet the diagnostic criteria initially proposed also consistent with similar cohort studies showing no adverse
by the authors, with lepra reaction occurring after 107 weeks of effects from treating leprosy reactions in HIV-leprosy co-infec-
starting HAART, a few leprosy IRIS cases presented with other tion with the usual dosage of prednisone with good response to
timings. This can be explained by considerable individual variation treatment.2 Although chronic corticosteroids may render HIV
in the reconstitution of both CD4+ and memory CD4+ T cells, which patients more susceptible to infections, the balanced benefit of
may persist up to 48 weeks of starting HAART. Hence, they revised treatment of reactions in preventing nerve damage and disabili-
a new classification identifying four possible situations of Leprosy ty is paramount in the disease process, and hence, a closer mon-
IRIS in HIV patients. Particularly, they identified a group of HIV pa- itoring for these patients should be observed.
tients on HAART who were later diagnosed with leprosy and devel-
oped lepra reactions later after starting MDT.4 CONCLUSION
Our patient presented with type 2 erythema nodosum lep- Considering that both Hansen’s disease and HIV directly af-
rosum reaction, with sign of deformity after being non-compli- fects T helper CD4+ lymphocytes in its pathogenesis, there
ant with the MDT regimen. Data have suggested that over-all seems to be no or little alteration in the course of patients
peripheral nerve damage is higher in HIV leprosy co-infection with HIV-leprosy co-infection. Hence, treatment of HIV-lep-
than patients with leprosy alone, especially in multibacillary rosy co-infection does not differ from that of a seronegative
forms. This greater damage was largely attributable to HIV dis- leprosy patient. This can also be explained by the positive
ease, but not related to neurotoxicity of HAART.6 response of our patient with the standard MDT therapy for
leprosy and antiretroviral for HIV, as both conditions are
In a clinical cohort study by Pires et al., they followed up treated as separate entities. This case highlights the occur-
patients for a period of at least two years for the occurrence of rence of ENL reaction in HIV-leprosy co-infection and the
leprosy reactions and have found reactions to be more com- need for immunosuppressive drugs to control reaction and
mon among seronegative leprosy patients, with type 1 reversal prevent nerve damage. The importance of close monitoring
reactions being predominant in both groups. This occurrence to screen for opportunistic infections is warranted while
is associated with the borderline clinical forms, since these taking his medications.
are immunologically unstable forms.1 In the same study, the
REFERENCES
1. Pires CA, Jucá Neto FO, de Albuquerque NC, Macedo GM, Batista Kde N, Xavier MB. Leprosy Reactions in Patients Coinfected with HIV: Clinical
Aspects and Outcomes in Two Comparative Cohorts in the Amazon Region, Brazil. PLoS Negl Trop Dis. 2015 Jun 1;9(6):e0003818. doi: 10.1371/
journal.pntd.0003818. PMID: 26029928; PMCID: PMC4451982.
2. Scollard DM, Gillis TP, et al. The International Textbook of Leprosy. 1st ed. American Leprosy Missions; 2019.
3. Camaclang, MLA. and Cubillan, ELA. Lepromatous Leprosy and Human Immunodeficiency Virus: A Rare Co-infection. Acta Medica Philippina. 53.
2. 177-180. https://doi.org/10.47895/amp.v53i2.205.
4. Deps P, Lockwood DN. Leprosy presenting as immune reconstitution inflammatory syndrome: proposed definitions and classification. Lepr
J Phil Dermatol Soc · November 2021 · ISSN 2094-201X 62
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Dermatological Society
Rev. 2010 Mar;81(1):59-68. PMID: 20496570.
5. Serrano-Coll H, Beltrán-Alzate J, Buitrago, S, Cardona-Castro N. Lepromatous leprosy and human immunodeficiency virus co-infection
associated with phenomenon of Lucio versus immune reconstitution inflammatory syndrome. Infectio. 20. 10.1016/j.infect.2015.10.011.
6. Xavier MB, do Nascimento MGB, Batista K de NM, Somensi DN, Juca Neto FOM, Carneiro TX, et al. Peripheral nerve abnormality in HIV leprosy
patients. PLOS Neglected Tropical Diseases, 12(7), e0006633. doi:10.1371/journal.pntd.0006633
63 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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Dermatological Society
Large basal cell carcinoma in a 101-year-old Filipino
female: A case report
Jianella Catrisse D. Diaz, MD,1 Daisy King-Ismael, MD, FPDS,1
Ma. Luisa Abad-Venida, MD, FPDS,1 Zharlah Gulmatico-Flores, MD, FPDS1
ABSTRACT
INTRODUCTION Basal cell carcinoma (BCC) is the most common type of malignancy worldwide. The incidence of BCC is positively
associated with increasing age; thus, centenarians, defined as those aged 100 years and above, become a vulnerable population
to developing malignancy. As a person ages, risk factors such as chronic sun exposure, ionizing radiation, and immunosuppres-
sion induce mutations that contribute to tumor formation. Impaired DNA repair capacity in response to carcinogens and immune
function dysfunction also increases BCC risk in the elderly. Currently, studies among centenarians with high-risk basal cell car-
cinoma treated with surgical interventions are limited.
CASE REPORT Presented herewith is a case of a 101-year-old female with a 15-year history of hyperpigmented, hyperkeratotic
plaque over the right malar area and a one-year history of progressive pain (PS 10/10) and enlargement of the lesion, forming an
ulcerated, hyperpigmented tumor. Laboratory workup showed normal findings. Histopathology was signed out as a pigmented
nodulocystic basal cell carcinoma. Moh’s micrographic surgery (MMS) and cheek advancement flap were performed with good
wound healing and no perioperative complications.
CONCLUSION Despite the limited options of medical and physical management due to decreased life expectancy of centenar-
ians, MMS remains the standard of therapy in high-risk BCC. MMS with reconstructive surgery is generally a safe and effective
modality with no increased risk of peri- and post-operative complications.
KEYWORDS Basal cell carcinoma, centenarians, Moh’s micrographic surgery
1Department of Dermatology, INTRODUCTION hensive assessment of several factors such as
Jose R. Reyes Memorial Medical functional status, cognition, life expectancy,
Center, Manila Basal cell carcinoma (BCC), which is the most comorbidities, social support, nutritional state,
common malignancy in humans, has been in- and financial capability to determine the best ap-
Corresponding author creasing exponentially among older adults. In proach to treatment.2
Jianella Catrisse D. Diaz, MD the Philippines, 215 cases of BCC in the geriat-
ric population aged 80 and above have been re- CASE REPORT
Conflict of interest corded in the Philippine Dermatologic Society
None Health Information System since 2011. Among A 101-year-old female presented with a 15-year
these cases, 188 patients were between 80-89 history of a solitary, hyperpigmented plaque
Source of funding years of age, 25 patients were between 90-99 initially measuring 1 cm x 1 cm over the right
None years, and 2 patients were above 100 years. malar area with no associated tenderness, pru-
Studies show that the proportion of BCC in the ritus, numbness, and bleeding over the area.
head and neck also increases with age, mani- There was no preceding trauma, no exacerbat-
festing 69% to 81% in these sites.1 ing nor relieving factors.
In a study by Lubeek et al., the majority of One year prior to consultation, she noted
BCC cases in the elderly present with a non-ag- a progressive increase in size of the mass with
gressive disease course, characterized by slow spontaneous ulceration at the center of the le-
tumor growth and rare metastasis. However, sion. It was also associated with tenderness (visu-
older individuals with BCC are at increased risk al analog scale 4/10) over the tumor. No oral med-
for poor treatment outcomes, with a higher mor- ications were taken, and no topical medications
tality rate in patients 85 years or older compared were applied over the affected area.
with younger patients.1 Thus, management of
elderly patients with BCC requires a compre- Five months prior, she noted foul-smelling
discharge with bleeding over the area with fur-
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B
Figure 1. Solitary, hyperpigmented tumor with surrounding telangiectasia and associated
ulceration, measuring approximately 3.5 cm x 4 cm x 2.5 cm over the right malar area.
ther increase in size and tenderness (visual analog scale 9-10/10, Figure 2. A. Islands of basaloid cells with peripheral palisading of nuclei and clefts around
radiating towards the periorbital area); thus, prompting con- (H&E stain, 10x); B. Numerous atypical cells and mitotic figures were noted (H&E stain, 40x).
sult.
out as pigmented nodulocystic basal cell carcinoma.
The patient was hypertensive for 30 years maintained on The patient underwent one stage of Moh’s micrographic
medications. She had a history of chronic sun exposure without
sunscreen use. There were no personal and family histories of surgery with clear margins. The repair was then performed us-
skin cancer and other skin diseases, nor was there a history of ing rotational cheek flap (Figure 3). No post-operative complica-
sunburns over the face and body. tions were noted. She was advised to take co-amoxiclav 625 mg
tablet every 12 hours for one week and apply topical mupirocin
On physical examination, the patient presented with a soli- 2% ointment twice daily for one month.
tary, firm, irregularly-shaped, hyperpigmented, friable, exudative
tumor with surrounding telangiectasia and associated whitish, One month postoperatively, the patient noted good wound
foul-smelling discharge and ulceration, measuring approximately healing with no pain, tenderness or bleeding over the surgical
4 cm x 2.5 cm over the right malar area (Figure 1). There were no site. After six months, no recurrence of the lesion was noted
palpable cervical, axillary, inguinal lymphadenopathies. The rest
of the physical examination was unremarkable.
Preoperative workups, including complete blood count
(CBC), prothrombin time (PT), partial thromboplastin time
(PTT), international normalized ratio (INR), fasting blood sugar
(FBS) and bleeding time (BT) were normal. Her biopsy revealed
flat epidermis, and attached to this and extending throughout
the dermis are islands of basaloid cells with cystic spaces, pe-
ripheral palisading of nuclei and retraction artifacts (Figure
2A). Numerous atypical cells, mitotic figures, and clumps of
melanin were noted. The dermis showed moderately dense lym-
phocytes and dilated blood vessels (Figure 2B). This was signed
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over the face and there were no associated symptoms over the and neck.4 Similarly, 51.7% to 60.7% of BCC cases in the elderly
post-operative site (Figure 4). are the nodular type, and the lesions are often distributed on
the head and neck.2,4 In some studies, tumor size in the elderly
DISCUSSION ranged from 1.8 to 3.0 cm with a depth of 1 cm to 2.5 cm, present-
ing as pigmented tumors on the head and chest.5,6 In this case, the
Basal cell carcinoma accounts for most documented cases of patient had a tumor size of 3.5 cm with a depth of 2.5 cm, which
malignant tumors in the elderly. Common risk factors of BCC was a relatively larger presentation compared to other studies.
are male sex, chronic sun exposure, old age, ionizing radiation,
immunosuppression, fair skin phototype, chronic arsenic in- Most BCCs are slow-growing skin tumors, characterized by
gestion, and family history.3 In this case, the patient’s age and local tissue invasion and minimal risk of metastasis.1 For this
inherent age-related cumulative UV exposure without the use of patient, she had a 15-year history of a hyperpigmented plaque
sun protection are the main factors that increased her predispo- on the face, which did not manifest with rapid enlargement un-
sition of developing BCC. til one year prior to consulting. Systemic signs and symptoms of
metastasis such as bone pain, dyspnea, and palpable lymphadenop-
The clinical manifestations of a patient with BCC differ athy were also absent, which is consistent with the features of BCC.7
based on the subtypes, which include nodular, pigmented, su-
perficial, morpheaform, and fibroepithelioma of Pinkus. The The most common dermatoscopic features in BCC include
pigmented nodulocystic type, which is seen in this case, often arborizing vessels, short-fine telangiectasia, large blue-gray
presents as a solitary, hyperpigmented, translucent nodule
with associated telangiectasia and rolled borders on the head
Figure 3. Appearance of surgical site after performing rotational cheek flap. Figure 4. Postoperative site after six months.
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ovoid nests, shiny white structures, and ulceration. In a study the elderly. In a study by Delaney et al., the average patient age
by Caresana and Giardini, the clinical and dermoscopic assess- of nonagenarians who underwent MMS was at 92.3 years with
ment of extension measurement showed concordance in 65% of no reported deaths one month post-operatively.10 Other charac-
cases.8 For this case, dermoscopy-guided assessment of lesion teristics such as defect size, number of surgical stages, and clo-
borders was done after one stage of Moh’s micrographic surgery sure type did not affect survival in this age group. MMS among
(MMS). Dermoscopic findings showed the absence of telangiec- elderly patients also did not result to increased morbidity and
tasia, which supported clearance of peripheral borders. mortality among patients with skin malignancy. Furthermore,
nonagenarians who underwent MMS for skin malignancy, peri-
BCC is managed using various treatment options that en- and post-operative complications were absent. There were no
compass medical, physical, and surgical management based on significant differences in prognosis between patients who un-
whether the tumor is high risk or low risk. High-risk BCC is clin- derwent 1 to 2 stages and those who had 3 and above. In this
ically based on several parameters such as location/size of le- case, the patient underwent one stage of MMS and reconstruc-
sion, border, recurrence, immunosuppression, and prior radia- tion with rotational cheek flap, which was well-tolerated and re-
tion therapy.9 In this case, the patient presented with a high-risk sulted in complete wound closure and repair.
tumor on the malar area with a diameter > 10 mm, with poorly
defined borders and inherent age-related immunosuppression. CONCLUSION
Surgery remains the mainstay of therapy in high-risk BCC Despite the limitations of medical and physical management
cases, since it provides complete removal of the tumor, reduces due to decreased life expectancy and longevity among centenar-
contiguous spread of malignant cells and preserves surround- ians, MMS remains the standard of therapy in high-risk BCC.
ing tissue. Among these modalities, MMS is the standard of As seen in this case, MMS with reconstructive surgery is gen-
treatment for high-risk BCC since it allows analysis of tumor erally a safe and effective modality in the elderly population.
margins while maintaining maximal tissue conservation.9 The risk of peri- and post-operative complications and mortality
is not increased among elderly patients who undergo surgery.
Even though MMS with reconstruction has a low risk of Thus, MMS and rotational cheek flap is advised as the primary
complications, some clinicians opt for medical management treatment modality among centenarians with high-risk basal
in centenarians since skin aging may contribute to decreased cell carcinoma. Due to the rising incidence of BCC and extend-
tolerance to complex surgery and reconstructions. Hence, there ed lifespans of the geriatric population, it would be beneficial
is paucity of literature on the surgical intervention and recon- for physicians to be aware of the complete curative technique of
struction to treat BCC among centenarians. MMS with reconstruction.
Nevertheless, Moh’s surgery with reconstructive surgery
has been shown to be a safe procedure for high-risk tumors in
REFERENCES
1. Lubeek SF, van Vugt LJ, Aben KK, van de Kerkhof PC, Gerritsen MP. The epidemiology and clinicopathological features of basal cell carcinoma
in patients 80 years and older: a systematic review. JAMA Dermatol. 2017;153(1):71-78. DOI: 10.1001/jamadermatol.2016.3628
2. Stoop, A., Lette, M., van Gils, P. F., Nijpels, G., Baan, C. A., & de Bruin, S. R. Comprehensive geriatric assessments in integrated care programs
for older people living at home: a scoping review. Health Soc Care Community. 2019 Sep; 27(5):549–566. DOI: 10.1111/hsc.12793
3. Hallaji, Z., Rahimi, H., & Mirshams-Shahshahani, M. Comparison of risk factors of single basal cell carcinoma with multiple basal cell
carcinomas. Indian J Dermatol. 2011;56(4),398-402. DOI: 10.4103/0019-5154.84766
4. Casari, A., Pellacani, G., Seidenari, S., Cesinaro, A. M., Beretti, F., Pepe, P., and Longo, C. Pigmented nodular basal cell carcinomas in differential
diagnosis with nodular melanomas: confocal microscopy as a reliable tool for in vivo histologic diagnosis. J Skin Cancer. 2011,406859. DOI:
10.1155/2011/406859
5. Shah, U., Agrawal, G., Vaghani, S. A case report on basal cell carcinoma: noduloulcerative variety. Int. J. Biomed. 2015; 6(04): 288-290. DOI:
10.7439/ijbr.v6i4.1905
6. Singh, K., Sharma, A., Chatterjee, T. Pigmented basal cell carcinoma: a rare case report. Indian J Cancer. 2016;53(3): 380-381. DOI: 10.4103/0019-
509X.200673
7. Kauvar AN, Cronin T Jr, Roenigk R, Hruza G, Bennett R. American society for dermatologic surgery consensus for nonmelanoma skin cancer
treatment: basal cell carcinoma, including a cost analysis of treatment methods. Dermatol Surg. 2015 May; 41(5):550-71. DOI: 10.1097/
DSS.0000000000000296
8. Caresana, G, and R Giardini. Dermoscopy-guided surgery in basal cell carcinoma. JEADV. 2010; 24(12):1395-9. DOI: 10.1111/j.1468-3083.2010.03652.x
9. Kim JYS, Kozlow, J., Mittal, B., Moyer, J., Olencki, T., Rodgers, P. Guidelines of care for the management of basal cell carcinoma. J Am Acad
Dermatol. 2018;78(3):540-559. DOI: 10.1016/j.jaad.2017.10.006
10. Delaney, A., Shimizu, I., Goldberg, L. H., & MacFarlane, D. F. Life expectancy after Mohs micrographic surgery in patients aged 90 years and
older. J Am Acad Dermatol, 2013; 68(2), 296–300. DOI: 10.1016/j.jaad.2012.10.016
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Severe papulopustular rosacea with demodicosis in a
47-year-old Filipino female: A case report
Aira Monica R. Abella, MD,1 Johannes F. Dayrit, MD, FPDS, FDSP1
ABSTRACT
INTRODUCTION Rosacea is a chronic relapsing inflammatory facial dermatosis often characterized by flare-ups and remissions
exclusively affecting the centrofacial skin.
CASE REPORT This is a case of multiple symmetric intensely erythematous papules, pustules, and plaques over both cheeks in
a 47-year-old Filipino female. Dermoscopy showed brown-yellowish structureless areas, straight vessels in a polygonal pattern,
dilated follicles, follicular plugs, ill-defined white rosettes, and non-specific scales. Skin punch biopsy showed spongiosis of
the epidermis and demodex folliculorum within the follicular infundibulum. The dermis revealed telangiectasia of blood vessels
and dense inflammatory infiltrates. Hypertrophy of sebaceous lobules was also seen. The patient was initially treated with oral
lymecycline 300mg twice a day for 2 weeks without improvement. Due to the persistence of centrofacial erythema, papules and
pustules, the patient was given prednisone 10mg once a day for 1 month and low dose isotretinoin 10mg once a day for 8 months
which resulted in significant decrease in erythema and number of existing lesions. To further decrease the inflammation con-
tributed by demodex mites, permethrin 5% cream twice a day for 1 month was applied. Long-pulsed Neodymium-doped yttrium
aluminum garnet (Nd:YAG) 1064 nm laser for a total of 10 sessions together with Isotretinoin 10 mg every other day effectively
maintained remission for 1 year and 5 months. Gentle skin care measures, sunscreen, metronidazole 0.75% cream once a day, and
desonide 0.05% cream twice a day for 1 week in cases of acute flares were maintained during the treatment course.
CONCLUSION An armamentarium of topical and oral antibiotics, corticosteroids, isotretinoin and non-ablative long-pulsed
Nd:YAG 1064 nm laser showed significant improvement in the inflammatory papules, pustules, and centrofacial erythema of rosa-
cea and proves to be beneficial in the maintenance of its long-term remission.
KEYWORDS Papulopustular rosacea, Isotretinoin, lymecycline, long-pulsed Nd:YAG laser
1Department of Dermatology, INTRODUCTION features may occur, burning, stinging, edema,
Research Institute for Tropical or dry appearance, are not generally considered
Medicine, Muntinlupa City Rosacea is a prevalent condition affecting more diagnostic.1,4 Several studies have shown success
than 20 million people worldwide.1 It is frequent- in addressing the papules and pustules as well as
Corresponding author ly diagnosed in women whose onset is seen in centrofacial erythema utilizing topical, systemic
Aira Monica R. Abella, MD ages 35-45 years old.1,2 Rosacea affects all seg- and/or physical interventions.5-10
ments of the population and all skin types.1 It is
Conflict of interest primarily diagnosed clinically based on patient’s CASE REPORT
None self-reported history, observations, triggers, and
overlapping symptoms.1,3,4 Additionally, the use A 47-year-old female Filipino, presented to our
Source of funding of a dermatoscope and histopathology may re- clinic with a 5-year history of on and off ap-
None veal other characteristics of rosacea that can help pearance of intense red papules, pustules and
guide the diagnosis. Current guidelines from the plaques on both cheeks. The lesions were exac-
2018 classification by the National Rosacea Soci- erbated by sun exposure, heat, hot weather, and
ety recommends a phenotype driven approach intense emotions. She had never experienced
in the diagnosis and treatment.1,4 The following ocular signs or symptoms. A previous derma-
features represent independent diagnostic cri- tologist managed her case as rosacea and was
teria of rosacea: fixed centrofacial erythema or prescribed brimonidine 0.33% gel which result-
phymatous changes.1,4 In their absence, diagno- ed in transient improvement of the lesions, but
sis can also be established by two or more major was followed by an exacerbation of the lesions,
features: papules/pustules, flushing, telangiecta- hence consult at our clinic. Clinical examina-
sia, or ocular manifestations.1,4 While secondary tion revealed multiple, symmetric, well-defined,
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Dermatological Society cream twice a day for 1 month. This led to the significant de-
crease of centrofacial erythema, papules and pustules (Figure
3A-D). Immediately after, the first session of long-pulsed Nd:YAG
1064nm laser toning was performed monthly for a total of 10
sessions while still maintained on low dose isotretinoin 10mg
every other day as a way to control flares and decrease vascu-
A
Figure 1. Dermoscopy on initial consult showed, brown-yellowish structureless areas B
(yellow arrows), straight vessels in a polygonal pattern sometimes called honeycomb
pattern (black arrows), dilated follicles (blue arrowheads), follicular plugs (white
arrowheads), ill-defined white rosettes (green arrows) and non-specific scales (black
ovals).
irregularly-shaped, erythematous, edematous, macules, pap- Figure 2. A. Hypertrophy of sebaceous lobules (H&E, 10x); B. Demodex folliculorum
ules, pustules, and plaques with telangiectasias on the central within the follicular infundibulum (H&E, 20x).
cheeks and some on the glabella, nose, and chin. Dermoscopy
showed brown-yellowish structureless areas, straight vessels in
a polygonal pattern, dilated follicles, follicular plugs, ill-defined
white rosettes, and non-specific scales (Figure 1). A 4-mm skin
punch biopsy was taken from a pustule on the left cheek. Histo-
pathologic examination using Hematoxylin and Eosin stain re-
vealed spongiosis of the epidermis, exocytosis of lymphocytes
and demodex folliculorum within the follicular infundibulum.
The dermis revealed telangiectasia of blood vessels, and a dense
perivascular, interstitial and periadnexal inflammatory infil-
trate of lymphocytes, plasma cells and neutrophils. Hypertro-
phy of sebaceous lobules was seen (Figure 2A-B).
With the clinical, dermoscopic, and histopathologic find-
ings, a diagnosis of papulopustular rosacea with Demodex fol-
liculorum was made. The patient was initially treated with oral
lymecycline 300 mg twice a day for 2 weeks without significant
improvement. Patient was then given prednisone (10 mg once
a day for 1 month) in combination with oral isotretinoin (10mg
once a day for 4 months then 10 mg every other day for 8 months)
to strongly address the inflammatory component of rosacea. Ad-
ditionally, the patient was instructed to apply permethrin 5%
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ABCD
Figure 3. Baseline and follow-up photos while on low dose isotretinoin. A. Initial consult B. Four (4) months of Isotretinoin 10 mg per day C. Three (3) months of Isotretinoin 10mg every other day D. Five
(5) months of Isotretinoin 10mg every other day.
larity. The vascular probe in genesis (GN) mode was delivered occurrence of severe transient rebound erythema several hours
with the following parameters: fluence of 7.1 J/cm2, 6mm spot after application and the occurrence of persistent erythema in
size, and frequency of 6Hz for the first pass followed by Top Hat skin adjacent to the site of long-term brimonidine application.5
(TH) beam profile with 1.4 J/cm2, 6 mm spot size, and frequency In our patient, brimonidine showed minimal to no improvement
of 6Hz. Post-laser sessions, patient was advised to apply a mois- owing to poor adherence and since brimonidine only addresses
turizer twice a day for 3 days only. Isotretinoin in combination the vascular problem of rosacea.
with long-pulsed Nd:YAG 1064 nm laser showed complete clear-
ing of papules and pustules and significant reduction in erythe- Demodex folliculorum mites are commensals in the human
ma and telangiectasia. The patient was in complete remission skin and was found particularly increased in the papules and
for 1 year and 5 months. She did not experience flares of flush- pustules of rosacea.4 Eliminating these mites with topical per-
ing nor episodes of persistent erythema. However, there was a methrin successfully reduces the inflammatory papules and
recurrence of few erythematous papules and pustules. Isotreti- pustules and was found to be as effective as metronidazole
noin (10mg twice a week) was resumed, metronidazole cream 0.75% gel, however the safety of long-term permethrin use is
0.75% cream twice a day, sunscreen, and gentle skincare was still unknown for it to be supported as a maintenance regimen.6
continued to maintain remission. Occasional flares were treat- Topical metronidazole was used as add-on therapy and as a
ed with desonide cream (twice daily for 1 week). To maintain maintenance regimen. It is most effective for the treatment of
remissions, isotretinoin (10 mg once to twice weekly) in combi- inflammatory papules and pustules, but may also contribute to
nation with metronidazole 0.75% cream (once daily), short term improvement in erythema by exerting anti-inflammatory effect
desonide cream (twice a day for 1 week) in cases of acute flares, affecting neutrophil migration and chemotaxis.7
and gentle skincare practices.
Due to the recurrent inflammatory papules, pustules, and
DISCUSSION centrofacial erythema, combined topical and systemic thera-
pies is a rational approach in this case.1,3 The patient is a good
Rosacea is characterized by multifactorial, inflammatory candidate for oral tetracyclines, considered as first-line therapy
events and often requires a multidisciplinary approach includ- for severe papulopustular rosacea.2 Lymecycline is approved for
ing adequate skincare, topical and/or systemic therapy as well restricted use in the treatment of severe papulopustular rosacea
as physical modalities to treat the various symptoms in an ap- and severe ocular rosacea in adults.11 In this case, lymecycline
propriate and targeted manner.1,3 Initially, our patient was pre- 300 mg twice a day for 2 weeks, was given to our patient owing to
scribed with topical brimonidine, indicated for persistent facial its good safety profile and is generally well-tolerated, occasion-
erythema of rosacea. Topical brimonidine 0.33% gel appears to ally causing transient mild gastrointestinal disturbances, and
be well tolerated, however, patients must be advised about the rare allergic reactions.
Despite the use of topical and oral antimicrobials, our
J Phil Dermatol Soc · November 2021 · ISSN 2094-201X 70
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patient showed very minimal reduction in the inflammatory especially telangiectasias.1,3,10 These modalities do not cure ro-
papules, pustules, and centrofacial erythema. However, there sacea, and periodic treatments to maintain improvement are
was significant improvement when topical antimicrobials were often required.10 Non-ablative long-pulsed Nd:YAG addresses
used in conjunction with isotretinoin. Due to its lacking ap- these facets of the disease well and has an important place in
proval, isotretinoin can only be used “off-label” for rosacea.10 rosacea treatment both improving vascular clearance and de-
Low-dose isotretinoin is an effective therapeutic option for dif- creasing the amount of scarring.1,3,10
ficult-to-treat papulopustular rosacea and to maintain remis-
sions.10 However, relapse was still observed within a median du- CONCLUSION
ration of 15 weeks.10 Long-term therapy of isotretinoin is hence
required to achieve optimum response.10 Isotretinoin in combi- The complex condition of rosacea implies that there is a need
nation with metronidazole 5% cream was done to optimize ther- for a tailored multimodal approach for treatment success. Pa-
apeutic benefit. To date an evidence-based clinical study on the tient education, skincare, and different therapeutic options
most suitable dose and therapy duration for treatment of rosa- such as those in our patient are necessary for the control of ro-
cea with Isotretinoin is still lacking.10 sacea but must be reiterated that none of these is curative. Our
patient’s presentation demonstrates how rosacea is a chronic,
Finally, laser and light-based therapies, which have been difficult-to-treat disease entity. Standardization of treatment al-
used extensively for the treatment of a variety of vascular le- gorithm is needed to help guide physicians, dermatologists, and
sions, have also been used for the vascular features of rosacea, patients alike.
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. 1419-1447
2. Sbidian E, Vicaut É, Chidiack H, Anselin E, Cribier B, Dréno B, et al. A Randomized-Controlled Trial of Oral Low-Dose Isotretinoin for Difficult-To-
Treat Papulopustular Rosacea. J Invest Dermatol. 2016 Jun;136(6):1124-1129. doi: 10.1016/j.jid.2016.01.025. Epub 2016 Feb 7. PMID: 26854486.
3. Anzengruber F, Czernielewski J, Conrad C, Feldmeyer L, Yawalkar N, Häusermann P, et al. Swiss S1 guideline for the treatment of rosacea. J Eur
Acad Dermatol Venereol. 2017 Nov;31(11):1775-1791. doi: 10.1111/jdv.14349. Epub 2017 Aug 21. PMID: 28833645.
4. Gallo RL, Granstein RD, Kang S, Mannis M, Steinhoff M, Tan J, et al. Standard classification and pathophysiology of rosacea: The 2017 update
by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018 Jan;78(1):148-155. doi: 10.1016/j.jaad.2017.08.037. Epub 2017 Oct
28. PMID: 29089180.
5. Routt ET, Levitt JO. Rebound erythema and burning sensation from a new topical brimonidine tartrate gel 0.33%. J Am Acad Dermatol. 2014
Feb;70(2):e37-8. doi: 10.1016/j.jaad.2013.10.054. PMID: 24438976.
6. Koçak M, Yağli S, Vahapoğlu G, Ekşioğlu M. Permethrin 5% cream versus metronidazole 0.75% gel for the treatment of papulopustular rosacea.
A randomized double-blind placebo-controlled study. Dermatology. 2002;205(3):265-70. doi: 10.1159/000065849. PMID: 12399675.
7. Dahl MV, Katz HI, Krueger GG, Millikan LE, Odom RB, Parker F, et al. Topical metronidazole maintains remissions of rosacea. Arch Dermatol. 1998
Jun;134(6):679-83. doi: 10.1001/archderm.134.6.679. PMID: 9645635.
8. Wilkin JK, DeWitt S. Treatment of rosacea: topical clindamycin versus oral tetracycline. Int J Dermatol. 1993 Jan;32(1):65-7. doi: 10.1111/j.1365-
4362.1993.tb00974.x. PMID: 8425809.
9. Korting HC, Schöllmann C. Tetracycline actions relevant to rosacea treatment. Skin Pharmacol Physiol. 2009;22(6):287-94. doi: 10.1159/000235550.
Epub 2009 Sep 25. PMID: 19786821.
10. Say EM, Okan G, Gökdemir G. Treatment Outcomes of Long-Pulsed Nd: YAG Laser for Two Different Subtypes of Rosacea. J Clin Aesthet
Dermatol. 2015 Sep;8(9):16-20. PMID: 26430486; PMCID: PMC4587890.
71 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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AIDS-associated Kaposi sarcoma: A case series in the
Philippine setting
Ricky H Hipolito, MD, FPDS,1 Ma Teresita G Gabriel, MD, FPDS,1
Johannes F Dayrit, MD, FPDS, FDSP,1 Ma Carmela P Bucoy, MD1
ABSTRACT
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.
KEYWORDS Kaposi sarcoma, AIDS-KS, HAART
1Department of Dermatology, INTRODUCTION The Philippines, with a 174% increase in
Research Institute for Tropical HIV incidence between 2010 and 2017, has the
Medicine, Alabang, Muntinlupa, Kaposi sarcoma (KS) is the second most frequent fastest growing HIV epidemic in the world.2 The
Philippines tumor occurring in patients with acquired im- great majority are MSM (87%); therefore, AIDS-
munodeficiency syndrome (AIDS) particularly in KS may become a more significant problem in the
Corresponding author men who have sex with men (MSM).1 A second in- future as people living with HIV/AIDS (PLHIV)
Ricky H. Hipolito, MD, FPDS fectious etiology, transmitted primarily through are aging and the disproportionate prevalence of
saliva was identified: the Kaposi sarcoma-related the epidemic among MSM.1
Conflict of interest herpes virus (KSHV).1
None Despite being one of the first AIDS-defin-
AIDS-KS has been recognized as a distinct ing illnesses recognized, there is still a paucity
Source of funding class of Kaposi sarcoma due to its unique epi- of published studies on the prevalence, clinical
None demiologic and clinical characteristics. It has a characteristics, and management of AIDS-KS in
predisposition towards MSM-human immunode- the local setting.
ficiency virus (HIV)-positive homosexuals, often
disseminated at presentation, rapidly progres- This report aimed to describe the epidemi-
sive and often fatal.1 ologic, clinical and histopathologic characteris-
tics of AIDS-KS patients seen at a tertiary referral
The availability of combination antiretro- center. It also aimed to determine the manage-
viral treatment (cART) was accompanied by a ment and outcomes of the patients. This report
significant decline in the incidence of AIDS-KS, can facilitate early recognition of AIDS-KS with
with an estimated occurrence of 900 per year in appropriate treatment leading to less deformity
the United States.1
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and other complications. It can also serve as basis for further topathologically confirmed AIDS-KS from 2012 to 2018 (Table
studies on AIDS-KS which can pave the way for better therapeu- 1). We reviewed the medical records, clinical photographs, and
tic strategies. histopathologic slides, which were read by the department der-
matopathologist.
CASE SERIES
All patients were Filipino MSM with a mean age of 36.55
A retrospective review was done among patients of the Research years (SD 11.54) (range, 23 to 58). The mean duration of skin
Institute for Tropical Medicine (RITM) Department of Derma- manifestations to diagnosis was 5.1 months (SD 6.6) (range, 1
tology, a tertiary referral center in Infectious Disease and Der- to 24). All patients presented with violaceous plaques and nod-
matology. This review included 11 patients with HIV and his- ules. Skin biopsy specimens stained with hematoxylin and eo-
Table 1. Clinical characteristics of patients
Patient Age Sex Lesion Duration Distribution Initial CD4+ Histopathology findings Opportunistic HAART
(months) Count infection / AIDS-related
Lamivudine
1 35 M Violaceous 1 Chest, arms, 154 Acanthosis; basal cell layer hyperpigmen- Conditions Zidovudine
axillae, palate tation; mixed inflammatory infiltrate; slit-like None Tenofovir
Plaques, Nodules (+ oral lesions) vessels; spindle shaped cells; promontory
sign; red blood cell extravasation None Lamivudine Zid-
2 33 M Violaceous 24 Back, left thigh, ovudine
plaques extremities 181 Acanthosis; basal cell layer hyperpigmentation; Chronic diarrhea, Myco-
slit-like vessels; spindle-shaped cells; capillary bacterium tuberculosis, Nevirapine
3 29 M Violaceous 2 Face, trunk, back, proliferation; red blood cell extravasation Pneumocystis jirovecci
Lamivudine
plaques, nodules upper extremities, 77 Acanthosis; slit-like vessels; spindle-shaped pneumonia Zidovudine
cells; promontory sign; red blood cell extrav- Efavirenz
lower extremities, asation
Lamivudine
left sole Zidovudine
Efavirenz
(+ oral lesions)
Lamivudine
4 48 M Violaceous 2 Neck 41 Acanthosis; basal cell layer hyperpigmenta- Recurrent pneumonia Zidovudine
papules Efavirenz
tion; slit-like vessels; spindle shaped cells; red
Lamivudine
blood cell extravasation Zidovudine
Efavirenz
5 29 M Violaceous 1 Face and scalp 73 Mixed inflammatory infiltrate; slit-like vessels; Oropharyngeal candidiasis
plaques spindle shaped cells; promontory sign Lamivudine
Zidovudine
6 25 M Hyperpigmented 4 Scalp, face and 4 Mixed inflammatory infiltrate; slit-like vessels; CMV retinitis, multi- Efavirenz
plaques on face trunk
and scalp spindle shaped cells; promontory sign; red drug-resistant pulmonary Lamivudine
Zidovudine
blood cell extravasation tuberculosis, oropharyngeal Tenofovir
candidiasis Lamivudine
Zidovudine
7 48 M Plaques and 7 Face, trunk, 10 Acanthosis; basal cell layer hyperpigmen- Multidrug-resistant pulmo- Tenofovir
nodules extremities,
tation; mixed inflammatory infiltrate; slit-like nary tuberculosis, oropha- Lamivudine
(+ oral lesions) Zidovudine
vessels; spindle shaped cells ryngeal candidiasis Efavirenz
4 Trunk and extrem-
8 23 M Violaceous ities (2 mos. after 30 Slit-like vessels; spindle-shaped cells; capillary None Lamivudine
9 46 M nodules and HIV diagnosis) proliferation, promontory sign, red blood cell Tenofovir to
extravasation Lamivudine
plaques 4 Face, neck, trunk Zidovudine
(+ oral lesions) 44 Acanthosis; basal cell layer hyperpigmenta- Pulmonary tuberculosis Lopinavir/ritonavir
Violaceous (3 mos after HIV
papules and diagnosis) tion; slit-like vessels; spindle-shaped cells; red
plaques 1 Trunk, upper and blood cell extravasation
lower extremities
10 28 M Violaceous 28 Acanthosis, mixed inflammatory infiltrates; None
6 Trunk and spindle-shaped cells; slit-like vessels; capillary None
papules, plaques extremities proliferation, promontory sign
and nodules 73 Acanthosis; basal cell layer hyperpig-
menation; mixed inflammatory infiltrate;
11 58 M Violaceous spindle-shaped cells;
nodules
HAART=Highly active antiretroviral therapy; CMV=Cytomegalovirus
73 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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A Dermatological Society
B C
D
Figure 1. A and B. A 29-year-old man presenting with violaceous plaques and nodules distributed face and oral mucosa. C and D. A known case of HIV since 2016 and presented with a
4-month history of a solitary violaceous macule on the left side of the neck evolving into nodules and plaques with subsequent affectation of the retroauricular area, scalp, and face.
sin were obtained from all patients. Ancillary procedures such Nine of 11 patients did not develop new lesions upon start-
as chest x-ray, colonoscopy, chest/abdominal CT scan were done ing HAART. Two patients were hospitalized, with one admitted
depending on clinical criteria. due to Pneumocystis jiroveci pneumonia. He was discharged
improved after 15 days and there was note of decreased thick-
The majority of patients (9/11) presented with widespread ness of lesions after 1 month of initiation of HAART. The other
skin involvement. The skin lesions were noted on the trunk in patient, however, succumbed on his second hospital day due to
9/11 patients (Figure 1), upper and lower extremities in 8, face acute respiratory distress syndrome (ARDS).
in 6, head and neck in 4 patients (Figure 2 B-D). Four patients
presented with oral lesions (Figure 2 A). The median CD4+ count DISCUSSION
of patients was 44 cells/µL (range, 4 to 181). Six of 11 patients,
whose CD4+ counts were between 4 to 77 cells/µL, presented This case series included all male patients with a mean age of 36
with opportunistic infections (OI) /AIDS-related conditions years. This is consistent with a previous case series.3 The mean
(ARC). The most common OI observed were pulmonary tuber- duration prior to diagnosis of 5.1 months (SD 6.6) is corroborat-
culosis (4/11), oropharyngeal candidiasis (3/11), and Pneumo- ed by a previous report where almost half of the patients expe-
cystis jiroveci pneumonia (2/11). The other OI and ARC seen rienced a diagnostic delay of more than 3 months.4 More than
were chronic diarrhea, Cytomegalovirus (CMV) retinitis, ane- half of the patients had lesions for at least four months prior to
mia and AIDS wasting syndrome. diagnosis, which represents a significant diagnostic delay. A
diagnostic lag of more than three months is proposed by some
The histopathologic findings from all patients were con- authors as a significant diagnostic delay as it is associated with
sistent with KS (Figure 3A-B). The most common findings were a poor-risk stage AIDS-KS at presentation.4 In a previous study,
spindle-shaped cells (11/11), slit-like vessels (10/11) and promon- lack of pain, financial difficulties and distance to health care
tory sign (6/11). Other histologic features noted were red blood facility were the most common reasons found for delay in di-
cell extravasation, inflammatory infiltrate, and capillary prolif- agnosis.4
eration.
Widespread skin involvement is consistent with the rapidly
All patients were started on highly active antiretroviral progressive clinical characteristic of AIDS-KS.5 Mucocutaneous
therapy (HAART) with a combination of 2 nucleoside reverse involvement is usually located in skin of the lower extremities,
transcriptase inhibitor (NRTI) and 1 non-nucleoside reverse face, trunk, genitalia and oropharyngeal mucosa.6
transcriptase inhibitor (NNRTI). One patient was later shifted to
2 NRTI and ritonavir-boosted protease inhibitor. While most physicians expect AIDS-KS to present in the
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A done in all patients with a high index of suspicion such as in ho-
mosexuals with HIV infection.9 AIDS-KS histology is consistent
B with tumorigenesis in a background of chronic inflammation,
immunosuppression and HIV-1 infection. Majority of KSHV-in-
Figure 2. A and B. Sections showing spindle-shaped cells with basophilic nuclei and fected cells demonstrate a spindle morphology and presumed to
eosinophilic cytoplasm surrounding vessels. No mitotic figures seen. have lymphatic origin.10 KSHV establishes a lifelong infection to
which the host response is chronic inflammation. In the back-
late stages of AIDS, a recent study suggests AIDS-KS among pa- ground of immunosuppression, chronic inflammation can fa-
tients with HIV and higher CD4+ cell counts is rising.7 Thus, the cilitate tumorigenesis. Chronic lymphedema, lymphangiogen-
index of suspicion should be high among patients with HIV pa- esis induced by HIV-1 tat protein with the above factors lead to
tients and violaceous lesions even with a relatively high CD4+ the development of slit like vessels and tumor formation.11 The
cell count. Most patients in the series presented with wide- detection of human herpesvirus-8 (HHV-8) within KS lesional
spread skin involvement and CD4+ count less than 150 cells/μL cells by using latency-associated nuclear antigen (LANA-1 or
consistent with a previous series.4 A significant association of LNA-1) is the most useful diagnostic immunostaining method to
OIs was found with CD4+ count less than 200 cells/μL, the most differentiate KS from similar lesions.8 AIDS-KS is characterized
common being tuberculosis, candidiasis, and diarrhea.8 This by its rapid course and frequent involvement of visceral organs
correlates with declining T helper function.8 at presentation.1 In a published series, the stomach is the most
frequent site affected.3 The gastrointestinal tract, lymph nodes,
Johnson et al. found in 2011 that Kaposi sarcoma can be a and lungs are other commonly involved extracutaneous sites in
clinical challenge7 and therefore recommended that biopsy be AIDS-KS.1
It was found that among patients treated with HAART, those
receiving efavirenz and protease inhibitor containing HAART reg-
imen were 6.9 times (95% CI 1.8, 27, p = 0.006) and 14 times more
likely (95% CI 1.8, 27, p = 0.006) to have lesion resolution compared
to patients receiving stavudine, lamivudine, and nevirapine.12 All
patients in this series received either a protease inhibitor as part
of their HAART regimen and/or efavirenz. Patients who had follow
up information showed either stabilization of lesions or decrease in
lesion size.12 HAART works by immune reconstitution, decreased
HIV-1 tat protein and decreased angiogenic cytokine production.13
A similar study was previously published which included six
patients with AIDS-KS in a tertiary referral hospital in the Philip-
pines.14
In a case series of 24 patients with AIDS-KS, two were suc-
cessfully treated with HAART. Eighteen were given chemother-
apy using adriamycin, bleomycin and vincristine (ABV). From
those given ABV, remission was induced in 10 patients with a
mean follow up time of 18.25 (±10.99) months while 3 died due to
lesions in the lungs. Those who failed ABV treatment were given
paclitaxel. Two patients achieved remission while another two
died while on second-line chemotherapy.15
CONCLUSION
Eleven patients with AIDS-KS presented in this case series had
similar demographic, clinical, and histopathologic characteris-
tics as previously published studies. The need for early diagno-
sis through clinical suspicion and biopsy of lesions will ensure
optimum outcome and quality of life of patients. HAART shows
favourable outcomes in most cases of AIDS-KS. Other treatment
options such as chemotherapy should be considered for appro-
priate patients.
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REFERENCES
1. Gonçalves PH, Uldrick TS, & Yarchoan R. HIV-associated Kaposi sarcoma and related diseases. AIDS. 2017;31(14):1903-16. doi: 10.1097/
QAD.0000000000001567.
2. Gangcuangco LMA. HIV crisis in the Philippines: urgent actions needed. Lancet Public Health. 2019 Feb;4(2):e84. doi: 10.1016/S2468-2667(18)30265-
2. PMID: 30738505.
3. Pires CAA, Noronha MAN, Monteiro JCMS, Costa ALCD, Abreu Júnior JMC. Kaposi's sarcoma in persons living with HIV/AIDS: a case series in a
tertiary referral hospital. An Bras Dermatol. 2018 Jul-Aug;93(4):524-8. doi: 10.1590/abd1806-4841.20186978. PMID: 30066758.
4. De Boer C, Niyonzima N, Orem J, Bartlett J, & Zafar SY. (2014). Prognosis and delay of diagnosis among Kaposi's sarcoma patients in Uganda: a
cross-sectional study. Infect Agents Cancer. 2014;9;17. doi: 10.1186/1750-9378-9-17.
5. Mehta S, Garg A, Gupta LK, Mittal A, Khare AK, & Kuldeep CM. Kaposi's sarcoma as a presenting manifestation of HIV. Indian J Sex Transm Dis
AIDS . 2011;32(2):108-10. doi: 10.4103/0253-7184.85415.
6. Pantanowitz L, & Dezube BJ. (Kaposi sarcoma in unusual locations. BMC Cancer. 2008;8:190. doi: 10.1186/1471-2407-8-190.
7. Crum-Cianflone NF, Hullsiek KH, Ganesan A, Weintrob A, Okulicz JF, Agan BK, & Infectious Disease Clinical Research Program HIV Working Group.
Is Kaposi's sarcoma occurring at higher CD4 cell counts over the course of the HIV epidemic? AIDS. 2010;24(18):2881-3.
8. Damtie D, Yismaw G, Woldeyohannes D. Anagaw B. Common opportunistic infections and their CD4 cell correlates among HIV-infected patients
attending at antiretroviral therapy clinic of Gondar University Hospital, Northwest Ethiopia. BMC Res Notes. 2013;6:534. doi: 10.1186/1756-0500-
6-534.
9. Johnson EL, Pierpont YN, Donate G, Hiro MH, Mannari RJ, Strickland TJ, et al. Clinical challenge: cutaneous Kaposi's sarcoma of the lower
extremity. Int Wound J. 2011;8:163-8. doi: 10.1111/j.1742-481X.2010.00763.x.
10. Radu O & Pantanowitz L. Kaposi Sarcoma. Arch Pathol Lab Med. 2013;137(2): 289-94. doi: 10.5858/arpa.2012-01010-RS.
11. D ouglas JL, Gustin JK, Moses AV, Dezube BJ, & Pantanowitz L. Kaposi sarcoma pathogenesis: a triad of viral infection, oncogenesis and
chronic inflammation. Transl Biomed. 2010;1(2):172.
12. Nguyen HQ, Okuku F, Ssewankambo F, Magaret AS, Johnston C, Wald A, et al. AIDS-associated Kaposi sarcoma in Uganda: response to treatment
with highly active antiretroviral therapy and chemotherapy. Infect Agents Cancer. 2009;4(Suppl 2):O5. doi: 10.1186/1750-9378-4-S2-O5.
13. Stebbing J, Portsmouth S, Gazzard B. How does HAART lead to the resolution of Kaposi's sarcoma? J Antimicrob Chemother. 2003 May;51(5):1095-
8. doi: 10.1093/jac/dkg199. PMID: 12668573.
14. C atedral L, Caro-Chang L, Tan HN, Velasco R Jr, King R, Ting, FI, et al. AIDS-related Kaposi sarcoma in a tertiary university hospital in Manila,
Philippines: a report of six cases. Asian J Oncol. 2020;06. doi: 10.1055/s-0040-1713317.
15. G waram BA. Clinical presentation and treatment outcome of HIV associated Kaposi sarcoma in a tertiary health centre in Nigeria. J Med Res.
2016;2:110-3.
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Acral lentiginous melanoma and tuberculosis
verrucosa cutis in a 78-year-old Filipino: A case report
Danielle Marlo R. Senador, MD,1 Leilani R. Senador, MD, FPDS,1
Johannes F. Dayrit, MD, FPDS, FDSP,1 Gisella U. Adasa, MD, FPDS1
ABSTRACT
INTRODUCTION Acral lentiginous melanoma is a subtype of melanoma common in Asians with one of the worst prognoses. It is
usually detected late especially when situated on the plantar surface of the feet. While other forms of malignancies have been
associated with cutaneous tuberculosis, melanoma is not one of them.
CASE REPORT This is a case of a 78-year-old male with a six-month history of a solitary asymptomatic reddish-brown papule on
the plantar aspect of the right foot, which increased in size evolving into a verrucous plaque. There was no improvement despite
treatment with oral antibiotics and topical antifungals. Dermoscopic findings on different parts of the lesion were suggestive of
both a granulomatous disease and a melanoma. Purified Protein Derivative (PPD) skin test was positive. Histopathologic findings
showed the presence of multinucleated giant cells as well as nests of melanocytes which were highlighted by CD-68 and Melan-A
respectively. With clinicopathologic correlation, diagnosis of the patient was tuberculosis verrucosa cutis and acral lentiginous
melanoma. Complete excision with adequate margins was advised. The patient was started on a 6-month course of anti-Koch’s
medications and was referred to a surgery and oncology for co-management. The patient was subsequently lost to follow up,
until worsening of the lesions 6 months later prompted online consultation, claiming poor compliance to his anti-Koch’s regimen.
Patient was referred to a surgeon who did wide excision biopsy. Histopathologic findings were consistent with acral lentiginous
melanoma. Shortly after the procedure, the patient expired.
CONCLUSION This is a rare case of acral lentiginous melanoma and tuberculosis verrucosa cutis existing concomitantly with
each other. This may also be presumed to be the first reported case of acral lentiginous melanoma arising from tuberculosis
verrucosa cutis.
KEYWORDS Melanoma, Tuberculosis, Dermoscopy
1Department of Dermatology INTRODUCTION We report an interesting case wherein both
Research Institute of Tropical entities occurred concomitantly with or conse-
Medicine, Research Drive, Tuberculosis is a global scourge affecting 33% quently to each other.
Filinvest, Muntinlupa City of the people of the world.1 It has been asso-
ciated with several immunocompromised CASE REPORT
Corresponding author conditions such as HIV and cancer.2 Patients
Danielle Marlo R. Senador, MD diagnosed with cancer are more susceptible This is a case of a 78-year-old male farmer
to being infected with tuberculosis. Converse- from Bacoor, Cavite presenting with a plaque
Conflict of interest ly, chronic inf lammation from long-standing on his right foot.
None cutaneous tuberculosis lesions may undergo
malignant transformation to non-melanoma Six months prior to consulting, the pa-
Source of funding cancers.3 tient developed a solitary asymptomatic red-
None dish-brown papule on the plantar aspect of the
Acral lentiginous melanoma (ALM) is a fourth digit of the right foot, which increased in
variant of melanoma that accounts for 29-46% of size evolving into a verrucous plaque with black
cases of melanoma in Asians with an incidence areas. Self-medication with an herbal concoc-
of 2-8%. It is commonly found on the palms and tion made of guava leaves proved ineffective.
soles and is usually detected late because acral Four months prior to consulting, the patient was
lentiginous melanoma, especially on the plantar seen and prescribed treatment for a non-heal-
aspect of the feet are misdiagnosed as other ver- ing wound at a local health center. Co-amoxiclav
rucous disease entities.4 625mg/tab three times a day for seven days and
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AB of the right foot measuring 2.5 x 2.5 x 1 cm. A black nodule mea-
suring 1.5 x 2.0 x 0.5 cm. was noted on plantar aspect (Figure 1
Figure 1. A and B. Multiple views of patient presenting with solitary well-defined, irregularly A-B). There were no palpable lymph nodes and diascopy did not
shaped, erythematous to hyperpigmented verrucous plaque with areas of maceration on the show apple jelly nodules.
lateral and plantar aspects of the fourth digit of the right foot associated with edema.
Dermoscopy reveals a multicomponent pattern with ab-
sertaconazole cream twice a day for two weeks likewise pro- sence of the typical ridge pattern, blood vessels, crusting,
vided no relief. An increase in size and maceration prompted brown dots and globules, as well as milky red areas (Figure 2A-
consult at our institution. The patient had no cough, hemopty- B). The medial aspect of the tumor revealed reddish-brown ar-
sis, fever, night sweat, weight loss, or anorexia. He was BCG vac- eas with small coiled vessels. Overlying white and yellow areas
cinated, with no known previous exposure to tuberculosis. the and scales are noted suggestive of a granulomatous disease (Fig-
patient denies any other illness nor intake of other medications. ure 2A). The plantar aspect of the tumor showed black areas and
He was an occasional alcoholic beverage drinker and a smoker clods suspicious of melanoma.
of 60 pack years. The patient claims to have had frequent injury
to his feet while working barefooted in the fields. Radiographic findings showed hilar infiltrates on the right
upper lobe, interpreted as pulmonary tuberculosis. Purified
Physical examination showed an irregularly shaped and Protein Derivative (PPD) skin test was positive, having an indu-
edematous verrucous tumor with areas of discoloration and ration greater than 15 mm.
maceration on the lateral and plantar aspects of the fourth digit
A four-millimeter punch biopsy was taken from the plantar
aspect of the patient’s right foot. Histopathologic examination
of the biopsy specimen stained with hematoxylin and eosin re-
vealed follicular plugging, hyperkeratosis, and parakeratosis of
the stratum corneum. There was prominent acanthosis of the
epidermis with spongiosis, focally lichenoid infiltrate with mul-
tinucleated giant cells, lymphocytes and plasma cells. (Figure
3A-B). Focal areas of the epidermis show a lentiginous prolifer-
ation of atypical melanocytes. Nests of melanocytes were also
observed. The dermis revealed a moderately dense perivascular
infiltrate of lymphocytes and plasma cells.
The histopathological diagnosis at this time was cutaneous
tuberculosis with focal areas of atypical melanocytic prolifera-
tion to rule out melanoma.
CD-68 and Melan-A stains were requested. CD-68 stain
AB
Figure 2. A to B. Dermoscopy findings of patient exhibiting a multicomponent pattern with blood vessels (red arrow), yellowish crusts (yellow arrow), brown dots and globules (blue arrow),
milky red areas (green arrow), and the absence of the typical ridge pattern.
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A
D
C
Figure 3. A and B. Histopathologic examination of the biopsy specimen stained with hematoxylin and eosin showing follicular plugging, hyperkeratosis, and parakeratosis of the stratum
corneum, prominent acanthosis of the epidermis with spongiosis, focally lichenoid infiltrate with multinucleated giant cells (yellow arrows), lymphocytes and plasma cells. Focal areas of
the epidermis showing a lentiginous proliferation of atypical melanocytes. C. Immunohistochemical stain; CD-68 staining histiocytes in the papillary dermis. D. Immunohistochemical stain;
Melan-A highlighting focal nests of melanocytes at the dermo-epidermal junction.
highlighted the multinucleated giant cells in the dermis (Figure 3C). The patient was subsequently lost to follow up, until wors-
This, along with the patient’s PPD and chest x-ray findings strong- ening of the lesions 6 months later (Figure 4) prompted online
ly point to a diagnosis of cutaneous tuberculosis. Melan-A stained consultation, claiming poor compliance to his anti-Koch’s regi-
the atypical melanocytes in the basal cell layer (Figure 3D) which men. He was referred to a surgeon who did wide excision of the
further confirmed the diagnosis of acral lentiginous melanoma. A 5.5 x 3.4 x 5.0 cm black nodular tumor on his right foot. Histo-
complete excision with adequate margins was advised. pathologic findings were consistent with acral lentiginous mel-
anoma. The patient developed and succumbed to pneumonia 2
The patient was referred to the Tuberculosis-Directly weeks after surgery.
observed treatment, short course (TB-DOTS) program for a
2-month course of isoniazid, rifampicin, pyrazinamide, and DISCUSSION
ethambutol followed by 4 months of isoniazid and rifampicin.
Referral to surgery and oncology for co-management was made. Cutaneous tuberculosis is a rare form of tuberculosis affect-
79 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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Dermatological Society
Figure 4. Photograph of patient’s lesion 6 months after last consult via telemedicine. culture or by PCR are considered the gold standards for diagnos-
ing the various types of cutaneous TB.6 Histopathologic findings
ing only 1-2% of individuals with tuberculosis worldwide.5 Of of tuberculosis verrucosa cutis include hyperkeratosis and par-
which, verrucous types predominate in tropical countries like akeratosis in the epidermis and epithelioid cells and giant cells
the Philippines. Tuberculosis verrucosa cutis is a paucibacillary in the upper and middle dermis. This is further supplemented
disorder caused by inoculation at sites of minor trauma, or from by immunostains such as CD68 which is strongly expressed by
the patient’s sputum. Tuberculosis verrucosa cutis present as epithelioid cells in regions where bacteria reside.6 These, along,
papules which eventually thicken and increase in size, evolving with positive AFB smears and growth of mycobacterium tuberculo-
into verrucous plaques with irregular borders.1 sis on culture, indicate an immensely high probability that a patient
is infected with cutaneous tuberculosis. However, the lack thereof
Tuberculosis verrucosa cutis, and other forms of cutaneous does rule the diagnosis out.6 Tuberculosis verrucosa cutis, being a
tuberculosis may be diagnosed through the following diagnostic paucibacillary disorder, would yield negative for the presence of
modalities: PPD or Tuberculin skin test, Quanti-FERON-TB gold Mycobacterium tuberculosis on culture.6
test, chest x-ray, histopathologic testing and TB culture. Histo-
pathologic testing and isolation of Mycobacterium tuberculosis in Left untreated, long-standing inflammatory conditions
such as cutaneous tuberculosis may develop into malignant,
non-melanoma conditions because increased cell turnover rate
increases the chance of genetic errors.1
Acral lentiginous melanoma (ALM) is a variant of mela-
noma frequently seen in Asians and darker skinned individu-
als with a predilection for the elderly. ALM lesions are usually
brown to black and commonly found on the palms, soles, and
under the nails, the sole being the most common site. They
are often misdiagnosed as verrucous lesions.1 Acral lentiginous
melanoma is one of the worst subtypes of melanoma and ear-
ly detection is warranted to improve its prognosis.7 The risk of
metastasis increases with the increase in depth of the primary
lesion, thus, certain characteristics of skin such as asymmetry,
irregularity in borders, discoloration, diameter of greater than
5mm, and evolution should raise the suspicion for melanoma.1
Dermoscopic findings including collection of melanocytes
in the crista intermedia or the ridges, a parallel-ridge pattern on
the volar skin, and a multicomponent pattern or the presence
of multiple colors and structures may help in the diagnosis of
ALM. ALM on the sole may also exhibit a fibrillar pattern but
thicker, darker, and more irregular.8 Most of these findings were
seen in our patient including the presence of blood vessels, yel-
lowish crusts, brown ovoid nests, irregular streaks, and white
globules. The thickness of the lesion precluded visualization of
furrows and ridges.
Suspected lesions should be subjected to prompt excisional
biopsy with wide margins. In lesions on the sole, tissue sample
should be taken from the most elevated or hyperpigmented area.
Histopathologic findings of melanoma may include asymmetry,
presence of ulceration, cell atypia, and pagetoid involvement
of the epidermis and nests of melanocytes of varying shapes
and sizes in the lower epidermis and dermis.4 However, none of
these findings are diagnostic of melanoma.1 Melan-A is needed
to confirm the nature of atypical cells as melanoma.4
Presence of increased tumor thickness, ulceration, mitot-
ic rate, vascular and lymphatic involvement indicates a poorer
prognosis. None of which were present in the histopathologic
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findings of our patient. Management of melanoma entails mul- CONCLUSION
tidisciplinary approach involving oncology and surgery.
Coexistence of a malignant neoplasm and a chronic skin infec-
Chronic inflammatory conditions such as long-standing tion may occur in elderly individuals. Acral lentiginous mela-
tuberculosis infection are known to cause malignant transfor- noma may be overlooked due to its similarities in presentation
mation. The most common associated malignancy is squamous with tuberculosis verrucosa cutis. Clinicians, especially those
cell carcinoma with few reported cases of basal cell carcinoma. residing in countries where there is a widespread tuberculosis
infection, should be aware of the presentations of both disease
Extensive search of literature, suggests that this is the first entities as well as of the possibility of malignant transformation
report of acral lentiginous melanoma existing concomitantly with in cutaneous tuberculosis. This case underscores the impor-
tuberculosis verrucosa cutis. It may also be presumed to be the first tance of comprehensive investigation for proper diagnosis and
case of acral lentiginous melanoma arising from tuberculosis ver- prompt treatment.
rucosa cutis.
REFERENCES
1. Kang S, Amagai M, Bruckner A, ENK A, Margolis D, McMichael A, Orringer J. Fitzpatrick’s Dermatology. 9th ed.
2. World Health Organization. The top 10 causes of death. World Health Organization. Retrieved from: https://www.who.int/news-room/fact-
sheets/detail/the-top-10-causes-of-death
3. Falagas ME, Kouranos VD, Athanassa Z, Kopterides P. Tuberculosis and malignancy. QJM. 2010 Jul;103(7):461-87. doi: 10.1093/qjmed/hcq068. Epub
2010 May 26. PMID: 20504861.
4. Patravala S, Malay A, Greskovich C, Stuart L, Parker D, Swerlick R. Discordance of histopathologic parameters in cutaneous melanoma: clinical
implication. J Am Acad Dermatol. 2016;74:75–80. DOI: 10.1016/j.ad.2017.09.018
5. Yang T, Su Y. A rare case of tuberculosis verrucosa cutis on the buttocks. The Kaohsiung Journal of Medical Sciences. DOI: 10.1002/kjm2.12150
6. Afsar I, Afsar FS. Evaluation of laboratory diagnosis for cutaneous tuberculosis. Indian J Pathol Microbiol. 2016 Jul-Sep;59(3):274-8. doi:
10.4103/0377-4929.188132. PMID: 27510659.
7. Redi U, Marruzzo G, Lovero S, Khokhar HT, Lo Torto F, Ribuffo D. Acral lentiginous melanoma: A retrospective study. J Cosmet Dermatol. 2021
Jun;20(6):1813-1820. doi: 10.1111/jocd.13737. Epub 2020 Oct 9. PMID: 32979858.
8. Maghoob A, Malvehy J, Braun R. Atlas of dermoscopy, 2nd ed.
9. Lim JA, Tan WC, Khor BT, Hukam Gopal Chand SD, Palanivelu T. Early Onset of Squamous Cell Carcinoma Arising From Tuberculosis Verrucosa
Cutis. J Am Coll Clin Wound Spec. 2018 Jun 21;9(1-3):35-38. DOI: 10.1016/j.jccw.2018.06.003
81 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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Dermatological Society
Herpes zoster after COVID-19 vaccination: A case series
Christine E. de Guia, MD,1 Ivy S. Cagulada, MD,1 Jonella Jean F. Nicolas, MD,1 Cecilia R.
Rosete, MD, FPDS,1 Czarina P. Chavez, DipClinRes, MD, FPDS1
ABSTRACT
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic caused a global health crisis, necessitating the development
of vaccines. An emerging cutaneous reaction is herpes zoster.
CASE SERIES We present 7 cases of Filipino patients who developed herpes zoster after receiving the COVID-19 vaccine. Four
patients received Sinovac Biotech Ltd (CoronaVac), 2 patients received Oxford AstraZeneca, and 1 patient received Pfizer-BioN-
Tech (COMIRNATY). Five patients developed herpes zoster after their first dose of the vaccine, while 2 patients developed herpes
zoster after their second dose. All patients were prescribed anti-viral medication, after which resolution of the lesions was
observed.
CONCLUSION As more vaccines are administered, further surveillance is necessary to expand our understanding of a possible
association between herpes zoster and COVID-19 vaccines. Additionally, awareness of cutaneous reactions following COVID-19
vaccines and their disease course can contribute to shifting the attitude towards pro-vaccination.
KEYWORDS COVID-19 vaccine, herpes zoster, COVID-19
1Department of Dermatology, INTRODUCTION HZ after their second dose (Figure 1). Five pa-
Rizal Medical Center, Pasig tients had comorbidities, while the two youngest
Boulevard, Pasig City The coronavirus disease 2019 (COVID-19) pan- patients were healthy and without other illness-
demic caused a global health crisis, necessitating es. All patients had a history of previous varicella
Corresponding author the development of vaccines. In the past year, infection. The lesions of HZ appeared within a
Christine E. de Guia, MD different types of vaccines were manufactured: median of 6 days (IQR 3-8) after COVID-19 vacci-
mRNA-based, viral vector-based, and inactivated nation and resolved in 6 patients after 7 days (IQR
Conflict of interest vaccines.1 Several cutaneous adverse effects of 5.25-8.5). One patient was lost to follow-up. All pa-
None COVID-19 vaccines have been reported, includ- tients were prescribed antiviral medication for HZ.
ing delayed large local reaction, local injection
Source of funding site reaction, urticarial eruption, and morbilli- DISCUSSION
None form eruption.2 An emerging cutaneous reaction
is herpes zoster (HZ),2-6 an uncommon reaction Herpes zoster, caused by reactivation of the VZV,
following vaccines other than varicella zoster vi- may occur spontaneously or may be triggered by
rus (VZV) vaccine.5 age-related immunosenescence, stress, fever,
trauma, or immunosuppression.3-5,7 Herpes zos-
CASE REPORT ter following vaccines other than VZV vaccine is
uncommon.7 A few reports have demonstrated
We present 7 cases of Filipino patients who de- HZ following hepatitis A, influenza, rabies, and
veloped their first episode of HZ after receiving Japanese encephalitis vaccines.7 Recently, HZ
COVID-19 vaccination from April to August 2021 has emerged as a possible cutaneous reaction
(Table 1). Four (57%) patients were female and 3 following COVID-19 vaccines. The postulated
(43%) were male. Their median age was 54 years mechanism behind this reaction is vaccine-re-
(IQR 28-67). Four (57%) patients received Sino- lated immunomodulation,3,5,7 which pertains to
vac Biotech Ltd (CoronaVac), 2 (29%) patients re- the immunosuppressive effect of vaccines due to
ceived Oxford AstraZeneca, and 1 (14%) patient impairment of cellular immunity and decrease
received Pfizer-BioNTech (COMIRNATY). Five in alloreactivity.7 One noteworthy limitation of
(71%) patients developed HZ after their first dose this study is that the history of VZV vaccination
of the vaccine, while 2 (29%) patients developed
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Table 1. Summary of patient characteristics
Patient Age Gender Allergies and Vaccine 1st or 2nd dose Latent Affected dermatome/s Cutaneous description Treatment given Number of days
comorbidities brand period (in of lesions until resolution
1 54 Male Hypertension, Sinovac 1st days) C8-T1, left Multiple, grouped vesicles, Acyclovir 800mg 6
8 V2, right some coalescing into BID for 5 days 3
diabetes mellitus V2-V3, left (adjusted for creat- 6
3 V1, right bullae, on a slightly ery- inine clearance), 8
type 2, end-stage 6 T11-T12, left thematous base pregabalin 75 mg 8
14 T11-T12, right 10
renal disease (on 3 once daily
C4, right Lost to follow up
dialysis) 7
2 28 Female None Sinovac 1st 3 Multiple, grouped papules Acyclovir 800mg
and vesicles on an ery- 5x/day for 7 days,
thematous base pregabalin 75 mg
once daily
3 68 Female Hypertension, Sinovac 1st Multiple, grouped vesicles Acyclovir 800mg
on an erythematous base 5x/day for 7 days,
diabetes mellitus with areas of crusting, with pregabalin 75 mg
type 2 involvement of the lips once daily
4 67 Male Psoriasis, hypo- Sinovac 2nd Multiple papules and ves- Valacyclovir 1g
icles on an erythematous TID for 7 days,
thyroidism base, with involvement of gabapentin 300
mg once daily
the right eyelid
5 53 Male Hypertension, Pfizer 1st Multiple, grouped vesicles Acyclovir 800mg
on an erythematous base 5x a day for 7
diabetes mellitus with areas of hemorrhagic
days, pregabalin
type 2 crusting 75mg BID for 7
days
6 61 Female Hypertension, Astra- 2nd Multiple, grouped vesicles Valacyclovir 1g
Zeneca on an erythematous base BID for 7 days,
allergy to cotri- paracetamol +
vitamin B complex
moxazole BID, acyclovir
cream BID, fusidic
acid + hydrocorti-
sone cream BID
7 27 Female None Astra- 1st Multiple, grouped vesicles Valacyclovir 1g
Zeneca on an erythematous base TID for 7 days
BID=Twice a day; TID=Three times a day
in most of our patients is unknown or unrecalled. ditionally, this was seen in both elderly and young patients.3-5,8
Several types of COVID-19 vaccines are currently avail- In a review of 40 cases of VZV reactivation after COVID-19 vacci-
nation, the median age of patients was 46 years, with patients as
able and include mRNA-based, viral vector-based, and inacti- young as 36 years old also affected,8 while other cases reported
vated vaccines. The mRNA-based vaccines are Pfizer-BioNTech this reaction to occur primarily in an older age group.3,4 Our re-
(COMIRNATY) and Moderna, the viral vector-based vaccines port describes HZ occurring in both immunocompetent and im-
are Oxford AstraZeneca and Johnson & Johnson, while the in- munocompromised patients, in both healthy patients and those
activated vaccines are Sinovac Biotech Ltd (CoronaVac) and with comorbidities, and in both the young and elderly after re-
Sinopharm.1 Herpes zoster has been reported following mRNA ceiving COVID-19 vaccination.
vaccine2,4-6 and inactivated COVID-19 vaccine.3 This reaction oc-
curs in both immunocompetent and immunocompromised pa- In the cases found in literature, majority of patients were
tients.3,6 There were no reports of disease dissemination even reported to develop HZ after their first dose of COVID-19 vac-
in immunocompromised patients.3,6 Herpes zoster was also re- cine, and for all cases, no adverse effects were noted after the
ported to occur both in patients with comorbidities and in those second dose.5,8 Our report shows similar findings, with 5 out of 7
who are healthy with no known illnesses.3-5,8 While most case patients developing HZ after their first dose. Of these 5 patients,
reports demonstrated cases of HZ occurring in patients with 3 received their second vaccine dose with no noted recurrence
comorbidities, a larger case series by Fathy et al. reported a of HZ. For the 2 remaining patients, one has yet to receive the
significant number of healthy patients who also developed HZ, second dose, while the other expired due to underlying renal
with 40% of these patients having no known comorbidities.8 Ad- disease prior to receiving the second dose.
83 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
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Dermatological Society
AB intention to no longer receive the second dose of COVID-19 vac-
cine due to the development of HZ after his first dose.8 A similar
C response was observed in one of our patients who initially ex-
pressed her refusal of the second dose of COVID-19 vaccine due
Figure 1. Representative images of herpes zoster occurring after recent COVID-19 vaccination. to fear of recurrence of HZ. After extensive counseling, the pa-
A. 68-year-old female with herpes zoster presenting as multiple, grouped vesicles on tient received the second dose, with no noted recurrence of HZ
an erythematous base with areas of crusting on the left side of the face along the V2-V3 nor other adverse effects. Other patients included in this study
dermatomes, with involvement of the lips. B. 54-year-old male with herpes zoster presenting who developed HZ after their first dose of COVID-19 vaccine did
as multiple, grouped vesicles, some coalescing into bullae, on a slightly erythematous base on not hesitate to receive the second dose. It has been shown that
the left arm along the C8-T1 dermatomes. C. 67-year-old male with herpes zoster presenting as while vaccine acceptance is attributed primarily to the interest
multiple papules and vesicles on an erythematous base on the right temporal aspect of the face in protecting oneself against the COVID-19 virus, vaccine hes-
along the V1 dermatome, with involvement of the right eyelid. itancy is most commonly due to concerns about the vaccine’s
side effects, highlighting the importance of reporting adverse
While most studies did not report the course of HZ fol- events after vaccination.9
lowing COVID-19 vaccination, there was no indication of poor
health outcomes or serious sequelae in these studies.3-5,8 Le- CONCLUSION
sions in our patients who were able to follow up resolved after
treatment with no disease dissemination nor serious sequelae. While this case series cannot establish a direct association be-
Although 1 patient expired 3 days after treatment completion, tween HZ and COVID-19 vaccine, this observation is notewor-
his cause of death was fatal arrhythmia secondary to hyperka- thy because of the temporal relationship. Despite the multitude
lemia, which is related to the patient's underlying renal disease of cases of HZ following COVID-19 vaccination, several doctors
rather than HZ. assert that no evidence of an association exists, and that these
events may merely be coincidental. Herpes zoster is triggered
Another notable finding is the perspective of patients on by physical or emotional stress, which have been found to be
vaccines and the vaccine hesitancy that ensues following ad- common during the pandemic. Herpes zoster is also usually
verse effects such as HZ. Vaccine hesitancy pertains to the un- seen in those who were the first to receive the COVID-19 vac-
willingness to receive safe and recommended vaccines and has cine, which includes the older population with comorbidities. It
become a concern especially during the COVID-19 pandemic.9 is speculated that these may explain the increased incidence of
A study by Fathy et al. reported one patient who expressed his HZ following COVID-19 vaccination, and that the vaccine itself
may be unrelated to HZ.10 Despite the divergent views on this
topic, the possibility of an association continues to be of inter-
est and must be further studied as more cases of HZ following
COVID-19 vaccination are coming to light.
As more vaccines are administered worldwide, further
surveillance is necessary to expand our understanding of this
association. Additionally, vaccine hesitancy is complex and dy-
namic. Awareness of cutaneous reactions following COVID-19
vaccines, their postulated mechanisms, disease course, and ap-
propriate interventions can contribute to shifting the attitude
towards pro-vaccination.
REFERENCES
The authors would like to acknowledge Dr. Maria Katherina Lat-Herrin and Dr. Maria Sharlene P. Temblique for providing the case details of their
patients. The patients in this manuscript have given written informed consent to publication of their case details.
REFERENCES
1. Creech CB, Walker SC, Samuels RJ. SARS-CoV-2 Vaccines. JAMA. 2021;325(13):1318–1320. DOI:10.1001/jama.2021.3199.
2. M cMahon DE, Amerson E, Rosenbach M, et al. Cutaneous reactions reported after Moderna and Pfizer COVID-19 vaccination: A registry-based
study of 414 cases [published online ahead of print, 2021 Apr 7]. J Am Acad Dermatol. 2021;S0190-9622(21)00658-7. DOI: 10.1016/j.jaad.2021.03.092.
3. B ostan E, Yalici-Armagan B. Herpes zoster following inactivated COVID-19 vaccine: A coexistence or coincidence? [published online ahead of
print, 2021 Feb 27]. J Cosmet Dermatol. 2021;10.1111/jocd.14035. DOI: 10.1111/jocd.14035.
4. Eid E, Abdullah L, Kurban M, Abbas O. Herpes zoster emergence following mRNA COVID-19 vaccine [published online ahead of print, 2021 Apr 29].
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Dermatological Society
J Med Virol. 2021;10.1002/jmv.27036. DOI: 10.1002/jmv.27036.
5. Rodríguez-Jiménez P, Chicharro P, Martos-Cabrera L, et al. Varicella-zoster virus reactivation after SARS-Cov2 BNT162b2 mRNA vaccination:
Report of five cases [published online ahead of print, 2021 Apr 24]. JAAD Case Rep. 2021;12:58-59. DOI: 10.1016/j.jdcr.2021.04.014.
6. Furer V, Zisman D, Kibari A, Rimar D, Paran Y, Elkayam O. Herpes zoster following BNT162b2 mRNA Covid-19 vaccination in patients with autoimmune
inflammatory rheumatic diseases: a case series [published online ahead of print, 2021 Apr 12]. Rheumatology (Oxford). 2021;keab345. DOI:
10.1093/rheumatology/keab345.
7. W alter R, Hartmann K, Fleisch F, Reinhart WH, Kuhn M. Reactivation of herpesvirus infections after vaccinations?. Lancet. 1999;353(9155):810.
DOI: 10.1016/S0140-6736(99)00623-6.
8. Fathy RA, McMahon DE, Lee C, et al. Varicella Zoster and Herpes Simplex Virus Reactivation Post-COVID-19 Vaccination: A Review of 40 Cases in
an International Dermatology Registry [published online ahead of print, 2021 Sep 6]. J Eur Acad Dermatol Venereol. 2021;10.1111/jdv.17646. DOI:
10.1111/jdv.17646.
9. Machingaidze S, Wiysonge CS. Understanding COVID-19 vaccine hesitancy. Nat Med. 2021;27:1338-1339.
10. Doheny K. Experts Debunk COVID-19 Vaccine-Shingles Link [Internet]. WebMD. 2021 [cited 15 September 2021]. Available from: https://www.
webmd.com/vaccines/covid-19-vaccine/news/20210209/experts-debunk-covid-19-vaccine-shingles-link.
85 J Phil Dermatol Soc · November 2021 · ISSN 2094-201X
Appendix 1
Journal of the Philippine Dermatological Society • Volume 30 Issue 2 • November 2021
Appendix 2
Journal of the Philippine Dermatological Society • Volume 30 Issue 2 • November 2021
Appendix 3
Journal of the Philippine Dermatological Society • Volume 30 Issue 2 • November 2021
Appendix 4
Journal of the Philippine Dermatological Society • Volume 30 Issue 2 • November 2021
Appendix 4
Journal of the Philippine Dermatological Society • Volume 30 Issue 2 • November 2021
Appendix 4
Journal of the Philippine Dermatological Society • Volume 30 Issue 2 • November 2021
Appendix 4
Journal of the Philippine Dermatological Society • Volume 30 Issue 2 • November 2021
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