JPDS Nov 2022 A

JPDS
Journal of the Philippine Dermatological Society
Volume 31 Issue 2 • November 2022 • ISSN 2094-201X

Generalized tense vesicles and bullae, showing linear deposits of IgG and C3 on the basement zone

Efficacy and safety of Childhood bullous pemphigoid: Knowledge, attitude,
turmeric 1% emollient A case report perception and practices
cream in the control of of primary care physicians
chronic kidney disease-
associated pruritus in regarding common
hemodialysis patients: A dermatological diseases: A
randomized double-blind
cross-sectional study
clinical trial



Editorial Board 2021-2022

Journal of the Philippine Dermatological Society • Volume 31 Issue 2 • November 2022

EDITOR-IN-CHIEF

Bryan Edgar K. Guevara, MD, FPDS

DEPUTY EDITOR MANAGING EDITOR

Hester Gail Lim Bueser, MD, FPDS Mara P. Evangelista-Huber, MD, FPDS

ASSOCIATE EDITORS

Czarina Chavez, MD, FPDS Elisa Rae Coo, MD, FPDS

Lian Jamisola, MD, FPDS Maria Jasmin J. Jamora, MD, FPDS

Hanna Lucero Orillaza, MD, FPDS Melanie Joy Doria-Ruiz, MD, FPDS

Ana Aurelia M. Santos, MD, FPDS Jennifer Aileen A. Tangtatco, MD, FPDS

Patricia Tinio, MD, FPDS Angeli Eloise E. Torres, MD, DPDS

Emmerson Gale S. Vista, MD, FPDS

SECTION EDITORS

Gisella Adasa, MD, FPDS Joyce C. Castillo, MD, FPDS

Tanya Perez-Chua, MD, FPDS Stephen Lacson, MD, FPDS

Sharon Lim, MD, FPDS Eugenio R. Pipo III, MD, FPDS

Lily Lyralin Laconico Tumalad, MD, FPDS Cybill Dianne C. Uy, MD, FPDS

Mia Angela C. Verzosa, MD, FPDS

SOCIAL MEDIA EDITORS

Terese Monette O. Aquino-Agas, MD, DPDS Jay-V James G. Barit, MD, DPDS
Jarische Frances S. Lao-Ang, MD, DPDS Ana Aurelia M. Santos, MD, FPDS
Erin Jane L. Tababa-Santos, MD, DPDS
Francesca Sumilang Sy-Alvarado, MD, FPDS

EDITORIAL ADVISER

Camille B. Angeles, MD, FPDS

COPYEDITORS LAYOUT ARTIST

Jaryll Gerard L. Ampog Clarence Xlasi D. Ladrero
Rodel C. Roño

EDITORIAL OFFICE

#73 Malakas Street, Diliman, Quezon City 1100 Philippines
(632) 8727 7309 • https://journal.pds.org.ph/
JPDS is indexed in the Western Pacific Rim Index Medicus (WPRIM) and HERDIN.
ISSN: 2094-201X PHILIPPINE COPYRIGHT @ 2014 Philippine Dermatological Society. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or
by any means without prior permission in writing from the copyright holder.

DISCLAIMER

The Philippine Dermatological Society and Editors cannot be held responsible for errors or any consequences arising from the use of information contained in this journal; the views and opinions expressed do not
necessarily reflect those of the Philippine Dermatological Society and Editors, neither does the publication of advertisments constitute any endorsement by the Philippine Dermatological Society and Editors. All
editorial staff are requested to disclose any potential conflict of interest, including current or recent financial relationships with any commercial entity whose products or services may be contained in the journal
content. The competing interests are disclosed in our website.

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X i

Philippine Dermatological Society

OFFICERS AND BOARD DIRECTORS 2021-2022

Journal of the Philippine Dermatological Society • Volume 31 Issue 2 • November 2022

PRESIDENT

Francisco D. Rivera IV, MD, FPDS

VICE PRESIDENT

Noemie Salta Ramos, MD, FPDS

SECRETARY

Roberto Antonio D. Pascual, MD, FPDS

TREASURER

Mary Charmaine G. Castillo, MD, FPDS

IMMEDIATE PAST PRESIDENT

Ma. Purita Paz-Lao, MD, FPDS

DIRECTORS

Christene Pearl F. Arandia, MD, FPDS
Blossom Tian Chan, MD, FPDS

Krisinda Clare Dim-Jamora, MD, FPDS
Lonabel A. Encarnacion, MD, FPDS
Nancy Garcia-Tan, MD, FPDS
Cecilia Roxas Rosete, MD, FPDS
Arnold C. Yu, MD, FPDS

ii J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

Table of Contents

Journal of the Philippine Dermatological Society • Volume 31 Issue 2 • November 2022

ORIGINAL ARTICLES CASE REPORTS
1 41

A cross-sectional study of the prevalence and factors An atypical case of a 14-year-old Filipino female
associated with self-medication among patients with non-classical congenital adrenal hyperplasia
at the out-patient clinic of the department of presenting with alopecia universalis
dermatology in Rizal Medical Center Erwin John R. Aquino, Aira Monica R. Abella,
Luisa Marie S. Cruz, Martha B. Tapales Ma. Teresita G. Gabriel

6 44

Sociodemographic and clinical profile of geriatric Childhood bullous pemphigoid: A case report
patients seen at the Southern Philippines Medical Gemma Theresa C. David-Corpuz, Cathrine B. Ang, Camille
Center Department of Dermatology from January B. Angeles, Maria Jasmin J. Jamora, Lian C. Jamisola
2016 to December 2019
Michelle D. Sim, Maricarr Pamela M. Lacuesta – Gutierrez, 48
Rea Tarro-Dapiton
An unusual presentation of painless penile erosions
14 of pemphigus vulgaris: A case report
Ma. Bianca Therese Relova-Haresco, Gisella U. Adasa,
Efficacy and safety of turmeric 1% emollient cream Sarah E. Nain
in the control of chronic kidney disease-associated
pruritus in hemodialysis patients: A randomized 52
double-blind clinical trial
Michaela M. Tabalon-Morales, Karla Phoebe B. Castaños, Treatment response as a diagnostic feature in zinc
Michelle D. Sim deficiency-associated dermatitis in a three-month-
old Filipino male: A case report
21 Sher Claranza O. Liquido, Jamaine Melisse L. Cruz-
Regalado
Knowledge, attitude, perception and practices
of primary care physicians regarding common
dermatological diseases: A cross-sectional study
Tanya Patricia A. Marasigan, Ma. Angela M. Lavadia,
Wilsie Salas-Walinsundin

31

Skin cancer in a public tertiary hospital in Manila,
Philippines from 2015 to 2019: A retrospective study
Aizlynn Anne J. Robledo, Krisinda Clare C. Dim-Jamora

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X iii

JPDS ORIGINAL ARTICLE
Journal of the Philippine
Dermatological Society

A cross-sectional study of the prevalence and
factors associated with self-medication among
patients at the out-patient clinic of the department

of dermatology in Rizal Medical Center

Luisa Marie S. Cruz, MD,1 Martha B. Tapales MD, FPDS1

ABSTRACT

INTRODUCTION The trend of self-medication practices is increasing worldwide especially in developing countries like the Philippines. If inappro-
priately practiced, this can lead to deleterious effects. Despite this, literature available in this area are limited.

OBJECTIVES The primary objective of this study was to determine the prevalence and factors that contribute to self-medication practices among
dermatology patients in the out-patient clinic of a tertiary government hospital.

METHODS An analytical cross-sectional study was conducted from December 2020 to April 2021 in an out-patient dermatology clinic of Rizal Med-
ical Center using a self-administered questionnaire. Descriptive statistics were used to summarize participant characteristics while univariate
binary logistic regression analysis was used to determine possible factors associated with self-medication.

RESULTS The practice of self-medication was prevalent in 88.70% of the participants. The most common facilitators for self-medication were
recommendation by family or friends (49%) and having a previous prescription (39%). The most common medicines utilized were topical steroids
(18%), combination topical medication (16%), and anti-acne preparations (10%). On univariate analysis, the likelihood of self-medication was almost
four-fold among those with a monthly income of less than PHP 9,000 compared to those who had a higher monthly income.

CONCLUSION There is a high prevalence of self-medication among patients with dermatologic conditions. Patients with low monthly income were
almost four times more likely to self-medicate.

KEYWORDS self-medication, self-care, dermatology

1Department of Dermatology, Rizal INTRODUCTION self-medication. When appropriately practiced,
Medical Center responsible self-medication becomes economi-
Corresponding author The World Health Organization (WHO) defines cal especially in countries with limited resources
Luisa Marie S. Cruz, MD self-care as a broad concept that refers to actions as it results to reduction in the load of medical
Conflict of interest people practice to maintain health, prevent dis- services.1 However, when inappropriately prac-
None eases, and deal with illnesses. These activities ticed, this leads to several possible deleterious
Source of funding are done individually or with the help of pro- effects.2,3 These include wastage of resources,
None fessionals to maintain good hygiene, nutrition, increased chances of microbial resistance to an-
and lifestyle. WHO noted an increasing trend in tibiotics, adverse drug reactions, and prolonged
1 self-care practices among individuals influenced morbidity.4
by lifestyle, easy access to medicines, public
health, and socioeconomic and environmental Self-medication is reported to be practiced
factors. Self-medication, an element of self-care, worldwide especially in developing countries
is defined as the use of medicine by individuals because most drugs are available over-the-
to treat self-recognized illness or symptoms. counter without prescription. The prevalence of
Socioeconomic factors which include improved self-medication practices in the Southeast Asia
educational levels and greater access to informa- was reported at 43% compared to 3% in North-
tion increases an individual’s interest in personal ern Europe.3,5 Similarly, a review focusing on
health thus making them likely to self-medicate. the prevalence of this practice on skin diseas-
Easy access to medications without the need for es showed that a larger number of individuals
a prescription also increases the likelihood of self-medicate in developing countries such as

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Brazil and those in the African continent.6 from December 2020 to April 2021 were invited to participate
Although it is common to encounter patients in dermatolo- in the study. Informed consent was obtained for all partici-
pants who agreed to participate. A self-administered structured
gy clinics who reported to have self-medicated, studies that in- questionnaire, in English and Filipino, with 10 items was used
vestigate the prevalence and factors that contribute to self-med- to collect data. For participants seen via teledermatology, both
ication practices among dermatology patients are limited. This consent forms and self-administered questionnaires were given
study aimed to determine the prevalence and factors associated via an online form.
with self-medication practices among dermatology patients.
The primary outcome assessed were the prevalence
METHODOLOGY of self-medication practice and the factors associated with
self-medication. These factors were theoretically grouped into
QUESTIONNAIRE CONSTRUCTION AND PREPARATION three domains based on the Anderson framework of health
The Andersen model of health service utilization is a framework utilization. Predisposing factors refers to the age, gender, edu-
that identifies factors that may facilitate or impede access to cational attainment, and employment status. Enabling factors
medical care. This model theoretically associates three (3) do- include monthly income and address. Need factors refers to the
mains of individual characteristics to self-care practices includ- duration of the illness prior to consultation.
ing medicine use: predisposing, enabling, and needs factors. No
variables are specified to measure these factors resulting to a STATISTICAL ANALYSIS
great diversity of variables utilized in studies to explain health- Descriptive statistics were used to summarize the general and
care practices and utilization. Our questionnaire was construct- clinical characteristics of the participants. Frequency and pro-
ed based on this model and were arranged according to these portion were used for nominal variables, median and range for
domains. Predisposing factors are the patient’s sociodemo- ordinal variables, and mean and standard deviation for inter-
graphic profile including age, gender, educational attainment, val/ratio variables.
and employment status. Enabling factors include both com-
munity and personal resources such as their monthly income Independent T-test, Mann-Whitney U test and Fisher’s
and address. Need factors, which were previously considered Exact/Chi-square test was used to determine the difference of
as the most powerful predictor of health service, refers to the mean, median and frequency between groups, respectively.
perceived severity of an illness. We used duration of the illness Odds ratios and the corresponding 95% confidence intervals
prior to consultation to evaluate this factor.7,8,9,10 from binary logistic regression was computed to determine the
association between patient profile and self-medication.
The questionnaire consisted of three (3) main parts: pre-
disposing factors, enabling factors, and need factors. Patients All valid data were included in the analysis. Missing data
were also asked of their source of knowledge. The questionnaire were neither replaced nor estimated. Null hypothesis was re-
was available in both English and Filipino language. The ques- jected at 0.05α-level of significance. STATA 15.0 was used for
tionnaire was pre-tested by 10 participants through purposive data analysis.
sampling followed by cognitive debriefing.
RESULTS
STUDY DESIGN AND POPULATION
An analytical cross-sectional study was conducted among pa- SOCIO-DEMOGRAPHIC PROFILE OF THE RESPONDENTS
tients of the Department of Dermatology of Rizal Medical Cen- Data from 141 dermatology patients were analyzed (Table 1).
ter to determine the factors associated with self-medication. Most patients were between 18-35 years of age (67%), female
All patients aged 18 years old and above seen at the out-patient (75%), attained tertiary education or higher (62%), and were
clinic or via teledermatology who consented to participate in the employed/self-employed (57%). More than half of patients had a
study were included. This study excluded individuals who were monthly income of less than PHP 9,000 (52%) and had their skin
not able to speak or understand English or Filipino. condition for more than one month prior to consultation (53%).
The reported prevalence of self-medication was by 88.70% (95%
The minimum number of patients was determined based CI = 82.20% to 93.40%).
on the anticipated proportion of 50%. At confidence level of 95%,
power of 80%, and margin of error of 10%, the required mini- The most common facilitators for self-medication were
mum number of patients was 97. the recommendation by family members or friends (49%) and
having a previous prescription (39%) (Table 2). Less common
DATA COLLECTION prompts cited were online information or social media (4%),
An approval of the Institutional Review Board of the hospital sales recommendation (3%), and advertisement (0.80%). Majori-
was obtained prior to data collection. Participants seeking con- ty of the products used without prescription were topical medi-
sult at the dermatology out-patient clinic or via teledermatology cations (86%), and the top products utilized were topical steroids
(18%), combination topical medications (anti-fungal, antibiotic,

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 2

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

Table 1. Socio-demographic profile of Dermatology patients (n=141) Table 2. Facilitators of self-medication and medicines used (n=125)

Total Self-medication No self-medication Event that evoked the use of medication Frequency
(n=141) (n=125) (n=16) Recommended by family and friends
Previous prescription 61 (49.19%)
Mean ± SD; Frequency (%) Internet/online search/social media 42 (33.87%)
Sales personnel recommendation 6 (4.39%)
Age 33.95±13.67 34.81±14.15 27.25±5.80 Advertisement 4 (3.23%)
More than 70 years 2 (1.42) 2 (1.60) 0 1 (0.81%)
35-69 years 44 (31.21) 42 (33.60) Medications
18-35 years 95 (67.38) 81 (64.80) 2 (12.50) Oral 18 (14.40%)
14 (87.50) Topicals 107 (85.60%)
Sex 106 (75.18) 95 (76.00)
Female 35 (24.82) 30 (24.00) 11 (68.75) Specific products used 22 (17.74%)
Male 5 (31.25) Topical steroids 20 (16%)
4 (2.84) 4 (3.20) Combination topical medications (anti-fungal, antibiotic,
Education level 49 (34.75) 42 (33.60) 0 steroid) 13 (10.04%)
Primary school 77 (54.61) 69 (55.20) 7 (43.75) Anti-acne preparations 12 (9.6%)
Secondary school 11 (7.80) 10 (8.00) 8 (50.00) Topical antibiotics 9 (6.38%)
Tertiary school 1 (6.25) Emollients 8 (5.67%)
Post graduate 81 (57.45) 68 (54.40) Antihistamine 8 (5.67%)
13 (81.25) Topical antifungal 7 (5.60%)
Employment 60 (42.55) 57 (45.60) Medicated soap 6 (4.80%)
Employed/Self-em- 3 (18.75) Anti-bacterial/anti-fungal ointment 6 (4.80%)
ployed 74 (52.48) 70 (56.00) Pain and itch relieving ointment 4 (3.23%)
Unemployed 33 (23.40) 26 (20.80) 4 (25.00) Oral steroids 2 (1.42%)
28 (19.86) 23 (18.40) 7 (43.75) Methotrexate
Monthly income, Php 6 (4.26) 6 (4.80) 5 (31.25)
<9,000 may have caused the lower prevalence rate of self-medication,
9,000-18,000 21 (14.89) 20 (16.00) 0 and this may be rooted from their fear and feelings of shame to
18,000-38,000 20 (14.18) 17 (13.60) divulge their self-medication practices.11,12 Other studies report-
>38,000 25 (17.73) 24 (19.20) 1 (6.25) ed prevalence rates of self-medication ranging from 20% to 50%.
17 (12.06) 12 (9.60) 3 (18.75) In the study by Khajuria et al in India, 42% self-medicated.13 De-
Duration of dermato- 58 (41.13) 52 (41.60) 1 (6.25) spite the varying prevalence reported, self-medication remains
logic disease before 5 (31.25) a widespread practice affecting developing countries.
consultation 6 (37.50)
<1 week It is also notable that the two (2) most common factors that
1-2 weeks lead to self-medication in our study were recommendations of
3-4 weeks family members and friends (49.19%) and the use of a previous
1-3 months prescriptions (33.87%). This is consistent with other studies
>3 months that showed that the reuse of previous prescriptions, sharing
medications, and recommendations of family and friends are
steroid) (16%), anti-acne preparations (10%), and topical antibi- frequent motivators of self-medication. Family members and
otics (10%). friends who experienced favorable response to a medication
could share or recommend that medication to others. It is also
FACTORS ASSOCIATED WITH SELF-MEDICATION AMONG a common practice to store previously prescribed medications
DERMATOLOGY PATIENTS at home encouraging the practice of self-medication.6,13,14 Our
On univariate analysis, the likelihood of self-medication was al- findings highlight the importance of addressing these motivat-
most four-fold (cOR=3.82, 95% CI=1.17 to 12.49, p=0.027) among ing factors during consultation with our patients.
those with a monthly income of less than PHP 9,000 compared to
those who had a higher monthly income (Table 3). Other patient Interestingly, our results also showed that the likelihood of
characteristics were not found to have significant association practicing self-medication for skin conditions was significantly
with odds of self-medication for dermatologic conditions. associated with monthly income. In particular, the odds of prac-
ticing self-medication was almost four (4) times higher among
DISCUSSION those with low monthly income (less than PHP 9,000 per month)
than those with higher monthly salary. This is consistent with
In our study, the prevalence of self-medication among der- the findings of a study by Aziz et al. showing that low monthly
matology patients was estimated to be 88.70% which is higher income prompts self-medication because the cost of self-medi-
than previous studies that reported self-medication among pa-
tients with dermatological conditions. Kombaté et al reported a
67.65% prevalence of self-medication for skin diseases among
711 dermatology patients in West Africa. According to the au-
thors, however, the legitimacy and honesty of the respondents

3 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

cating for a skin condition is perceived to be more affordable.15 Table 3. Univariate binary logistic regression analysis of the factors associated with self-
Patients with low monthly income encounter difficulties in ac- medication among Dermatology patients (n=141)
cessing appropriate and adequate medical care making them
seek a more affordable alternative to manage their dermato- Age Crude Odds Ratio p
logical condition, thus leading to self-medication.6,16 Although 18-35 years (95% CI)
we did not further explore the underlying mechanism, it is also 35-69 years -
possible that our patients who had low monthly income initially More than 70 years Reference .098
self-medicated because of their perception that seeking treat- 3.63 (0.79 to 16.72)
ment for their condition is more expensive than self-medicat- Sex -
ing. This emphasizes the need to explore potential mechanisms, Male -
policies, and programs that could assist financially challenged Female -
dermatology patients in seeking access to medical consult, ther- Reference .529
apy, and healthcare facility.16 In contrast, several studies, most Education Level 1.44 (0.46 to 4.47)
of which were conducted in university settings, identified a pos- Post graduate -
itive association of higher monthly income and the likelihood Tertiary school Reference .894
of self-medication which may be due to the higher purchasing Secondary school 0.87 (0.10 to 7.65) .650
power of patients with higher income.17,18,19 This shows that the Primary school 0.60 (0.07 to 5.45)
factors that lead to self-medication may vary according to soci- -
etal context. Employment -
Employed/Self-employed -
Other variables including age, educational attainment, em- Unemployed Reference .052
ployment status, and duration of dermatologic disease before 3.63 (0.99 to 13.38)
consultation, were not significantly associated with self-medica- Monthly income, Php -
tion practices among our respondents. These findings contrast ≥9,000 Reference .027
with the findings of several studies done in European, Asian, <9,000 3.82 (1.17 to 12.49)
and African countries suggesting that factors such as older age, -
female gender, lower educational attainment, unemployment Duration of dermatologic disease before Reference .294
status, and longer duration of dermatologic disease increases consultation 0.28 (0.03 to 2.98) .900
the likelihood of self-medication. Although health and cultural <1 week 1.20 (0.07 to 20.43) .066
beliefs as well as financial perspectives may account for this dif- 1-2 weeks 0.12 (0.01 to 1.15) .452
ference, our study is a single-center study which may not reflect 3-4 weeks 0.43 (0.05 to 3.83)
the general Filipino population and therefore larger nationwide 1-3 months
studies should be conducted on the association of these so- >3 months
cio-demographic characteristics with self-medication practices
of Filipinos.12,17,18,20 We limited the recall period to minimize this, but self-report-
ed questionnaires may still result to either under-reporting or
Despite the presented results, this study has certain lim- over-reporting of data.
itations. First, the study employed a cross-sectional study de-
sign thus, temporality may be a potential issue. Second, the CONCLUSION
questionnaire was not validated, and it did not explore on all
the possible patient characteristics of the Andersen’s health ser- Our study showed a high prevalence of self-medication among der-
vice utilization model. Third, the study was conducted during matology patients motivated by recommendation of family mem-
the coronavirus disease 2019 (COVID-19) pandemic wherein bers and friends and using previous prescriptions. In addition, low
there is a decrease in out-patient dermatology consultations in monthly income was significantly associated with self-medication,
the country.21 This may have contributed to the high prevalence increasing its likelihood by almost four (4) times.
of self-medication practices either because non-urgent derma-
tological conditions were not prioritized in health facilities at The results of this study has two (2) clinical implications.
this time or because patients were reluctant to go to the hospi- First, having the knowledge that self-medication of dermato-
tal for fear of contracting COVID-19. Lastly, a self-administered logical conditions is a highly prevalent practice among Filipino
questionnaire was utilized posing a potential for recall bias. patients, clinicians and health policymakers should explore po-
tential means and approaches to correct and address the mis-
use of medications to avoid preventable adverse events. Second,
noting that low income may contribute to self-medication prac-
tices, stakeholders may need to explore potential mechanisms,
policies, and programs to educate and extend assistance to pa-
tients with financial constraints in seeking access to appropri-
ate healthcare facilities.

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 4

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

ACKNOWLEDGMENTS

The authors would like to thank Dr. Czarina P. Chavez and Dr. Jacqueline D. Melendres for their insightful comments and suggestions. This
research was supported by the PDS research grant.

REFERENCES

1. WHO Consultative Group on the Role of the Pharmacist, World Health Organization. Division of Drug Management and Policies. The role of
the pharmacist in the health care system : preparing the future pharmacist : curricular development : report of a third WHO Consultative
Group on the Role of the Pharmacist, Vancouver, Canada, 27-29 August 1997. World Health Organization; 1997.

2. Kheder S, Mohammed R. The impact of pharmaceutical promotion on rational prescribing and drug use in Sudan. Sudan Med Monit
[Internet]. 2017;12(1):19. Available from: http://dx.doi.org/10.4103/summ.summ_2_17

3. Nepal G, Bhatta S. Self-medication with antibiotics in WHO southeast Asian region: A systematic review. Cureus [Internet]. 2018; Available
from: http://dx.doi.org/10.7759/cureus.2428

4. Mageto T. Modeling self medication risk factors (A case study of Kiambu county, Kenya). Am j theor appl stat [Internet]. 2018;7(2):58.
Available from: http://dx.doi.org/10.11648/j.ajtas.20180702.12

5. Shah H, Patel R, Nayak S, Patel H, Sharma D. A questionnaire-based cross-sectional study on self-medication practices among
undergraduate medical students of GMERS Medical College, Valsad, Gujarat. Int J Med Sci Public Health [Internet]. 2018;1. Available from:
http://dx.doi.org/10.5455/ijmsph.2018.0101324012018

6. Corrêa-Fissmer M, Mendonça MG, Martins AH, Galato D. Prevalence of self-medication for skin diseases: a systematic review. An Bras
Dermatol [Internet]. 2014;89(4):625–30. Available from: http://dx.doi.org/10.1590/abd1806-4841.20142872

7. Porteous T, Wyke S, Hannaford P, Bond C. Self-care behaviour for minor symptoms: can Andersen’s Behavioral Model of Health Services Use
help us to understand it?: Using Andersen’s model to understand self-care. Int J Pharm Pract [Internet]. 2015;23(1):27–35. Available from:
http://dx.doi.org/10.1111/ijpp.12116

8. McEachreon S, Salmoni A, Pong R, Garg R, Viverais-Dresler G. Anticipated choices among self-, informal, and formal care by older
canadians. J Health Psychol [Internet]. 2000;5(4):457–72. Available from: http://dx.doi.org/10.1177/135910530000500405

9. Linden K, Jormanainen V, Swigonski NL, Pietilä K. Self-medication among Finnish young men in the beginning of common military service:
SELF-MEDICATION AMONG FINNISH YOUNG MEN. Pharmacoepidemiol Drug Saf [Internet]. 2005;14(3):193–201. Available from: http://dx.doi.
org/10.1002/pds.1040

10. Aday LA, Andersen R. A framework for the study of access to medical care. Health Serv Res. 1974 Autumn;9(3):208–20. PMCID: PMC1071804
11. Pandya P, Pandya I. Prevalence and patterns of self-medication for skin diseases among medical undergraduate students. Int j res

dermatol [Internet]. 2018;4(2):162. Available from: http://dx.doi.org/10.18203/issn.2455-4529.intjresdermatol20181815
12. Kombaté K, Técléssou JN, Saka B, Akakpo AS, Tchangai KO, Mouhari-Toure A, et al. Prevalence and factors associated with self-medication

in dermatology in Togo. Dermatol Res Pract [Internet]. 2017;2017:1–5. Available from: http://dx.doi.org/10.1155/2017/7521831
13. Khajuria V, Gupta S, Arora S, Sadiq S, Kumar N, Sharma R. Research Journal of Pharmaceutical , Biological and Chemical Sciences Self

Medication in Dermatological Conditions - A Northern Indian Tertiary Hospital Experience. Res J Pharm Biol Chem Sci. 2013;4(1):247–52.
14. Gualano MR, Bert F, Passi S, Stillo M, Galis V, Manzoli L, et al. Use of self-medication among adolescents: a systematic review and meta-

analysis. Eur J Public Health [Internet]. 2015;25(3):444–50. Available from: http://dx.doi.org/10.1093/eurpub/cku207
15. Aziz MM, Masood I, Yousaf M, Saleem H, Ye D, Fang Y. Pattern of medication selling and self-medication practices: A study from Punjab,

Pakistan. PLoS One [Internet]. 2018;13(3):e0194240. Available from: http://dx.doi.org/10.1371/journal.pone.0194240
16. Zhang XJ, Wang AP, Shi TY, Zhang J, Xu H, Wang DQ, et al. The psychosocial adaptation of patients with skin disease: a scoping review. BMC

Public Health [Internet]. 2019;19(1):1404. Available from: http://dx.doi.org/10.1186/s12889-019-7775-0
17. Araia ZZ, Gebregziabher NK, Mesfun AB. Self medication practice and associated factors among students of Asmara College of Health

Sciences, Eritrea: a cross sectional study. J Pharm Policy Pract [Internet]. 2019;12(1):3. Available from: http://dx.doi.org/10.1186/s40545-019-
0165-2
18. Gelayee DA. Self-medication pattern among social science university students in Northwest Ethiopia. J Pharm (Cairo) [Internet].
2017;2017:8680714. Available from: http://dx.doi.org/10.1155/2017/8680714
19. Hoai NT, Dang T. The determinants of self-medication: Evidence from urban Vietnam. Soc Work Health Care [Internet]. 2017;56(4):260–82.
Available from: http://dx.doi.org/10.1080/00981389.2016.1265632
20. Yuefeng L, Keqin R, Xiaowei R. Use of and factors associated with self-treatment in China. BMC Public Health [Internet]. 2012;12(1). Available
from: http://dx.doi.org/10.1186/1471-2458-12-995
21. Angeles C, Chavez C, Lim H, Guevara B, Jamisola L. Impact of the COVID-19 pandemic on dermatology practice in the Philippines: A cross-
sectional study. Australas J Dermatol [Internet]. 2021;62(4):e594–6. Available from: http://dx.doi.org/10.1111/ajd.13714

5 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL ARTICLE
Journal of the Philippine
Dermatological Society

Sociodemographic and Clinical Profile of Geriatric
Patients seen at the Southern Philippines Medical
Center Department of Dermatology from January

2016 to December 2019

Michelle D. Sim, MD, DPDS,1 Maricarr Pamela M. Lacuesta – Gutierrez, MD, FPDS,1 Rea Tarro-Dapiton, MD1

ABSTRACT

INTRODUCTION Geriatric health has become a major issue worldwide. According to the World Health Organization(WHO), between 2015 and 2050,
the proportion of the world's population over 60 years will nearly double from 12% to 22%. There is paucity of literature involving the spectrum of
frequencies of Filipino geriatric dermatoses.

OBJECTIVES To report on sociodemographic and clinical profiles of geriatric patients seen at the department of Dermatology of Southern Philip-
pines Medical Center from January 2016 to December 2019.

METHODS A retrospective descriptive study was conducted. Sociodemographic and clinical parameters were recorded and analyzed. Descriptive
statistics such as frequencies and percentages were used.

RESULTS Study population involved 470 patients with 372 out-patients and 98 in-patients. There was a preponderance of elderly patients with ages
of 70-79 and a slight female predominance. Most were married, residents of Davao City, retired or unemployed and had no vices. About 711 derma-
tologic dermatoses were recorded. Majority of concerns(22.08%) were classified under allergic and eczematous disorders. A greater number of
cases were managed by a combination of topical and oral medications. A proportion of these patients(38.09%) had at least one known co-morbid
condition; most common of which is hypertension.

The top 10 most common dermatoses include (1)xerosis, (2)contact dermatitis, (3)lichen simplex chronicus, (4)dermatophytosis, (5)stasis derma-
titis, (6)seborrheic dermatitis and seborrheic keratosis, (7)acrochordon, (8)psoriasis vulgaris, (9)herpes zoster and (10)verruca plana.

CONCLUSION Geriatric dermatology is an emerging branch in the new millennium. Raising the level of awareness about these dermatoses may be
crucial in proper management and improved quality of life for Filipino elderly patients.

KEYWORDS Geriatric dermatoses, elderly, geriatric dermatology, aging, Philippines

1Department of Dermatology, Southern INTRODUCTION overtake those with ages 0–14 years old by 2065.2
Philippines Medical Center Hence, the dermatology practice in the future
BACKGROUND OF THE STUDY may also see an increase in the number of geriat-
Corresponding author Geriatric health has become a major issue world- ric patients.
Michelle D. Sim, MD, DPDS wide, as the pace of population aging has become
much faster than in the past. With the develop- According to the Philippine Statistics Author-
Conflict of interest ment of new medications, eradication of diseases, ity, 7.5% out of 100,981,437 total population are
None better standards of living, and improvements in senior citizens as of its latest census in 2015.3 Ma-
the health delivery system, people worldwide are jority of the senior citizens live in Calabarzon and
Source of funding living longer. According to the World Health Or- Central Luzon. Davao Region ranks 8th place at
None ganization, between 2015 and 2050, the proportion 4.6% having 344,530 senior citizens, with a slight
of the world's population over 60 years will nearly female predominance among the total senior cit-
double from 12% to 22%.1 In the Philippines, de- izen population. Most senior citizens are married
spite the larger number of young Filipinos, the and literate with 51% having completed primary
older population ages 60 and above is expected to education. Several of them are categorized under
increase by 4.2%, whereas the 80 years and older gainful workers, skilled agricultural, forestry and
population is expected to increase by 0.4% from fishery workers.
2010 to 2030.2 The Philippines’ population has
increased by 35% over the last two decades. The Aging is an inevitable process with variable
population with ages 60 and above is expected to manifestations in all organ systems including the
skin. Due to the functional and structural chang-

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 6

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

es in the skin as a person grows older, skin disorders are more of geriatric patients seen at the Department of Derma-
commonly seen among elderly patients. Prevalence of skin dis- tology of SPMC (Southern Philippines Medical Center)
eases may reflect underlying systemic diseases. Skin disorders in from January 2016 to December 2019
the elderly are not only due to physical consequences of aging;
but also, due to effect of prolonged environmental exposure es- SPECIFIC OBJECTIVES
pecially UV radiation, decreased skin barrier function, impaired 1. To describe the volume of consults involving geriat-
wound healing, low immune responsiveness, and impaired DNA ric patients seen at the Department of Dermatology of
repair. These dermatoses may lead to significant morbidity af- SPMC from January 2016 to December 2019
fecting a patient’s quality of life. 2. To describe the sociodemographic profile of geriat-
ric patients seen at the Department of Dermatology of
With advancement of medical sciences, the average human SPMC from January 2016 to December 2019 according to
life expectancy has invariably increased. Given that Asian coun- these parameters: age, sex, marital status, place of res-
tries have rapidly aging populations, there is a need to address idence, nature of employment, smoking and/or alcohol
the tremendous burden of care for elderly patients. Geriatric pa- drinking history
tients are considered to belong amongst the vulnerable popula- 3. To describe the clinical profile of geriatric patients seen
tions of society and unfortunately, there is paucity of literature at the Department of Dermatology of SPMC from Janu-
involving spectrum of frequencies of age-related skin changes. ary 2016 to December 2019 using these parameters: type
Even though the elderly are the ones who need the most medical of cutaneous condition, management strategy, associat-
attention, they are also the ones who are most often neglected.4 A ed co-morbid condition/s
detailed knowledge about the pattern of geriatric dermatoses will 4. To identify and enumerate the top 10 most common
help health care workers in implementing essential changes in chief complaints and most common cutaneous diseases
disease control and preventive strategies in the future. among geriatric patients seen at the Department of Der-
matology of SPMC from January 2016 to December 2019
SIGNIFICANCE OF THE STUDY
Dermatological diseases in the geriatric population are increas- METHODOLOGY
ing, putting a great burden on health care systems. Dermatol-
ogists worldwide are likely challenged by increasing difficulties RESEARCH DESIGN
and complexities involved in delivery of skin health care to the A retrospective descriptive study was conducted which included
geriatric population. patients aged 65 and above seen at the Department of Dermatolo-
gy of SPMC (Southern Philippines Medical Center) from January
Information regarding the sociodemographic and clinical 2016 to December 2019.
profiles of elderly patients coupled with the extent and patterns
of dermatologic concerns affecting this population may create STUDY SETTING AND PARTICIPANTS
heightened awareness to mobilize medical and community re- This study was conducted at Southern Philippines Medical Cen-
sources targeting this vulnerable sector. ter. Medical records of geriatric patients seen at the Department
of Dermatology from January 2016 to December 2019 were ana-
Moreover, data from this study may be utilized to generate a lyzed.
template for educational materials which may be shared to either
family members or caregivers at senior residential facilities so that The investigators recorded the sociodemographic param-
they may be able to provide enhanced quality of care addressing eters which included patients’ age, marital status, place of resi-
the dermatologic concerns of geriatric patients. Gathered data from dence, nature of employment, smoking and/or alcohol drinking
this research will help influence health care providers and policy history. Clinical profile parameters which included type of cuta-
makers in assessing the health care status and needs related to der- neous condition, management strategy, and associated co-mor-
matologic concerns of geriatric patients for better allocation of re- bid condition/s were described. The most common dermatologic
sources and distribution of manpower, to improve on health care concerns were identified, tallied, and reported.
programs tailored to the needs of the elderly.
A. INCLUSION CRITERIA
Furthermore, although an almost similar study has been • Patients aged 65 and above seen at the Department of
done in 1999 by Serrano et al,5 the present study intends to bring Dermatology of SPMC from January 2016 to December
up-to-date the scope of dermatologic concerns affecting the geri- 2019
atric population two decades later. • All patient with initial consults
• Patients for follow up who have a new and different di-
OBJECTIVES agnosis as compared to the previous consults

GENERAL OBJECTIVE
1. To report on the sociodemographic and clinical profiles

7 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

• If the patient has more than one diagnosis, all diagno- RESULTS
ses were accounted for
Table 1 shows that a total of 11,064 consults involved geriatric pa-
B. EXCLUSION CRITERIA tients in the Department of Dermatology of SPMC from January
• Follow ups with the same diagnosis as the first consult 2016 to December 2019. The study population involved a total of
• Charts with incomplete data and essentially non-medi- 470 elderly patients. About 372 patients with ages 65 and above
cal diagnosis who sought consult at the out-patient clinic of the Department of
Dermatology of SPMC from January 2016 to December 2019. All
SAMPLE SIZE 98 admitted patients with ages 65 and above who were referred to
This study made use of random sampling of patients aged 65 and the Department of Dermatology of SPMC from January 2016 to De-
above who consulted at the Department of Dermatology of SPMC cember 2019 were included and accounted for in this study. Table
from January 2016 to December 2019. Slovin’s formula was used 2 shows that most of the retrieved charts were those of patients
to calculate the sample size to get a power of 95% with a standard seen in 2019 (35.74%) followed by those seen in 2016 (24.26%), 2017
deviation of 50% and 5% margin of error for the patients seen at (122.34%) and 2018 (17.66%).
the Dermatology outpatient department.
Table 3 highlights the sociodemographic profile of the
To get a 95% confidence level, a minimum of 372 patients elderly patients. A large number of patients belonged to the age
charts seen as out-patient were reviewed and included in this range of >70-79 years (44.47%), followed closely by those aged >65-
study. Meanwhile, all patients referred as in-patients who were 69 (41.06%). A little more than half of the population were females
able to satisfy the inclusion criteria were also included in the (53.83%). Majority of the patients were married (54.68%); In
study. terms of place of residence, almost all are residents of Davao City,
with 47.87% belonging to the second congressional district (Dis-
DATA GATHERING trict 2) of the city. Only about 10% of the patients resided outside
A written request to the head of the medical records section was Davao City. It is quite understandable that the bulk of the patients
sent prior to data gathering. A list of patients aged 65 and above were retired / unemployed while about 9% who were previously
seen during the four-year study period was requested and ob- employed were involved with either primarily manual labor or
tained from the hospital records section. The list was prepared primarily intellectual work. Employment data for about 37.66%
and randomization was done to complete the calculated sample of patients were not stated. Up to about 65% of patients neither
size of 372 for patients seen at the out-patient division, while all smoked nor consumed alcoholic beverages.
patients listed as in-patients were included. These charts were
then retrieved and reviewed. A data collection form was utilized Table 4 shows that a total of 711 dermatologic diagnoses
to collect all pertinent data for this study. were recorded. A preponderance of the dermatologic concerns

DATA HANDLING AND ANALYSIS Table 1. Total number of patients seen from 2016 to 2019.
Descriptive statistics was used to summarize the general and
clinical characteristics of the study participants. Categorical Year Number of Patients Number of In-Pa- Total
data were recorded as frequencies and percentages. All valid data with Ages 65 and tients with ages 65
were included in the analysis. Missing variables were neither re- 2019 above seen by Der- and above seen by 2,893
placed nor estimated. 2018 matology OPD 2,900
2017 2,857 Dermatology 2,716
ETHICAL CONSIDERATIONS 2016 2,863 36 2,555
The protocol for this study was approved by the Department of TOTAL 2,698 37 11,064
Health Region XI – Cluster Ethics Review Committee (DOH XI- 2,536 18
CERC). Approval from the Medical Records Section of the hos- 19
pital was also obtained prior to commencement of the study to 10,954
access the medical records of the patients. 110

No patient was contacted, nor any home visit was done Table 2. Patient charts reviewed and analyzed in this four-year study period.
during data collection. The data collected were anonymized.
Names of the patients were not used. Patients were assigned a Year of consult n (%)
designated number to conceal their identity and further prevent 114 (24.26%)
other parties from linking it to them. 2019 105 (22.34%)
2018 83 (17.66%)
2017 168 (35.74%)
2016

TOTAL 470

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 8

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

Table 3. Sociodemographic Profile of Geriatric Patients seen at the Department of Dermatology Table 4. Clinical Profile of Geriatric Patients seen at the Department of Dermatology of SPMC
of SPMC from January 2016 to December 2019. from January 2016 to December 2019.

Age n (%) Classification of Consult n (%)
>65 – 69 In-patient 98 (20.85%)
>70 – 79 193 (41.06%) Out-patient 372 (79.15%)
>80 – 89 209 (44.47%)
>90 – 95 64 (13.62%) Type of Cutaneous Condition 117 (16.46%)
Study Population Xerosis 151 (21.23%)
Patients >65 w/ Derma Consult 4 (0.85%) Infectious Diseases
470 Fungal Infections 50
Sex Dermatophytosis 43
Male 11,062 Candidiasis 5
Female Chronic Paronychia 2
217 (46.17%) Bacterial Infections 34
Marital Status 253 (53.83%) Cellulitis 13
Single Impetigo/Folliculitis 7
Married 22 (4.68%) Leprosy 6
Widow/er 257 (54.68%) Furuncle/Carbuncle 3
Not Indicated 154 (32.77%) Ecthyma 4
37 (7.87%) Erythrasma 1
Viral Infections 67
Place of Residence 112 (23.83%) Herpes Zoster 25
District 1 Davao City 225 (47.87%) Verruca Vulgaris 15
District 2 Davao City 85 (18.09%) Verruca Plana 17
District 3 Davao City 48 (10.21%) Herpes Simplex 3
Outside Davao City Post Herpetic Neuralgia 7
32 (6.81%)
Nature of Previous Employment 12 (2.55%) Infestations 13 (1.83%)
Primarily manual labor 249 (52.98%) Scabies 12
Primarily intellectual work 177 (37.66%) Pediculosis 1
Retired/Unemployed
Not Stated Allergic and Eczematous Disorders 157 (22.08%)
Nummular Dermatitis 4
Smoking / Alcohol Consumption 22 (4.68%) Seborrheic Dermatitis 34
Smoker 24 (5.11%) Contact Dermatitis 89
Alcoholic Drinker 74 (15.74%) FDE/Drug Hypersensitivity 15
Both 308 (65.53%) Insect Bite Hypersensitivity 2
Non-Smoker/Non-Alcoholic 42 (8.94%) Urticaria 7
Not Indicated Dyshidrotic Eczema 1
Miliaria Rubra 5
among elderly patients in this study were classified under aller-
gic and eczematous disorders (22.08%) and the top condition in Papulosquamous Diseases 38 (5.34%)
this classification is contact dermatitis. The second most com- Psoriasis Vulgaris 26
mon dermatologic concern involved infectious diseases (21.23%) Pityriasis Rosea 2
followed by xerosis (16.46%) and then proliferations & cutaneous Lichen Planus 1
tumors (14.77%). The least common diagnoses involved autoim- Lichen Sclerosus 1
mune & metabolic disorders, vesicobullous diseases, and infes- Erythroderma 8
tations. With regard to management strategy, most of the cases
(23.49%) were managed by combination of both oral and topical Psychodermatoses 50 (7.03%)
medications. Closely following at second is procedural interven- Lichen Simplex Chronicus 47
tions which may include electrocauterization of the various ac- Prurigo Nodularis 3
quired benign epithelial tumors or proliferations which may be
quite common with advancing age. Vesicobullous Diseases 8 (1.13%)
Bullous Pemphigoid 7
Table 5 shows that about 304 patients out of the 470 (64.68%) Paraneoplastic Pemphigus 1
had associated co-morbid condition. A proportion of those pa-
tients (38.09%) had at least one (1) known co-morbid condition Pigmentary Disorders 22 (3.09%)
and the most of common of which is hypertension. Idiopathic Guttate Hypomelanosis 3
Vitiligo 5
Table 6 enumerates the top 10 chief complaints of geriatric Solar Lentigines 3
patients seen at the Department of Dermatology of SPMC from Post-Inflammatory Hypo/hyperpigmentation 7
January 2016 to December 2019. Figure 1 depicts how the top 10 Leukoderma 1
Ochronosis 1
Melasma 2

Vascular Disorders 40 (5.63%)
Vasculitis 5
Stasis Dermatitis 35

Autoimmune & Metabolic Disorders 2 (0.28%)
Alopecia Areata 1
Lichen Amyloidosis 1

Proliferations and Cutaneous Tumors 105 (14.77%)
Acrochordon 28
Dermatosis Papulosa Nigra 4
Seborrheic Keratosis 29
Basal Cell Carcinoma 5
Keloid/Scar 3
Epidermal Inclusion Cyst 5
Seborrheic Hyperplasia 4
Milia 6
Pyogenic Granuloma 2
Lipoma 4
Corn 1
Xanthelasma 3
Fibrous papule 1
Cutaneous Metastasis 1
Syringoma 2
Trichoepithelioma 1
Neurofibroma 2
Cutaneous Horn 3
Mycosis Fungoides 1

Others 8 (1.13%)
Acanthoma fissuratum 1
Senile Comedones 1
Friction Blister 3
Pressure Ulcer 2
Hematoma 1

Management Strategy 75
Emollients 77
Topical Medications 68
Oral Medications 167
Combination of Topical and Oral Medication 25
Combination of Topical and Emollients 41
Combination of Emollients and Oral Medication 105
Emollients, Topical and Oral Medications 136
Procedural Intervention/s 17
Observation / Referral to Other Departments

9 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Table 5. Associated Co-morbid Medical Conditions n (%) chief complaints differ based on sex. For both male and female
patients, presence of plaques ranked 1st on the list.
Co-morbidities 179 (38.09%)
116 (24.68%) Table 7 and Figure 2 enumerates and illustrates the top 10
One co-morbidity 37 (7.87%) most common cutaneous diseases involving geriatric patients.
Hypertension 13 (2.77%) Notably, xerosis, contact dermatitis and lichen simplex chronicus
Diabetes are among the top 3 common conditions.
Dyslipidemia 7 (1.49%)
Arthritis 3 (0.64%) DISCUSSION
CKD 3 (0.64%)
Asthma/COPD The number and ratio of elderly population has been increasing
100 (21.28%) in developing and developed countries. In comparison to a simi-
Two co-morbidities 55 (11.70%) lar study done by Serrano et al5 in this same institution from 1996
Both Hypertension and Diabetes 25 (5.32%) to 1999, there is a noted rise in dermatologic consults involving
Both Hypertension and Dyslipidemia 5 (1.06%) geriatric patients. The previous study recorded a total of 1,269
Both Hypertension and Arthritis 4 (0.85%) out-patient clinic dermatologic consults done within a four-year
Both Hypertension and Asthma/COPD 11 (2.34%) study period. Utilizing the same time frame, the current study re-
Both Diabetes and Dyslipidemia corded a total of 10,954 consults at the out-patient division alone.
16 (3.40%)
Three co-morbidities Table 7. Top 10 Most Common Cutaneous Diseases among Male and Female Geriatric Patients
5 (1.06%) seen at the Department of Dermatology of SPMC from January 2016 to December 2019
Four co-morbidities
4 (0.85%)
Others (BPH, Hypothyroid, Gout,
Schizophrenia, Malignancy) 166 (35.32%)

None

Table 6. Top 10 Chief Complaints of Geriatric Patients Seen at the Department of Dermatology of MALE PATIENTS FEMALE PATIENTS TOTAL FOR BOTH GENDERS
SPMC from January 2016 to December 2019 1. Xerosis 1. Xerosis 1. Xerosis
2. ACD/ICD 2. ACD/ICD 2. ACD/ICD
1. Plaque
2. Papule 3. Seborrheic Dermatitis 3. Lichen Simplex Chronicus 3. Lichen Simplex Chronicus
3. Pruritus Dermatophytosis
4. Vesicle 4. Lichen Simplex Chronicus 4. Dermatophytosis
5. Patch 5. Dermatophytosis 4. Acrochordon 5. Stasis Dermatitis
6. Erythema
7. Nodule and Scaling 5. Seborrheic Keratosis
8. Pain
9. Ulcer 6. Stasis Dermatitis 6. Herpes Zoster 6. Seborrheic Dermatitis
10. Edema 7. Psoriasis Vulgaris Seborrheic Keratosis
8. Seborrheic Keratosis 7. Verruca Plana
Stasis Dermatitis 7. Acrochordon

8. Cellulitis 8. Psoriasis Vulgaris
Psoriasis Vulgaris
Verruca Vulgaris

9. Erythroderma 9. Drug Hypersensitivity 9. Herpes Zoster
Reaction 10. Verruca Plana
10. Acrochordon
Herpes Zoster 10. Scabies

Figure 1. Top 10 chief complaints of male and female geriatric patients seen at the Department of Figure 2. Top 10 diagnoses of male and female geriatric patients seen at the Department of
Dermatology of SPMC from January 2016 to December 2019. Dermatology in SPMC from January 2016 to December 2019.

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 10

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

Another notable difference is that, in a similar study done previ- Elderly patients may be dependent on others and may en-
ously, majority of the patients belonged to the age range of 65 to counter difficulty in visiting hospitals. Paucity of institutional
74 with a male predominance, while this study noted that many care programs in the Philippines means that older Filipinos are
patients belonged to the age range of >70 to 79 years (44.47%) with often cared for by family members at home. Although care-giving
a female predominance. is expected of Filipino families, those who are of lower socioeco-
nomic status may be financially strained in providing adequate
Our findings also differ from the study by our colleagues in care to an ailing loved one.2 Thus, most of the skin diseases of
India which showed that more than 60% of their study population these patients are notably chronic in nature.
belonged to the >60-69 age group.6 In the Philippines, the current
optional retirement age is at 60 while the compulsory retirement In comparison to the two (2) previous surveys done by Tian-
age is at 65.7 However, with advances in medicine and technology, co, et al. as well as Serrano, et al. involving skin concerns among
people are now living longer and can still be productive long after Filipino elderly patients, lichen simplex chronicus only ranked
the ages of 65. Findings from the 2007 Philippine study on aging 3rd as opposed to their identification of lichen simplex chronicus
by Cruz et al. showed that many older people continue to be eco- as the topmost cutaneous problem.5,15
nomically productive, wherein three (3) out of ten of those aged
70–79, and one tenth of those aged 80 and over are still currently Comparable to a number of studies, high incidence of xe-
working.8 In an interview with assistant national statistician Wil- rosis was commonly observed and was often listed among the
ma Guillen conducted by One News PH, she said that as of June top 10 dermatologic consults/conditions. This current study’s re-
2022, there are 11,000 individuals who are 65 years and older who sults showed that at least one known comorbidity was reported
are still looking for work, available for work and have no work.9 in majority of patients (38.09%). The most common co-morbid-
This may be one of the reasons why in our study, majority of pa- ities included hypertension (24.68%) and diabetes (7.87%). This
tients were in their 70s. finding is similar to a study done by Krishnendra et al. in a clini-
co-epidemiological study at a tertiary care center in Ujjain and
A new house bill was proposed by senior citizen party-list by Raveendra and Agarwal.16,17,18 Furthermore, high incidence of
representative Rodolfo Ordanes Jr. that seeks to amend the La- xerosis may be theorized to be due to less use of emollients, cer-
bor Code of the Philippines.9,10 In this proposed House Bill 3220, tain medications, low indoor humidity and use of hot water and
an employee who reaches 65 years can choose to continue their harsher soaps by patients.4,16
employment provided that the senior citizen qualifies under the
bona fide occupational qualifications of his/her job. Hence, once Decreased levels of skin lipids and epidermal barrier dys-
approved, will repeal a provision in the Labor Code that sets the function may be quite common among the elderly population.
compulsory retirement age at 65 years.10 These, in turn, lead to increased sensitivity and susceptibility to
the allergens and irritants in the form of creams or even herb-
This current study reveals a slightly female-predominant al preparations which are locally and easily available.19,20,21 In a
population with computed male to female ratio of 0.9. This slight study done by Tolentino et al. in Batangas, they concluded that
female predominance was likewise noted in the studies done by although there are known risks, most Filipinos still adhere to the
Durai et al. and Kartal et al.11,12 Most of the patients were married, old practice of utilizing traditional medicine such as plant-de-
which was similar to the studies done by Chowdhury et al. in 2016 rived substances, in treating ailments and enhancing general
and Sheethal et al. in 2014.6,13 health and well-being.22 This may possibly explain why allergic
and eczematous disorders in the form of contact dermatitis is
A greater number of our study population were identified among the top dermatologic conditions in our study. This is com-
as being unemployed or retired. It may be promising to note that parable to a study done by Yildiz in Turkey wherein they listed
increased benefits provided by the state may be evident in the Re- contact dermatitis as top 1 diagnosis.21
public Act 9994 wherein elderly patients are given priority and
granted additional benefits and privileges such as medication With advancing age, immune responsiveness status of the
discounts and monthly pension to help them in their living ex- elderly patients decline thereby predisposing them to infections.
penses. In fact, in a survey done across provinces by Sangel et This study shows that infections ranked 2nd among the top 10
al., more than 90% of the respondents rated the implementation most common cutaneous diseases. Viral infections occur fre-
of RA 9994 as average to very satisfactory in terms of the 20% dis- quently in old age secondary to impaired immune function.20
count provision.14 In previous studies done, the prevalence of viral infection was
at 2.1% by Mponda et al. in Tanzania, 4.6% by Polat et al. in Tur-
Majority of the patients reside within the confines of the 2nd key, 6.8% by Souissi et al. in Tunisia.23,24,25 Herpes zoster infection
congressional district of Davao City and this may be reasonably may be associated with a characteristic pain syndrome called
explained by the fact that the institution itself belongs to this said post-herpetic neuralgia, which may explain why pain is among
district. This information may be further utilized to convince the the top 10 common chief complaints in this study. The reduction
district political representatives to modify programs to better ca- of epidermal turnover, and immunologic functions as well as fac-
ter to the health care needs of the poor and vulnerable geriatric tors such as decrease in personal care, poor hygiene, neglect and
sector.

11 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

overcrowding are possibly responsible for the high prevalence of proper education to elderly patients and their caregivers.
infections.20 Studies done by Yap et al., Kilicet al., Souissi et al., This study described and reported the sociodemographic
Furue et al. and Yalcin et al. all found infections were quite com-
mon among elderly patients.25,26,27,28,29, and clinical profiles of geriatric patients seen at the Department
of Dermatology of SPMC from January 2016 to December 2019
Various benign proliferations were also noted. Acrochordon having a total of 470 elderly patients as its study population. A
(3.94%) and seborrheic keratoses (4.08%) were among the most total of 711 dermatologic dermatoses were recorded, giving an
common. As compared to the findings of studies by Raveendra in updated scope of dermatologic concerns affecting the geriatric
India and Beauregard & Gilchrest in the West,17,30 these numbers population in the country.
are by far less. Malignant tumors such as basal cell carcinoma
and mycoses fungoides were only noted in 0.7% and 0.1% of pa- LIMITATIONS AND RECOMMENDATIONS
tients. The lower incidence of skin tumors compared to data of Due to the retrospective nature of the study and utilization of sec-
studies from Western countries may be attributed to the fact that ondary data, the following limitations were encountered: first, a
pigmented skin offers more protection against ultraviolet radia- substantial proportion of data from the patients’ charts were left
tion compared to individuals with Fitzpatrick skin types I and II.31 blank and recorded as not applicable because of missing infor-
mation that may be due to incomplete data from chart collection
In our study, papulosquamous disorders mostly psoriasis forms of the hospital. Second, data were based on the clinical
vulgaris were only seen among 6.05% of cases. These findings judgement of the attending physician, with several diagnoses
are similar to the study done by Verma et al. wherein psoriasis unconfirmed. Furthermore, only the diagnoses for which patient
ranked highest amongst the papulosquamous disorders.16 Pig- sought consultation have been noted thus other asymptomatic
mentary disorders and vascular disorders were also noted albeit age-related changes may have been missed out.
in a small number of patients. Among cases of vesicobullous dis-
orders, bullous pemphigoid was the most frequent condition at Therefore, we recommend that patient chart collection
1.13% of cases. Bullous pemphigoid is a disease found primarily forms of the hospital be reviewed and updated as well as high-
in the elderly population at age 60 years and over.20 Findings were light the importance of completing dermatological clinical re-
comparable to the study done by Chopra et al. who observed 1.8 cords in the hospital to ensure that future studies will be more
% cases of bullous pemphigoid.32 detailed and complete.

Management of cutaneous disorders in the elderly popula- A larger, prospective, multicenter study may also be con-
tion is different from the general population. Treatment compli- ducted preferably in different regions in the country to be able
ance is affected by several factors. These factors include declining to reflect the true burden of geriatric dermatoses in the different
cognitive status such as loss of memory and dementia, physical communities and to explore if the variable environmental condi-
limitations, and impaired sensory functions.19 This study showed tions may affect disease frequencies.
that most cases were handled with a multidisciplinary approach
with treatments done involving combination of emollients as well CONCLUSION
as topical and oral medications. Bulk of the topical medications
belong to the corticosteroid class and this may be coincident with In conclusion, geriatric dermatology is undoubtedly an emerging
the sizeable percentage of steroid-responsive dermatoses among branch in the new millennium therefore updates in current and
the listed most common cutaneous problems. emerging trends of dermatoses involving the Filipino elderly pop-
ulation in each locality may help us in implementing necessary
Roughly, around 40% of the patients had hypertension as a changes in health education as well as cutaneous disease detec-
co-morbid medical condition either solely or in conjunction with tion, control, and prevention. This study further highlights the
other systemic diseases. This information may be significant pattern of xerosis, contact dermatitis, and lichen simplex chron-
since cutaneous events have been associated with intake of anti- icus as major top 3 cutaneous dermatoses affecting geriatric
hypertensive agents.33 Increased awareness regarding the myri- patients. Raising the general level of awareness about common
ad adverse reactions to medications, notably antihypertensives, geriatric dermatoses may be crucial in proper management and
among clinicians may be essential to promote vigilance and improved quality of life for Filipino elderly patients.

REFERENCES

1. World Health Organization website. Aging and Health. 5 Feb, 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/ageing-and-
health

2. Badana ANS, Andel R. Aging in the Philippines. Gerontologist [Internet]. 2018;58(2):212–8. Available from: http://dx.doi.org/10.1093/geront/gnx203
3. Philippine Statistics Authority. Facts on Senior Citizens: Results of the 2015 Census of Population. 2015. Retrieved from: https://psa.gov.ph/system/

files/2015%20Fact%20Sheets%20on%20Senior%20Citizen_pop.pdf?width=950&height=700&iframe=true.
4. Garibyan L, Chiou AS, Elmariah SB. Advanced aging skin and itch: addressing an unmet need: Pruritus in the elderly. Dermatol Ther [Internet].

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 12

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

2013;26(2):92–103. Available from: http://dx.doi.org/10.1111/dth.12029
5. Ramirez ML, Serrano MAC. Dermatoses in the elderly: A 4-year retrospective study in a tertiary hospital skin clinic at Davao city. Journal of the

Philippine Society of Cutaneous Medicine. 2022;3(1):33-34.
6. Sheethal M, Shashikumar B. A cross-sectional study on the dermatological conditions among the elderly population in Mandya city. Int J Med Sci

Public Health [Internet]. 2015;4(4):467. Available from: http://dx.doi.org/10.5455/ijmsph.2015.2711201497
7. Government Service Insurance System website. Lowering the Retirement Age of Government Employees. 10 August, 2022. Available from: https://

www.gsis.gov.ph/frequently-asked-%20questions/lowering-the-%20retirement-age-of-government-%20employees/.
8. Cruz GT, Cruz CJP, Cruz C. Ageing and Health in The Philippines [Internet]. Economic Research Institute for ASEAN and East Asia. ERIA, Demographic

Research and Development Foundation; 2019. Available from: https://www.eria.org/publications/ageing-and-health-in-the-philippines/
9. Desiderio L. “NEDA Backs Removal Of Mandatory Retirement Age.” One News PH. 10 August 2022. Accessed on 18 August 2022. Available from: https://

www.onenews.ph/articles/neda-backs-removal-of-mandatory-retirement-age
10. Crisostomo S. “Bill seeks removal of compulsary retirement age.” Philippine Star Global. 7 August 2022. Accessed on 18 August 2022. Available from:

https://www.philstar.com/headlines/2022/08/07/2200828/bill-seeks-removal-compulsary-retirement-age
11. Durai PC, Thappa DM, Kumari R, Malathi M. Aging in elderly: chronological versus photoaging. Indian J Dermatol [Internet]. 2012;57(5):343–52. Available

from: http://dx.doi.org/10.4103/0019-5154.100473
12. Kartal D, Çınar SL, Akın S, Ferahbaş A, Borlu M. Skin findings of geriatric patients in Turkey: A 5-year survey. Dermatol sin [Internet]. 2015;33(4):196–200.

Available from: http://dx.doi.org/10.1016/j.dsi.2015.04.001
13. Chowdhury J, Das S, Roy AK. Skin diseases in elderly population from Eastern India- An observational study. Journal of Pakistan Association of

Dermatologists; 2016:26(4):318–321
14. Salenga RL, Loquias MM, Sarol JN. Effect of the expanded senior citizens act of 2010 (republic act 9994) on drug accessibility among the elderly. Acta

Med Philipp [Internet]. 2016;50(2). Available from: http://dx.doi.org/10.47895/amp.v50i2.832
15. Tianco EA, Buendia-Teodosio G, Alberto NL. Survey of skin lesions in the Filipino elderly. Int J Dermatol [Internet]. 1992;31(3):196–8. Available from:

http://dx.doi.org/10.1111/j.1365-4362.1992.tb03935.x
16. Verma K, Shesha H and Kumar U. A Clinico-Epidemiological Study of Geriatric Dermatosis in Tertiary Care Centre, Ujjain. Indian Journal of Clinical and

Experimental Dermatology, 2017;3(4):142-147
17. Raveendra L. A clinical study of geriatric dermatoses. Our Derm Online [Internet]. 2014;5(3):235–9. Available from: http://dx.doi.org/10.7241/

ourd.20143.59
18. Jafferany M, Huynh TV, Silverman MA, Zaidi Z. Geriatric dermatoses: a clinical review of skin diseases in an aging population: Geriatric dermatoses.

Int J Dermatol [Internet]. 2012;51(5):509–22. Available from: http://dx.doi.org/10.1111/j.1365-4632.2011.05311.x
19. Jafferany, M., Huynh, T. V., Silverman, M. A., & Zaidi, Z. (2012). Geriatric dermatoses: A clinical review of skin diseases in an aging population.

International Journal of Dermatology, 51(5), 509–522. https://doi.org/10.1111/j.1365-4632.2011.05311.x
20. Thapa DP, Jha AK, Kharel C, Shrestha S. Dermatological problems in geriatric patients: a hospital based study. Nepal Med Coll J. 2012;14(3):193–5. PMID:

24047013
21. Yıldız H. The prevalence of the geriatric dermatoses among elderly patients attending dermatology outpatient clinic in Eskisehir, Turkey. South Clin

Istanb Eurasia [Internet]. 2019; Available from: http://dx.doi.org/10.14744/scie.2019.46855
22. Tolentino RD, Tomas VC, Travezonda JC, andd Magnaye, BP. Herbal Medicine Utilization among Batangueños. Asia Pacific Journal of Education, Arts

and Sciences. January 2019; 6:9-22.
23. Mponda K, Masenga J. Skin diseases among elderly patients attending skin clinic at the Regional Dermatology Training Centre, Northern Tanzania: A

cross-sectional study. BMC Research Notes. 2016;9(1).
24. Polat M, İlhan MN. Dermatological complaints of the elderly attending a dermatology outpatient clinic in turkey: A prospective study over a one-

year period. Acta Dermatovenerol Croat. 2015;23(4):277–81. PMID: 26724880.
25. Souissi A, Zeglaoui F, El Fekih N, Fazaa B, Zouari B, Kamoun MR. Pathologie cutanée chez le sujet âgé. Ann Dermatol Venereol [Internet].

2006;133(3):231–4. Available from: http://dx.doi.org/10.1016/s0151-9638(06)70885-7
26. Yap KB, Siew MG, Goh CL. Pattern of skin diseases in the elderly seen at the National Skin Centre (Singapore) 1990. Singapore Med J. 1994;35(2):147–50.

PMID: 7939809.
27. Kiliç A, Gül U, Aslan E, Soylu S. Dermatological findings in the senior population of nursing homes in Turkey. Arch Gerontol Geriatr [Internet].

2008;47(1):93–8. Available from: http://dx.doi.org/10.1016/j.archger.2007.07.007
28. Furue M, Yamazaki S, Jimbow K, Tsuchida T, Amagai M, Tanaka T, et al. Prevalence of dermatological disorders in Japan: a nationwide, cross-

sectional, seasonal, multicenter, hospital-based study: Prevalence of dermatological disorders in Japan. J Dermatol [Internet]. 2011;38(4):310–20.
Available from: http://dx.doi.org/10.1111/j.1346-8138.2011.01209.x
29. Yalçin B, Tamer E, Toy GG, Oztaş P, Hayran M, Alli N. The prevalence of skin diseases in the elderly: analysis of 4099 geriatric patients. Int J Dermatol
[Internet]. 2006;45(6):672–6. Available from: http://dx.doi.org/10.1111/j.1365-4632.2005.02607.x
30. Beauregard S, Gilchrest BA. A survey of skin problems and skin care regimens in the elderly. Arch Dermatol [Internet]. 1987;123(12):1638–43. Available
from: http://dx.doi.org/10.1001/archderm.123.12.1638
31. Goyal A, Balai M, Mittal A, Khare AK, Gupta LK. Pattern of geriatric dermatoses at a Tertiary Care Teaching Hospital of South Rajasthan, India. Our
Derm Online [Internet]. 2017;8(3):237–41. Available from: http://dx.doi.org/10.7241/ourd.20173.71
32. Chopra A. Skin diseases in the elderly. Indian J Dermatol Venereol Leprol. 1999;65(5):245–6. PMID:20921675.
33. Ranugha PSS, Betkerur J. Antihypertensives in dermatology Part II - Cutaneous adverse reactions to antihypertensives. Indian J Dermatol Venereol
Leprol [Internet]. 2018;84(2):137. Available from: http://dx.doi.org/10.4103/ijdvl.ijdvl_992_16

13 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL ARTICLE
Journal of the Philippine
Dermatological Society

Efficacy and safety of turmeric 1% emollient cream
in the control of chronic kidney disease-associated

pruritus in hemodialysis patients: A randomized
double-blind clinical trial

Michaela M. Tabalon-Morales, MD, DPDS,1 Karla Phoebe B. Castaños, MD, FPDS,1 Michelle D. Sim, MD, DPDS1

ABSTRACT

INTRODUCTION Chronic kidney disease-associated pruritus (CKD-aP) remains a frequent and distressing symptom in hemodialysis patients, fur-
ther compromising their quality of life. Turmeric, or Curcuma longa, is a naturally-occurring, widely available product that inhibits major inflamma-
tory mechanisms associated with CKD-aP.

OBJECTIVES This study aimed to determine the efficacy and safety of turmeric 1% emollient cream versus a bland emollient in the reduction of
chronic kidney disease-associated pruritus in hemodialysis patients.

METHODS This study was a randomized, double-blind, controlled trial of the effect of turmeric 1% cream in the reduction of chronic kidney disease
associated pruritus in hemodialysis patients compared to a bland emollient. The main outcome measure was the proportion of subjects who
demonstrated response to treatment, as well as the incidence of adverse effects.

RESULTS Intention to treat analysis on 106 patients, 53 assigned to turmeric 1% cream and 53 to bland emollient cream, was done. There was a sig-
nificant difference (P=0.03) in the proportion of patients who achieved treatment success between the turmeric group (66%) and bland emollient
group (45%). The mean decrease in pruritus score (VAS) of the group treated with turmeric was significantly greater than that of the bland emol-
lient group (P=0.018). No adverse effects were noted in both groups.

CONCLUSION Among hemodialysis patients diagnosed with CKD-aP, topical application of turmeric 1% cream twice daily for four weeks was supe-
rior to that of bland emollient cream based on efficacy and safety outcome measures.

KEYWORDS turmeric, Curcuma longa, chronic kidney disease-associated pruritus, uremic pruritus, hemodialysis

1Department of Dermatology, Southern INTRODUCTION The pathophysiology of CKD-aP is multifac-
Philippines Medical Center torial but remains incompletely understood. Dry
Chronic Kidney Disease (CKD) is one of the most skin or xerosis is suggested to be a major contrib-
Corresponding author common systemic causes of pruritus, affecting utor. More current understanding points towards
Michaela M. Tabalon-Morales, MD, DPDS 42% of patients on hemodialysis as reported by roles for the immune and neurogenic systems. It
the Dialysis Outcomes and Practice Pattern Study is hypothesized that CKD-aP is a manifestation
Conflict of interest (DOPPS).1,2 CKD-associated pruritus (CKD-aP) is of a deranged immune system that results in a
None the apt term given to this condition, defined as proinflammatory state.8,9
itching directly related to kidney disease, with-
Source of funding out the presence of another comorbid condition Despite the high prevalence and increased
None producing the pruritus.3,4 It remains a frequent morbidity of CKD-aP, to date, no drug has been
and distressing symptom of CKD.5 A meta-anal- approved by the U.S. Food and Drug Administra-
ysis done by Hu Xinmiao et. al. showed the prev- tion (FDA) for this condition. Most patients are
alence of CKD-aP in hemodialysis patients to be not amenable to its definitive treatment, which is
55%.3 Itching in these patients can impair sleep, renal transplantation. Other therapeutic options
interfere with work and social functioning, thus are largely empirical, these include moistur-
compromising quality of life (QOL).4,6,7 If left un- izers, antihistamines, gabapentin/pregabalin,
treated, patients may develop depression.4 Fur- kappa-opioid agonists, capsaicin, gamma-lin-
thermore, the scratching may lead to skin exco- oleic acid, sertraline, mirtazapine, thalidomide,
riations that may result to soft tissue infections.6 and UVB therapy. Gabapentin is the most studied
These factors contribute to the increased morbid- therapeutic option, however, its side effects and
ity and mortality among hemodialysis patients.4,7 cost limit its usage.10,11,12 Also, dialysis patients of-

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 14

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

ten have hesitations in taking oral medications. This highlights ney disease associated pruritus in hemodialysis patients com-
the need to explore an efficacious yet safe and readily available pared to a bland emollient (placebo). This study was carried out
topical treatment option. from September to November 2019 at the hemodialysis unit of
Southern Philippines Medical Center (SPMC), Davao City, Phil-
Curcuma longa, commonly known as turmeric, is one of the ippines. The study was approved by the institution’s research
most common spices being used today. By tradition, it has been ethics committee and written informed consent was obtained
used as a flavoring and medicinal agent.13,14 Curcumin, its prin- from all its participants.
cipal active component, has been documented to inhibit major
inflammatory mechanisms like lipoxygenase (LOX), cycloo- SAMPLING PROCEDURES, RANDOMIZATION, AND BLINDING
xygenase (COX)- 2, tumor necrosis factor (TNF)- a, interferon The study utilized purposive sampling procedures to select
(IFN)- λ, and nuclear factor (NF)-кB.15,16 It has been granted a the participants who have chronic kidney disease-associated
“Generally Recognized as Safe” (GRAS) status as a food ingre- pruritus from the hemodialysis unit at SPMC. Face-to-face re-
dient by the US Food and Drug Administration.17 A systematic cruitment was done wherein the investigator interviewed and
review done by Vaughn et. al. concluded that both oral ingestion examined all hemodialysis patients to obtain participants for
and topical application of turmeric/curcumin products may be the study. Patients aged 18-75 years old, with pruritus visual an-
used in the treatment of a variety of dermatologic diseases such alogue scale (VAS) score of more than or equal to 4, were includ-
as atopic dermatitis, acne, facial photoaging, alopecia, pruritus, ed in the study. Those with hypersensitivity to any ingredients
and psoriasis. In a particular controlled study, patients applied used in the study, use of specific pruritus treatments aside from
either a combination cream containing turmeric, with saffron, cetirizine within the last week prior to starting the study, and
sandalwood, and other ingredients, or a bland moisturizer for severe hyperphosphatemia (phosphate levels greater than 14
their pruritus. Both groups showed statistically significant im- mg/dL) were excluded from participating in the study.
provement in the participants’ subjective rating of pruritus.18
A local randomized controlled trial done by Guevara et.al. The participants were randomly allocated to either group
comparing the efficacy and safety of turmeric 1% cream to clo- A (turmeric 1% emollient cream) or group B (bland emollient
betasol propionate 0.05% cream in the treatment of plaque-type cream). Allocation was generated electronically from the web-
psoriasis showed that topical application of turmeric 1% cream site: http://www.randomization.com. The participants and the
for four weeks reduced both psoriasis assessment severity in- primary investigator were not aware of the sequence of group
dex and pruritus scores, furthermore, no adverse effects were allocations done. The research assistant allocated the treatment
seen in the turmeric group.19 The pharmacological efficacy and to the patients following the random numbers in sequence of pa-
safety of curcumin makes it an interesting focus for the control tients who were seen and evaluated to be eligible for the study.
of pruritus in hemodialysis patients compared to other drugs The turmeric 1% emollient cream, and the bland emollient
which have more side effects.18,20 cream were in identical containers labeled as A and B to blind
the patients and the primary investigator. Likewise, the creams
OBJECTIVES were similar in consistency, appearance, and smell. The pri-
mary investigator recruited and assessed the participants and
This study aimed to determine the efficacy and safety of turmer- gathered the data. The gathered data were analyzed by an in-
ic 1% emollient cream versus a bland emollient in the reduction dependent statistician. The treatment allocation was disclosed
of chronic kidney disease-associated pruritus in hemodialysis to the investigator and the patients only at the end of the study.
patients.
SAMPLE SIZE COMPUTATION
Specifically, it aimed to determine and compare the im- Sample size for this study was computed using the online sam-
provement of chronic kidney disease-associated pruritus in ple size calculator from powerandsamplesize.com with the as-
both groups through evaluation of the following: sumption that the mean value of the outcome of group A is 61%
+/- 19%. Estimation was done for the study to detect a 19% differ-
1. The proportion of patients who responded to treat- ence in outcome values between two groups. In the comparison
ment. of two means carried out at 5% level of significance, a sample
size of 53 per group (total of 106 participants) was needed for the
2. The mean pruritus scores from baseline and after study to have 80% power.
treatment using a visual analogue scale (VAS) for pru-
ritus and the 5D- itch scale. INTERVENTIONS AND COMPARISONS
This study compared the efficacy of turmeric 1% emollient
3. The incidence of patient reported adverse events. cream versus a bland emollient cream in reducing pruritus in


METHODOLOGY

RESEARCH DESIGN AND STUDY SETTING
This study was a randomized, double-blind, controlled trial of
the effect of turmeric 1% cream in the reduction of chronic kid-

15 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

hemodialysis patients. Any medication with presumed anti- duration, dialysis frequency, and Kt/V), VAS, and 5D-itch scale
pruritic effects was discontinued one (1) week before the study. scores were gathered by the primary investigator using a data
Both turmeric 1% emollient cream and the bland emollient collection form. Kt/V is a number used to quantify adequacy of
cream was prepared by a local FDA-approved manufacturer hemodialysis treatment, with a level of > 1.2 being adequate.
compliant with local Good Manufacturing Practices (GMP). For Treatment was started and patients were evaluated by the pri-
the turmeric cream, the part used for the extract is the root. Pu- mary investigator at the end of week 2 and week 4. To assess pru-
rity of extract was ensured prior to compounding of the cream. ritus, two (2) scoring systems were used, the VAS and the 5D-itch
The appearance, color, consistency, and smell were similar in scale, which was obtained from an open-access document with
both groups, and they were repackaged and labelled properly by permission to be utilized in this study.
a pharmacist into uniform 20-gram plastic containers (Figure
1). Cultures of the preparations were obtained to verify sterility The visual analogue scale (VAS) is a simple scoring system
of the creams. which uses a 10-cm long line on which the patients denote the
intensity of their pruritus by marking the line at the point cor-
Participants were instructed to apply their assigned responding to their respective severity of pruritus. The leftmost
cream, either turmeric 1% emollient cream or the bland emol- portion of the scale refers to absence of pruritus (0) and the
lient cream, to all involved body surfaces, twice a day, 12 hours rightmost to the most severe pruritus imaginable to them (10).
apart, for four (4) weeks. Both groups were instructed by the re- The method of categorization by Reich et. al. was used as refer-
search assistant on how to apply the cream. After application, ence when classifying the VAS score. Severity of pruritus was
participants were advised to avoid washing the area where the classified as: < 4 points, mild; ≥ 4 points but < 7 points, moder-
assigned creams were applied. Participants were instructed to ate; ≥ 7 points but < 9 points, severe; and ≥ 9 points, very severe
bring the container on each follow-up visit to ensure compli- pruritus.22
ance. The co-investigator inspected and weighed the contents
of the containers. The amount that should have been used was The 5-D itch scale is used for the multidimensional quan-
evaluated by estimating the surface area involved (rule of hand). tification of pruritus in clinical trials. This scale is sensitive
This was then used to calculate the number of fingertip units to changes over time. The duration, degree, and direction are
(FTU) that the patient used, in that 2% surface area is equivalent single-item domain scores, and is equivalent to the value be-
to 1 FTU which corresponds to 0.5 g.21 The containers were re- low the respective response choice (range of 1 to 5). The sleep,
filled every follow-up as needed. social/leisure activities, errands/housework, and school/work
domains are part of the disability domain that assess the im-
Participants were given cetirizine 10 mg/tab 1 tab once dai- pact of itching on daily activities. The score for this domain is
ly as standard of care for their pruritus. They were instructed attained by taking the highest score on any of the four (4) items.
to take a bath daily using mild soap and apply the creams after For the distribution domain, the number of affected body parts
bathing. The same mild soap was given to all patients. Partici- is tallied with a potential sum of 0 to 16. The sum is then sorted
pants were also instructed to neither take nor apply any other into five (5) scoring bins: the sum 0–2 is equivalent to 1, 3–5 is
medication during the study period. equivalent to 2, 6–10 to 3, 11–13 to 4, and 14–16 to 5. The scores of
each of the five (5) domains will then be added together to obtain
DATA GATHERING a total 5-D score. The potential range of 5-D scores is between 5,
On day 1 (week 0), baseline demographic and clinical data (age, corresponding to no pruritus, and 25 corresponding to the most
sex, duration of pruritus, body surface area involved, dialysis severe pruritus.23

Figure 1. Turmeric 1% emollient cream (A) and bland emollient cream (B). Presence of adverse events such as pain, erythema, burn-
ing, pruritus, and scaling were asked and recorded. Classifica-
tion of adverse event, if present, are as follows: mild if it results
to mild or transient discomfort that does not require interven-
tion or treatment and does not limit or interfere with daily ac-
tivities; moderate if it is sufficiently discomforting to limit or
interfere with daily activities and requires interventional treat-
ment; severe if it results to significant symptoms that prevents
normal daily activities and requires hospitalization or invasive
intervention.

OUTCOME MEASURES
The primary outcome measure of the study was treatment re-
sponse, measured by the proportion of subjects who demon-

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 16

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

strated a reduction of >/= 50% in their VAS scores after four (4) RESULTS
weeks.24 The secondary outcome measures were reduction in
pruritus from baseline to week 4 in terms of mean VAS score per STUDY POPULATION
visit and mean 5D-itch scale scores per visit, and incidence of Among 138 hemodialysis patients assessed for eligibility, a total
adverse effects (erythema, burning, pruritus, scaling) related to of 106 patients with CKD-aP who signed the consent and satisfied
the treatments during the study period. the inclusion criteria were enrolled and randomized into either
turmeric 1% emollient cream or bland emollient cream group.
In case of adverse events, the investigator will give im- Follow-up was done every two (2) weeks for four (4) weeks. Five
mediate and free medical treatment, and monitor accordingly. (5) participants dropped out from the study, producing a drop-
These study participants will be considered as withdrawals. But out rate of 5%. All participants were included in the analysis.
in this study, no adverse events were encountered. The flow diagram is shown below in Figure 2. The baseline char-
acteristics of the study population are summarized in Table 1.
DATA HANDLING AND ANALYSIS The result shows that in terms of age, sex, duration of pruritus,
Descriptive statistics was used to summarize the clinical char- surface involved, dialysis duration, dialysis frequency, and
acteristics of the patients. Mean and standard deviation were Kt/V, there is no statistical difference seen, suggesting that both
used to express the continuous variables, and frequency and have the same baseline measurements among the parameters
percentage for categorical data. Comparative analysis among identified. Common areas affected reported by the participants
the categorical data was done using Chi-square test. Compara- were the back and forearms. Mean Kt/V for both groups were
tive analysis for two (2) groups was done using t-test for two in- > 1.2, roughly indicating adequacy of hemodialysis treatment.
dependent means for continuous data and t-test for two propor-
tion for categorical data. The comparative analysis using VAS OUTCOME ANALYSIS
and 5D itch scale also made use of t-test for two independent Comparison of pruritus scores using VAS in both groups at base-
means. line and subsequent follow-up visits are shown in Table 2. The
mean pruritus score between the two (2) groups did not differ
significantly at baseline (p = 0.953), but after treatment the mean
decrease in pruritus score of the group treated with turmeric
was significantly greater than that of the bland emollient group
(p = 0.018); the mean difference in pruritus scores before and
after treatment in the turmeric group at four (4) weeks was 4.12
± 2.17 vs. 3.14 ± 1.46 in the bland emollient group.

Comparative analysis of pruritus scores was also done us-
ing the 5D-itch scale as shown in Table 3. The mean pruritus
score between the two (2) groups did not differ significantly at
baseline (p = 0.143). There was a significant difference in 5D-itch
scale scores from baseline and week 4 of treatment in the tur-
meric group (12.15 vs 7.51, p < 0.01); the same was also noted for

Table 1. Baseline Demographic Characteristics of Participants.

Figure 2. CONSORT diagram to show participant flow in the trial. Characteristics Turmeric 1% Bland emollient p-value
emollient cream cream 0.062
Mean age ± SD, years 0.171
46.77±13.45 49.17±13.21
Sex, frequency (%) 0.645
Male 27(51%) 32(60%) 0.100
Female 26(49%) 21(40%) 0.371
37.09±27.87 38.47±31.45 0.325
Duration of pruritus 0.187
(months), mean ± SD 21.31±6.9 20.21±6.89

Surface involved 49.38±36.06 52.5±35.79
(%), mean +_ SD
2.15±0.36 2.19±0.39
Dialysis duration
(months), mean ± SD 1.81±0.26 1.77±0.27

Dialysis frequency/
week

Kt/V, mean ± SD

17 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Table 2. Comparison of Pruritus Score using VAS for the 2 Treatments at Week 0 and 4. Table 4. Comparison of the therapeutic efficacy of turmeric 1% emollient cream versus bland
emollient after 4 weeks (intention-to-treat analysis).
Turmeric 1% Bland emollient
Total pruritus score emollient cream cream p-value Turmeric 1% Treatment Treatment Total P-value
0.953 emollient cream success, >/= 50% failure, < 50% 53(100%) 0.031503
Before trial 6.79±1.65 6.81±1.63 0.002 reduction in VAS reduction in VAS 53(100%)
After trial 4.44±1.66 4.94±1.93 Bland emollient score (n, %)
p-value 0.018 cream score (n, %)
Mean decrease VAS <0.01 <0.01 35(66%) 18(34%)
4.12±2.17 3.14±1.46
24(45%) 29(55%)

Table 3. Comparison of Pruritus Score using 5D-itch scale for the 2 Treatments at Week 0 and 4.

Total pruritus score Turmeric 1% Bland emollient p-value between the two (2) groups at the end of the study, in favor of
emollient cream cream 0.143 turmeric. There was also a significant difference based on the
Before trial <0.01 proportion of participants who achieved treatment success, still
After trial 12.15±2.8 12.77±3.17 in favor of turmeric. This study shows that turmeric 1% emol-
p-value 7.51±1.84 8.9±2.5 0.468 lient cream is more efficacious than the bland emollient cream
Mean decrease <0.01 in reducing the severity of CKD-aP. The beneficial effect of tur-
5D-itch <0.01 5.14±4.45 meric on CKD-aP could be attributed to its anti-inflammatory
4.2±2.11 property.

the bland emollient group (12.77 vs 8.9, p < 0.01). The mean pru- Xerosis is found in most CKD and dialysis patients, fre-
ritus score between the two groups differs significantly at week quently contributing to the severity of their pruritus. This was
4 (p < 0.01); however, there was no statistical difference noted in evident in the patients included in the analysis of this study.
the mean decrease in their pruritus scores (p = 0.468). The cornerstone of CKD-aP therapy is adequate skin hydration
with aqueous cream emollient applied two to four times daily.
When the efficacy of each cream was assessed by compar- Unfortunately, pruritus is often resistant to emollient therapy
ing the proportions of participants who achieved treatment suc- alone.4,12 Included study participants also attest to this finding.
cess (>/= 50% reductions in VAS scores), outcomes in the turmer-
ic group were superior to those in the bland emollient cream Several studies have shown that inflammation plays a major
group. In the turmeric group, 66% (35/53) of participants had factor in the development of CKD-aP in hemodialysis patients.
successful treatments, while in the bland emollient group, 45% CKD-aP has been reported to be associated with elevated C-re-
(24/53) of participants improved. The Chi-square test for 2x2 ta- active protein (CRP) values and high levels of T-helper 1 cells,
bles revealed that there was a statistically significant difference interleukin-6, and interleukin-2.8.24,25 Therefore, treatments
between the two (2) groups (p=0.031503, p <0.05) (Table 3). directed toward inhibiting this inflammatory process may be
effective in the reduction of CKD-aP. Curcumin, the active com-
Computation of the relative risk reduction (RRR) for failed ponent of turmeric, has been shown to shift cytokine profiles
outcomes revealed that turmeric will improve VAS scores 37.93% from the pro-inflammatory Th1 to the anti-inflammatory Th2
more (RRR = 0.3793, 95% confidence interval [CI] 0.0283–0.6035) type. It has inhibitory effects on inflammatory cytokines like
than bland emollient. The absolute risk reduction (ARR) was TNF-α, IL-1, IL -2, IL-6, IL-8, and IL-12, as well as, LOX, COX- 2,
20.75%, favoring turmeric (ARR = 0.2075, 95% CI 0.0187–0.3768). IFN-λ, and NF-кB.16,18,26 As a result, turmeric may inhibit early
The number needed to treat (NNT) revealed that five (5) study steps of inflammation and modulate CKD-aP. In a double-blind
participants were required to be treated with turmeric 1% emol- placebo-controlled trial using turmeric in 500 mg capsules tak-
lient cream for four (4) weeks to demonstrate improvement. en three (3) times a day for eight (8) weeks, Pakfetrat and col-
leagues found that the pruritus score and CRP values of the di-
Based on repeated interviews during follow-up in the alysis patients in their study significantly improved at the end
study, the patients mentioned no minor or major adverse effects of the trial with no noted adverse effects.27 Our study further
to both turmeric 1% and bland emollient cream. reinforces the role of turmeric in the treatment of pruritus in
hemodialysis patients.
DISCUSSION
This study supports the idea that addition of a naturally
CKD-aP is a common and bothersome condition affecting dialy- occurring, inexpensive, and safe, anti-inflammatory agent, like
sis patients. It has a significant impact on the quality of life and turmeric, to a cream emollient can be used to reduce the sever-
physical comfort of these patients.1,5 Our results have shown ity of pruritus in patients with CKD-aP. No adverse reactions
that turmeric 1% emollient cream reduces pruritus in patients were reported in both arms of the study, although the possibil-
with CKD-aP. A decrease in pruritus scores was seen in both
the turmeric and bland emollient groups, however, there was a
significant difference between the mean decrease in VAS scores

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 18

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

ity that oral cetirizine may have contributed to the attenuation sample size would better establish the robustness of the results
of pruritus that may have been brought about by application of in this study. The 4-week duration of the treatment phase may
turmeric cannot be excluded. not be enough to confirm long-term efficacy and safety of tur-
meric in hemodialysis patients. Extension of the study duration
LIMITATIONS AND RECOMMENDATIONS to 8 or 12 weeks is recommended. Lastly, although pruritus is
To the best of our knowledge, this is the first randomized, dou- inherently a subjective complaint, it may be prudent to measure
ble-blind, controlled trial investigating and demonstrating the biochemical inflammatory markers as well to assess and moni-
efficacy and safety of topical turmeric in reducing the severi- tor attenuation of inflammation associated with CKD-aP.
ty of CKD-aP in hemodialysis patients. The result of this study
adds to the existing literature on the use of medicinal plants in CONCLUSION
dermatology and serves as a basis to other researchers on con-
ducting further studies on topical turmeric. Among hemodialysis patients diagnosed with CKD-aP, topical
application of turmeric 1% emollient cream twice daily for four
A limitation of this study is that although it has a relatively (4) weeks is a promising treatment approach in reducing the se-
large sample size with adequate power, it was only done in a sin- verity of CKD-aP. No adverse effects were associated with appli-
gle center. Future multicenter randomized trials with a larger cation of turmeric in this study.

REFERENCES

1. James WD, Berger T, Elston D. Andrew’s Diseases of the Skin: Clinical Dermatology. 12th ed. 2016.
2. Goldsmith LA, Katz SI, Gilchrest BA, Paller A, Leffell DJ, Wolff K. Fitzpatrick’s dermatology in general medicine, eighth edition, 2 volume set.

8th ed. New York, NY: McGraw-Hill Medical; 2012.
3. Hu X, Sang Y, Yang M, Chen X, Tang W. Prevalence of chronic kidney disease-associated pruritus among adult dialysis patients: A

meta-analysis of cross-sectional studies. Medicine (Baltimore) [Internet]. 2018;97(21):e10633. Available from: http://dx.doi.org/10.1097/
md.0000000000010633
4. Shirazian S, Aina O, Park Y, Chowdhury N, Leger K, Hou L, et al. Chronic kidney disease-associated pruritus: impact on quality of life and
current management challenges. Int J Nephrol Renovasc Dis [Internet]. 2017;10:11–26. Available from: http://dx.doi.org/10.2147/IJNRD.S108045
5. Mettang T. Pruritus in Renal Disease. In: Carstens E, Akiyama T, editors. Itch: Mechanisms and Treatment. Boca Raton (FL): CRC Press/Taylor &
Francis; 2014. Chapter 5.
6. Narita I, Alchi B, Omori K et al. Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients. Kidney Int
2006; 69: 1626–1632.
7. Combs SA, Teixeira JP, Germain MJ. Pruritus in Kidney Disease. Semin Nephrol. 2015;35(4):383-91.
8. Kimmel M, Alscher DM, Dunst R, Braun N, Machleidt C, Kiefer T, et al. The role of micro-inflammation in the pathogenesis of uraemic pruritus
in haemodialysis patients. Nephrol Dial Transplant [Internet]. 2006;21(3):749–55. Available from: http://dx.doi.org/10.1093/ndt/gfi204
9. Simonsen E, Komenda P, Lerner B, Askin N, Bohm C, Shaw J, et al. Treatment of uremic pruritus: A systematic review. Am J Kidney Dis
[Internet]. 2017;70(5):638–55. Available from: http://dx.doi.org/10.1053/j.ajkd.2017.05.018
10. Kfoury LW, Jurdi MA. Uremic pruritus. J Nephrol [Internet]. 2012;25(5):644–52. Available from: http://dx.doi.org/10.5301/jn.5000039
11. Mathur VS, Lindberg J, Germain M, Block G, Tumlin J, Smith M, et al. A longitudinal study of uremic pruritus in hemodialysis patients. Clin J Am
Soc Nephrol [Internet]. 2010;5(8):1410–9. Available from: http://dx.doi.org/10.2215/CJN.00100110

12. Kuypers DRJ. Skin problems in chronic kidney disease. Nat Clin Pract Nephrol [Internet]. 2009;5(3):157–70. Available from: http://dx.doi.
org/10.1038/ncpneph1040
13. Ravindran PN, Babu KN, Sivaraman K, editors. Turmeric: The genus Curcuma. CRC Press; 2007:1-14
14. Chattopadhyay I, Biswas K, Bandyopadhyay U, Banerjee RK. Turmeric and curcumin: Biological actions and medicinal applications. Curr Sci
[Internet]. 2004;87(1):44–53. Available from: http://www.jstor.org/stable/24107978
15. Chan EWC, Lim YY, Wong SK, Lim KK, Tan SP, Lianto FS, et al. Effects of different drying methods on the antioxidant properties of leaves and
tea of ginger species. Food Chem [Internet]. 2009;113(1):166–72. Available from: http://dx.doi.org/10.1016/j.foodchem.2008.07.090
16. Hanai H, Iida T, Takeuchi K, Watanabe F, Maruyama Y, Andoh A, et al. Curcumin maintenance therapy for ulcerative colitis: randomized,
multicenter, double-blind, placebo-controlled trial. Clin Gastroenterol Hepatol [Internet]. 2006;4(12):1502–6. Available from: http://dx.doi.
org/10.1016/j.cgh.2006.08.008
17. GRAS notice inventory [Internet]. U.S. Food and Drug Administration. FDA; [cited 2022 Nov 27]. Available from: https://www.fda.gov/food/
generally-recognized-safe-gras/gras-notice-inventory
18. Vaughn AR, Branum A, Sivamani RK. Effects of turmeric (Curcuma longa) on skin health: A systematic review of the clinical evidence: Effects
ofCurcuma longaon skin health. Phytother Res [Internet]. 2016;30(8):1243–64. Available from: http://dx.doi.org/10.1002/ptr.5640
19. Guevara BEK, Coo ER, Bunagan MJ. A randomized, double-blind clinical trial on the efficacy and safety of turmeric 1% cream in the treatment
of plaque-type psoriasis in adults. J Phil Dermatol Soc 2019, 28(1), 23-32.
20. Samadian F, Dalili N, Poor-Reza Gholi F, Fattah M, Malih N, Nafar M, et al. Evaluation of Curcumin’s effect on inflammation in hemodialysis
patients. Clin Nutr ESPEN [Internet]. 2017;22:19–23. Available from: http://dx.doi.org/10.1016/j.clnesp.2017.09.006
21. Zaghloul SS, Goodfield MJD. Objective assessment of compliance with psoriasis treatment. Arch Dermatol [Internet]. 2004;140(4):408–14.

19 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Available from: http://dx.doi.org/10.1001/archderm.140.4.408
22. Reich A, Heisig M, Phan NQ, Taneda K, Takamori K, Takeuchi S, et al. Visual analogue scale: evaluation of the instrument for the assessment

of pruritus. Acta Derm Venereol [Internet]. 2012;92(5):497–501. Available from: http://dx.doi.org/10.2340/00015555-1265
23. Elman S, Hynan LS, Gabriel V, Mayo MJ. The 5-D itch scale: a new measure of pruritus: The 5-D itch scale. Br J Dermatol [Internet].

2010;162(3):587–93. Available from: http://dx.doi.org/10.1111/j.1365-2133.2009.09586.x
24. Nofal E, Farag F, Nofal A, Eldesouky F, Alkot R, Abdelkhalik Z. Gabapentin: A promising therapy for uremic pruritus in hemodialysis patients: A

randomized-controlled trial and review of literature. J Dermatolog Treat [Internet]. 2016;27(6):515–9. Available from: http://dx.doi.org/10.3109
/09546634.2016.1161161
25. Chen HY, Chiu YL, Hsu SP, Pai MF, Lai CF, Yang JY, et al. Elevated C-reactive protein level in hemodialysis patients with moderate/severe
uremic pruritus: a potential mediator of high overall mortality. QJM [Internet]. 2010;103(11):837–46. Available from: http://dx.doi.org/10.1093/
qjmed/hcq036
26. Fallahzadeh MK, Roozbeh J, Geramizadeh B, Namazi MR. Interleukin-2 serum levels are elevated in patients with uremic pruritus: a novel
finding with practical implications. Nephrol Dial Transplant [Internet]. 2011;26(10):3338–44. Available from: http://dx.doi.org/10.1093/ndt/
gfr053
27. Pakfetrat M, Basiri F, Malekmakan L, Roozbeh J. Effects of turmeric on uremic pruritus in end stage renal disease patients: a double-blind
randomized clinical trial. J Nephrol [Internet]. 2014;27(2):203–7. Available from: http://dx.doi.org/10.1007/s40620-014-0039-2

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 20

JPDS ORIGINAL ARTICLE
Journal of the Philippine
Dermatological Society

Knowledge, attitude, perception and practices
of primary care physicians regarding common
dermatological diseases: A cross-sectional study

Tanya Patricia A. Marasigan, MD, DPDS,1 Ma. Angela M. Lavadia, MD, FPDS,1 Wilsie Salas-Walinsundin, MD, FPDS1

ABSTRACT

INTRODUCTION Dermatologic diseases are one of the common reasons for consult in primary care. Primary care physicians such as the doctors
to the barrios (DTTBs) assigned in geographically isolated areas play a critical role in providing primary skin health services since they are the
first, and sometimes, only doctors patients rely on for consult. In managing skin diseases, adequate knowledge and skills are needed to arrive at
a correct diagnosis, and a physician’s proper initial treatment and timely referral to dermatologists will lead to less affectation on quality of life.
Identifying what is lacking in skin health services and referral system would aid dermatologists in finding out how to bridge the gap in knowledge
and access to our specialized skin health care.

OBJECTIVES The study aimed to determine the knowledge, attitudes, practices, and perceptions of primary care physicians in the Philippines
regarding common dermatologic conditions.

METHODS This is a cross-sectional study that utilized a self-administered questionnaire to collect data from rural government primary care phy-
sicians (doctors to the barrios). At the end of the study, the proponents collated the data and data analysis was done using STATA 13.1 guided by a
statistician.

RESULTS A total of 118 DTTBs were included in the study. The mean age of the physicians is 28 years old. One-half of the physicians were assigned to
low-income class municipalities; 26.85% and 25% are from 4th class and 5th class municipalities respectively. Factors such as age, sex and clinical
experience were not associated with level of knowledge of the respondents. Majority or 55% of the primary care physicians were classified as hav-
ing insufficient knowledge on common skin diseases. The respondents have an average of 250 consultations per week and 6% of these are derma-
tologic diseases. The most common skin diseases they encountered were impetigo (46.61%), scabies (46.61%), contact dermatitis (43.22%), fungal
infection (25.42%) and cellulitis (20.34%). The most prescribed and available medications for skin diseases are oral and systemic antibiotics. Only
42.37% of the physicians are able to refer to dermatologists through various online communication platforms while the rest refer through phone
calls or advise their patients to seek dermatologic consult. 25% of the respondents have direct access to dermatologists. DTTBs also have recog-
nized the importance of having adequate knowledge on skin diseases and majority are very interested in learning more about these conditions.
The top 3 barriers to the proper management of skin diseases were lack of training, lack of experience, and lack of medications. Most of the re-
spondents have rated themselves as average to bad in their perceived competency in diagnosing and managing different common skin diseases.

CONCLUSION The study showed that majority of the respondents had insufficient knowledge on the diagnosis and management of common der-
matological diseases but had a strong interest to learn more. A significant number of the respondents do not always refer to dermatologists and
have poor access to specialty care. Overall, our findings suggest that there are indeed barriers to delivery of skin-related health services that
should be addressed.

KEYWORDS primary care physicians, common dermatologic diseases

1Department of Dermatology, East Avenue INTRODUCTION Primary care physicians play a critical role
Medical Center, East Ave, Diliman, Quezon in the health care system of the Philippines. They
City, Philippines The Global Burden of Diseases Study 2010 stated are the first and sometimes the only doctors pa-
that skin diseases are one of the most common tients can consult especially in geographically
Corresponding author human illnesses. At the global level, skin condi- isolated areas where specialized health care is
Tanya Patricia A. Marasigan, MD, DPDS tions were the fourth leading cause of nonfatal less accessible. The Department of Health (DOH)
disease burden. Collectively, skin conditions recognized the importance of the presence of
Conflict of interest ranged from the 2nd to 11th leading cause of physicians in rural areas and the lack thereof,
None years lived with disability at the country level.1 hence they created the Doctors to the Barrios
This emphasizes the importance of giving more program where hundreds of doctors were de-
Source of funding attention to skin diseases at the community lev- ployed to disadvantaged and hard to reach areas
None el, especially where there is limited access to der- of the Philippines to work on public health poli-
matologists and where primary physicians are cies and to provide primary care. These doctors
solely being relied on.

21 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

manage patients daily on an outpatient basis and they provide METHODOLOGY
basic health services. They see a wide array of diseases includ-
ing dermatologic conditions. It is vital that they recognize the STUDY DESIGN
importance of being able to diagnose and manage skin diseas- This is a cross-sectional study conducted on rural government
es, and to know when to refer to dermatologists especially those primary care physicians, specifically the DTTBs of the DOH, us-
cases with high impact such as skin cancer, leprosy, and psori- ing a self-administered questionnaire.
asis.
The researcher formulated the questionnaires, it was based
Referral of patients from primary care to specialized care on the results of previous similar studies conducted by Al Zahra-
accounts for a considerable part of primary care activity, since ni, M. A. et al. (2017) and Bahaullah, S. O. et al. (2015).3,4 The top-
it is key to reducing costs and increasing the safety, efficacy, and ics and questions were selected and framed based on the desired
effectiveness of health care.2 Dermatologists, on the other hand, outcome measures of the researcher. The questions assessing
should lead in initiating efforts to help effect change towards im- the knowledge of the respondents were based on the dermatol-
proving health care delivery for patients with skin diseases. ogy textbooks Fitzpatrick’s Dermatology in General Medicine
(8th Ed), Andrew’s Diseases of the Skin: Clinical Dermatology
This study aimed to determine the knowledge, attitudes, (12th Ed) and Dermatology by Bologna (2012) with the guidance
and self-perception of competency of our primary care physi- of the researcher’s advisers.5,6,7 For pilot testing, the question-
cians in rural areas of our country in the diagnosis and man- naires were distributed to general physicians and DTTBs who
agement of common skin disease and the frequency of skin have already graduated from the program. Kappa agreement
diseases. This study also determined the status of the service analysis and Cronbach’s alpha analysis was used to determine
delivery network in terms of dermatologic diseases and to deter- the reliability and consistency of the data collection tool.
mine whether health units have the appropriate protocols and
resources to facilitate referrals to dermatologists when needed. SETTING
This will help identify what is lacking in services and health This study was done at institutions where primary care physi-
care delivery in terms of skin diseases and enlighten dermatolo- cians or DTTBs had their continuing medical education (CME)
gists on how they can work with primary care physicians so that classes. The researcher coordinated with the DTTBs and con-
specialized care for skin diseases can be extended and made cerned authorities to obtain the required data. The parts of the
more accessible to the people who need it the most. questionnaire containing questions on general data, attitudes,
practices, and perceptions were emailed beforehand to the doc-
DEFINITION OF TERMS: tors for more convenient data collection from their own munic-
1. Competence: The ability of a physician to provide cor- ipalities. The questionnaire containing questions for the knowl-
rect, safe, and reliable diagnosis and management for edge part was administered to the physicians during their CME
his/her patients consistently. between October to November 2020. The respondents’ identities
2. High-impact skin diseases: Diseases that significantly were kept anonymous.
affect quality of life of patients, especially when there
is a delay in diagnosis or inadequate treatment. SUBJECT SELECTION
Purposive sampling was done in this study. The respondents
RESEARCH OBJECTIVES were primary care physicians under the DTTB program of the
The general objective of this study was to determine the knowl- DOH. There are currently 298 active doctors to the barrios serv-
edge, attitudes, practices, and perceptions of primary care phy- ing in various municipalities all over the Philippines.
sicians in the Philippines, regarding dermatologic conditions.
Specifically: 1) to determine the frequency of dermatologic INCLUSION CRITERIA
problems/consultations in the rural areas in the country; 2) to 1. Physicians enrolled to the Doctors to the Barrios
assess the basic knowledge of rural government primary care program of the Department of Health, both munic-
physicians regarding dermatologic conditions; 3) to determine ipal health officers and rural health physicians who
the common attitudes of rural government primary care phy- have served in their municipalities for at least six (6)
sicians regarding dermatologic conditions; 4) to investigate the months.
common practices of rural government primary care physi-
cians regarding dermatologic conditions; and 5) to determine EXCLUSION CRITERIA
the self-perception of competency of rural government primary 1. Physicians who have already undergone specialty
care physicians regarding diagnosis and management of der- training in dermatology.
matologic conditions. 2. Physicians who were absent at the day of face-to-face

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 22

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

data collection using the self-administered question- ical variables and mean and standard deviation for normally
naire. distributed continuous variables. Independent sample T-test
and Fisher’s exact/Chi-square test were used to determine the
OUTCOME MEASURES difference of mean and frequency, respectively, between prima-
As per the objectives of this study, the outcome measures are as ry care physician with and without sufficient knowledge. Odds
follows: ratio and corresponding 95% confidence intervals from binary
logistic regression was computed to determine the association
1. Sociodemographic profile of demographic profile to insufficient knowledge of the primary
a. Age care physicians. All statistical tests were two-tailed tests. Miss-
b. Sex ing variables were neither replaced nor estimated. Null hypoth-
c. Highest educational level (MBBS, specialized diplo- eses were rejected at 0.05 α-level of significance. STATA 13.1 was
ma/specialty, masters) used for data analysis. Conclusions and recommendations were
d. Clinical experience (in years) then made after discussions among all the authors of the study.
e. Assigned municipality
f. Total population served ETHICAL CONSIDERATIONS
g. Average number of patients seen per day The proposal was submitted to the East Avenue Medical Center
h. Average number of dermatologic cases seen per day Institutional Ethics Review Board (EAMC IERB) for evaluation
i. Presence or absence of educational activities on and approval, after the evaluation and approval of the EAMC De-
dermatologic diseases in your area (yes/no) partment of Dermatology. The privacy of the results of the study
j. Presence or absence of data on dermatologic dis- was the tacit responsibility of the authors of the study.
eases (yes/no)
k. Presence or absence of guidelines/protocol for BIAS
management of dermatologic diseases To minimize bias, pilot testing and tests for reliability and con-
l. Access to dermatologists sistency were done to ensure comprehensiveness and clarity of
the questionnaire. An adequate amount of representative sam-
2. Top 5 most common dermatologic skin diseases seen ple was also achieved to provide unbiased estimates of attitudes
in their municipality and practices in the target population.

3. Top 4 most common treatments given for dermatologic SAMPLE SIZE
diseases The formula for sample size computation was taken from the
Oxford Handbook of Medical Statistics by Peacock.8 A minimum
4. Knowledge, attitudes, practices, and perceptions of 82 rural government primary care physicians were required
(KAPP) for this study on the assumption that 30.48% of physicians have
a. Knowledge scores (excellent (>85% correct an- sufficient knowledge of common dermatological problems from
swers), very good (75-85% correc answers), good (60- the study of Al Zahrani et.al,3 with 5% level of significance and
75% correct answers), insufficient (<60% correct an- 10% desired half width of the confidence interval.
swers))
b. Attitudes (toward referral to dermatologists, inten- RESULTS
tion to learn, barriers and difficulties in managing
skin diseases) A total of 142 doctors to the barrios (DTTBs) were present at the
c. Practices (regarding the management of common data collection and were screened for eligibility. Out of the 142,
dermatological problems) 118 DTTBs were included in the study. The exclusion of the other
d. Self-perception on competency on their ability to physicians from the study was due to failure to meet inclusion
diagnose skin diseases (very good, good, average, bad, criteria and absence at the time of data collection. 118 DTTBs
very bad) were able to submit the questionnaires, however, several of them
e. Self-perception on competency on their ability to had missing data due to incompletely answered questionnaires
treat skin diseases (very good, good, average, bad, (see Figure 1). Pairwise deletion was done in the treatment of the
very bad)

STATISTICAL ANALYSIS
At the end of the study, the study proponents collated the data
and data analysis was done using appropriate statistical tools,
guided by a statistician. Descriptive statistics was used to sum-
marize the demographic and clinical characteristics of the re-
spondents. Frequency and proportion were used for categor-

23 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Figure 1. Number of respondents and number of respondents with missing data for each variable. data analysis, there was no association between knowledge on
common skin diseases and the demographic profile of the re-
Table 1. Demographic profile of the Primary Care Physicians and Knowledge on Common Skin spondents including age, sex, educational attainment, or clini-
Diseases cal experience (Table 1).

Total (n=118) Insufficient Sufficient Odds ratio According to Executive Order No. 249, municipalities of the
knowledge knowledge (95% CI) Philippines have been divided into six (6) main classes accord-
(n=65, 55%) (n=53, 45%) P-value ing to the average annual income that they realized during the
1.09 (0.94‒1.26) last four (4) calendar years. Our data show that the higher the
Frequency (%); Mean + SD 0.258 class of the municipalities, the higher the income and the more
1.000 (reference) population is being served, which translate to a greater number
Age (years) 28.54 + 3.12 28.83 + 3.67 28.16 + 2.20 0.97 (0.47‒2.03) of patients and dermatologic cases seen per week (Table 2). The
average number of consults that these doctors see per week is
Sex 54 (46.55) 30 (46.88) 24 (46.15) 250 and the average number of consults due to skin diseases is
Male 62 (53.45) 34 (53.13) 28 (53.85) 15 per week. This means that 6% of the average number of con-
Female sultations per week is regarding skin diseases.
65 (55.08) 32 (49.23) 33 (62.26) 0.194 0.59 (0.28‒1.23)
Highest 71 (60.17) 38 (58.46) 33 (62.26) 0.709 0.85 (0.41‒1.79) The doctors to the barrios included in the study were each
educational assigned to different municipalities all over the Philippines
attainment 0.647 from Luzon, Visayas, and Mindanao (Table 3). 46.3%, 37.04%
and 16.67% were assigned to Mindanao, Visayas and Luzon, re-
MD 73 (65.77) 44 (69.84) 29 (60.42) (reference) spectively. Half of the respondents are from 4th class (26.85%)
Masters/ 24 (21.62) 11 (17.46) 13 (27.08) 0.56 (0.22‒1.41) and 5th class (25.00%) municipalities.
Doctorate 12 (10.81) 7 (11.11) 5 (10.42) 0.92 (0.27‒3.19)
2 (1.80) 1 (1.59) 1 (2.08) 0.66 (0.04‒10.9) For the rural health unit profiles of the physicians (Tables
Clinical experi- 4 and 5), data shows that 89.74% of them serve more than 10,000
ence before the people in their municipality. 55.26% of them have more than 200
DTTB Program patients seen per week and 34.78% and 33.04% see 5-10 and 21-30
(in years) dermatologic cases per week, respectively. This shows that der-
matologic diseases remain as common reasons for consultation
<1 even in these far-flung areas. However, in these municipalities,
1 only 25% have an accessible dermatologist, which further estab-
2 lishes that majority (75%) of them must manage skin diseases on
3 their own. It was also noted that only 38.46% of the rural health
units make official records or have available data on skin dis-
Clinical experi- eases that they see in their municipality and only 12.82% have
ence in the DTTB educational activities on skin diseases. Our results also show
Program (in that 42.37% of the physicians are able to refer to dermatologists
years) through Viber and other online communication platforms,
however, 13.56% refer only through phone call being unable to
<1
1 0.341
2
3 Table 2. Class of Municipalities and Average Number of Patients of the Doctors to the Barrios

63 (53.39) 32 (49.23) 31 (58.49) (reference) Class Annual Income Population (by Average number of Average number of
11 (9.32) 8 (12.31) 3 (5.66) 2.58 (0.63‒10.6) (Pesos) 1000) patients per week dermatologic cases
43 (36.44) 25 (38.46) 18 (33.96) 1.35 (0.62‒2.94) 1st class
1 (0.85) 1 (1.89) 2nd class >/= 15,000,000 67.5 (51 to 84.55) 300 (250 to 400) per week
0 - 10,000,000- 62 (54.25 to 68) 310 (300 to 500) 23 (10 to 50)
3rd class 14,999,999 20 (15 to 25)
missing data. The mean age of the physicians is 28 years old and 4th class 39.5 (33.64 to 43.3) 250 (200 to 500)
there were more females than males who were able to partici- 5th class 5,000,000-9,999,999 28.82 (24.5 to 34.61) 245 (150 to 300) 20 (10 to 30)
pate. Majority (65.77%) of the doctors had less than one (1) year 6th class 3,000,000-4,999,999 200 (100 to 200) 15 (10 to 23)
of clinical experience in their municipality as DTTBs. Based on 1,000,000-3,000,000 15.3 (10.23 to19) 175 (90 to 275) 10 (7 to 20)
8.4 (2.55 to 25) 6 (3 to 30)
< 1,000,000

Overall 29.98 (17.26 to 51) 250 (150 to 300) 15 (10 to 30)

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 24

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

Table 3. Municipalities of the Doctors to the Barrios

Frequency (%) First Class Second Class Third Class Fourth Class 29 Fifth Class 27 Sixth Class
Luzon 9 (8.33%) 13 (12.04%) (26.85%) (25.00%) 9 (8.33%)
18 (16.67%) 21 (19.44%) Calayan, Cagayan Uyugan, Batanes
Goa, Camarines Sur Lasam, Cagayan Burdeos, Quezon San Quintin, Abra Sabtang, Batanes
Visayas Palanan, Isabela Mercedes, Camarines Norte Padre Burgos, Quezon Tinglayan, Kalinga Bucloc, Abra
40 (37.04%) Cabagan, Isabela Igbaras, Iloilo
Gattaran, Cagayan Bacacay, Albay Toboso, Negros Occidental Iguig, Cagayan Samboan, Cebu San Sebastian, Samar
Lal-lo, Cagayan Palompon, Leyte Mabinay, Negros Oriental San Rafael, Iloilo
Tuao, East Cagayan Victoria, Oriental Mindoro Nueva Valencia, Guimaras Dimasalang, Masbate San Rafael, Iloilo Concepcion, Misamis
Asingan, Pangasinan Leyte, Leyte Matuguinao, Samar Occidental
Catanauan, Quezon New Corella, Davao de Culion, Palawan Barugo, Leyte Biri, Northern Samar
Tagkawayan, Quezon Norte Pola, Oriental Mindoro Matuguinao, Samar Sapang Dalaga, Misamis
Sibunag, Guimaras Sto. Nino, Samar Occidental
Puerto Galera, Oriental Claver, Surigao Del Norte Talaingod, Davai del Norte San Enrique, Negros Samboan, Cebu
Mindoro Balingasag, Misamis Mawab, Compostela Valley El Salvador City, Misamis
Oriental Occidental Pilar, Cebu Oriental
Sta. Cruz, Occidental Cabanglasan, Bukidnon Siruma, Camarines Sur Gainza, Camarines Sur
Mindoro Opol, Misamis Oriental Cabanglasan, Bukidnon Magarao, Camarines Sur Cabusao, Camarines Sur Pandag, Maguindanao
Sultan Naga Dimaporo, Gloria, Oriental Mindoro Tomas Oppus, Southern Datu Blah Sinsuat, Magu-
San Jose, Occidental
Mindoro Lanao del Norte Oslob, Cebu Leyte indanao
Pintuyan, Southern Leyte
Talibon, Bohol Lanuza, Surigao del Norte Mercedes, Eastern Samar
Dalaguete, Cebu Lopez Jaena, Misamis
Occidental Matungao, Lanao Del Norte
Mindanao Kapalong, Davao del Norte Salvador, Lanao del Norte
50 (46.30%) Glan, Sarangani Don Voctoriano, Misamis Sultan Mastura, Maguin-
Occidental
Laak, Davao de Oro danao
Lupon, Davao Oriental Magsaysay, Misamis San Francisco, Surigao
Maco, Compostela Valley, Oriental
del Norte
Davao Medina, Misamis Oriental San Isidro, Surigao del
T'boli, South Cotabato Tagoloan, Misamis Oriental
Impasugong, Bukidnon Norte
Sto. Tomas, Davao del Maigo, Lanao del Norte General Luna, Surigao
Pantao Ragat, Lanao del
Norte del Norte
Norte Alegria, Surigao del Norte
Marawi City, Lanao del Sur Tigbao, Zamboanga del Sur
San Isidro, Davao del Norte Rizal, Zamboanga del Norte
Basilisa, Dinagat Islands
Santiago, Agusan del Norte Maimbung, Sulu
Dinas, Zamboanga del Sur Turtle Islands, Tawi-Tawi

Midsalip, Zamboanga
del Sur

Jose Dalman, Zamboanga
Del Norte

Sirawai, Zamboanga del
Norte

Buldon, Maguindanao

show the actual lesions of their patients to dermatologists. sis followed by tinea corporis. Overall, the top 5 most common
The most common skin diseases diagnosed by the re- skin diseases the respondents diagnosed were impetigo/bullous
impetigo and scabies at 46.61% each, followed by allergic/irri-
spondents in their municipalities is shown in Figure 2. Among tant contact dermatitis at 43.22%, fungal infection (unspecified)
the groups of skin diseases, dermatitis (29.21%) was the most at 25.42%, cellulitis at 20.34%, and carbuncle at 17.8%. Among
common followed by superficial skin and soft tissue infections these, impetigo/bullous impetigo (22.88%) frequently ranked as
(25.27%) and superficial fungal infection (14.34%). Among the top 1 diagnosis followed by atopic dermatitis (13.56%) and sca-
dermatitis group of diseases, allergic/irritant contact derma- bies (10.17%).
titis was the most frequent diagnosis. For superficial skin and
soft tissue infections group, impetigo/bullous impetigo was the The results for the most common medications prescribed
most common, and for the superficial fungal infection group, for their patients showed congruent results with the top diag-
fungal infection (unspecified) was the most common diagno- nosis they have recorded in their municipalities. The most com-

25 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Table 4. Summary of Rural Health Unit Profiles Valid observation Frequency (%)
117
Total Population Served 114 5 (4.27)
≤ 5000 115 7 (5.98)
5001-10000 105 (89.74)
>10000
2 (1.75)
Total Number of Patients per Week 16 (14.04)
<50 15 (13.16)
50-100 18 (15.79)
101-150 63 (55.26)
151-200
>200 12 (10.43)
40 (34.78)
Total Number of Dermatologic Cases seen per Week 25 (21.74)
<5 38 (33.04)
5-10
11-20
21-30

Table 5. Rural Health Unit Profile on Dermatology Frequency (%)
29 (25)
Accessible Dermatologist
Available Data on Dermatologic Diseases 45 (38.46)
Educational activities on Skin Diseases 15 (12.82)
Guidelines or Protocols in the Management of Skin Diseases 11 (9.57)
How do you refer
50 (42.37)
Viber/Messenger/other online communication 16 (13.56)
Phone call 47 (39.83)
Transfer of patient to a Dermatologist 26 (22.03)
Others

mon medications prescribed were topical and systemic antibi- Figure 2. Most Common Skin Diseases by Group of Diseases and by Specific Diagnosis
otics, which were ranked as top 1 by 70.94% and 88.5% of the
respondents respectively (Tables 6 and 7). The most common- tional materials (42.45%) (Table 10).
ly ranked as top 2 medications were systemic corticosteroids Regarding the attitude of the respondents towards derma-
(52.78%) and topical antifungals (50.43%). Regarding the avail-
ability of medications, 97.41% have available oral antibiotics tological diseases (Table 11), majority (93.22%) of the DTTBs in-
however only 20.69% and 53.45% have available oral antifungal cluded in the study think that it is very important to have ade-
and corticosteroids respectively. For the topical medications, quate knowledge on the diagnosis and management of common
66.38% have available topical antibiotics, however, only 43.97% dermatological diseases and 84% think that it is important to
have available antifungals and steroids (Table 8). have access to dermatology specialists. It is also shown that ma-
jority (91.45%) of the respondents are very interested in learning
In terms of knowledge for common dermatologic diseases, more about dermatological diseases.
scores were classified to excellent (>85% correct answers), very
good (75%-85% correct answers), good (60-75% correct answers) Practices on diagnosis and management of skin diseases
and insufficient (<60% correct answers). Table 9 summarizes were also determined (Table 12). About 49.15% of the respon-
the results for the knowledge of primary care physicians on dents always refer and 45.76% sometimes refer to dermatolo-
common skin diseases. More than half or 55% of the physicians gists when they are unsure of their diagnosis. This means that
scored <60% correct answers classifying them under insuffi- almost half of them seek the expertise of dermatologists to help
cient knowledge. them diagnose and treat skin diseases that they encounter when

The possible barriers to the proper management of skin
diseases ranked by the respondents were topped by lack of
training (75.47%) and followed by lack of experience (73.58%).
The rest were lack of medications (70.75%), lack of guidelines
(60.38%), ineffective referral system (46.23%), and lack of educa-

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 26

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

Table 6. Top 4 Most Common Topical Medications

Ranking

Valid observation Median (IQR) 1 23 4

2 (2 to 3) 11 (9.40) Frequency (%) 2 (1.71)
1 (1 to 2) 83 (70.94) 1 (0.85)
Antifungal 117 3 (2 to 3) 23 (10.18) 59 (50.43) 45 (38.46) 3 (2.63)
Antibiotic 117 4 (4 to 4) 104 (94.55)
Corticosteroids 114 1 (0.91) 24 (20.51) 9 (7.69)
Retinoids 110 Median (IQR) 4
1 33 (28.95) 55 (48.25)
3 (2 to 3) 9 (8.33)
1 (1 to 1) 5 (4.63) 1 (0.91) 4 (3.64) 1 (0.88)
2 (2 to 3) 100 (88.5) 3 (2.78)
Table 7. Top 4 Most Common Systemic Medications 4 (4 to 4) 7 (6.48) 93 (87.74)

1 (0.94) Ranking

Valid observation 23

108 Frequency (%)
113
Antifungal 108 44 (40.73) 50 (46.3)
Antibiotic 106
Corticosteroids 8 (7.08) 4 (3.54)
Retinoids
57 (52.78) 41 (37.96)

2 (1.89) 10 (9.43)

Table 8. Availability of oral or topical medications for Dermatological Diseases needed. However, majority of them (67.8%) sometimes treat pa-
tients even when they are unsure of the diagnosis.
Medication Frequency (%)
Potassium hydroxide examination is a test to aid in the
Oral medications 24 (20.69) diagnosis of fungal infections. This is a simple test that can be
Antifungal 113 (97.41) done by medical technologists as well. Majority (87.29%) of the
Antibiotic 62 (53.45) physicians do not do this or possibly do not have this test avail-
Corticosteroids able. Only 5.08% of the respondents answered “always” in terms
Retinoids 4 (3.45) of the availability of medications for the skin diseases that they
encountered further supporting the previous results saying that
Topical medications 51 (43.97) lack of medications is a barrier to managing common skin dis-
Antifungal 77 (66.38) eases.
Antibiotic 51 (43.97)
Corticosteroids With regards to self-perception of competency, what
Retinoids 0 is noteworthy is that for the most common skin diseases diag-
19 (16.38) nosed in their municipalities, majority of the physicians have
Emollients 1 (0.86) rated themselves as just average to bad in their perceived ability
to diagnose and manage these skin diseases (Figure 3).
Others
DISCUSSION
Table 9. Knowledge of Primary Care Physicians on Dermatological Diseases
KEY RESULTS
Excellent Very good Good Insufficient Primary care physicians are in the frontlines in managing skin
65 (55.098) diseases in geographically isolated areas with no access to der-
Frequency (%) matologists. As seen in the results, majority of them belong to
4th and 5th class municipalities, which implies that half of the
2 (1.69) 2 (1.69) 49 (41.53) respondents are assigned to municipalities with low-income
and most probably the ones that are geographically isolated,
Table 10. Difficulties or barriers encountered in the Management of Skin Diseases making the DTTBs the only physicians that are being relied on
for consultation. The primary care physicians assigned should
Excellent Very good therefore be knowledgeable of the common skin diseases they
Barriers Frequency (%) might encounter and there should be accessible dermatologists
Difficulty/Barrier for referral of difficult cases that need specialized care.
Lack of experience 78 (73.58)
Lack of training 80 (75.47) According to El-Wahed et al. (2015) skin diseases are the
Lack of guidelines 64 (60.38) third most common complaint encountered in primary care
Lack of educational materials 45 (42.45)
Lack of medications 75 (70.75)
Ineffective referral system 49 (46.23)

27 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Table 11. Attitudes of Primary Care Physicians on Dermatologic Diseases Very important Somewhat important Not important
Frequency (%)
Importance of having adequate knowledge on diagnosis and management of common 110 (93.22) 8 (6.78) 0
dermatological diseases.
Importance of having access to a dermatology specialist. 84 (71.19) 33 (27.97) 1 (0.85)
Very interested Somewhat interested Not interested
Interest in learning more about dermatological diseases
107 (91.45) 10 (8.55) 0

Table 12. Practices of Primary Care Physicians on Diagnosis and Management Dermatologic Cases

Always Sometimes Never
Frequency (%)
Do you refer to a Dermatologist when unsure of a diagnosis? 58 (49.15) 6 (5.08)
Do you treat a patient even when unsure of a diagnosis? 25 (21.19) 54 (45.76) 13 (11.02)
Do you do KOH examination before treating suspected fungal infection? 80 (67.8) 103 (87.29)
Do you have available medications for the dermatological diseases that you encounter? 0 15 (12.71) 15 (12.71)
6 (5.08) 97 (82.2)

Figure 2. Self-Perception of Competency on Diagnosis and Management of Skin Diseases and family practitioners are responsible for a large number of
skin-related health care visits. In their study entitled “Pattern
of Dermatologic Care by Family Physicians versus Dermatolo-
gists”, the authors mentioned that the prevalence of skin diseas-
es seen by family physicians were 30% of total patients in an out-
patient clinic of primary health care.9 Our study also shows that
for DTTBs, skin complaints remain as a common reason for con-
sultation being 6% of the average number of weekly consults.
However, even when dermatologic diseases remain as common
reasons for consultation, educational or preventive activities for
skin diseases are not being prioritized or being given attention
to in most of the municipalities. As mentioned previously, most
of these municipalities belong to the low-income class, hence,
it is vital to minimize costs for health care and one of the best
ways to do this is to establish good educational and preventive
measures for skin diseases.

In dermatology, examination of the actual lesions is in-
valuable in arriving at a correct diagnosis. This specialty has
the advantage of being able to do consultations through online
communication platforms since pictures or videos will make it
possible for lesions to be examined. This technology should be
maximized and be made available especially in geographically
isolated areas. Our study showed that a significant number of
our respondents still refer through phone calls being unable to
show the actual lesions to the dermatologist they are referring
to. It would be quite difficult or sometimes even impossible to
accurately diagnose and manage skin diseases without being
given the actual pictures of the lesions. For these doctors, a good
internet connection or having access for face-to-face consults
with dermatologists could make a big difference in the diagno-
sis and management of these diseases and in the prevention of
further complications.

As seen in our results, the most common diseases that our
respondents encounter are the ones caused by infection, infes-

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 28

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

tation, genetic, and environmental factors. These skin diseases which medications to procure for their health units.
affect quality of life significantly if not treated properly and im- The study by El Wahed et al. (2015) recommended that
mediately. It is essential therefore, that primary physicians can
recognize these diseases and have basic knowledge on how to proper qualification, support, and continuous medical educa-
manage them and what medications to procure and dispense. tion of family physicians are needed for management of differ-
The commonly prescribed medications were topical and sys- ent dermatological lesions making them up to date with current
temic antibiotics followed by systemic corticosteroids and top- clinical guidelines. Also, they emphasized the importance of
ical antifungals. However, despite being commonly prescribed proper communication between primary care physicians and
medications for skin diseases, majority of our respondents do specialists for proper referral system for complicated cases.9
not have oral and topical medications available for free at their Our results show that a proper referral system is also lacking
health centers. This means that patients must make out of pock- since a significant number of our respondents do not have direct
et expenditures to be able to get access to medications for their access to dermatologists and there are no definite dermatology
skin diseases. referral centers assigned to their municipalities. Because of
this, they proceed with the treatment of the skin diseases they
An evaluation study done by Bahelah et al. (2015) found encounter even when they are unsure of the diagnosis. To add to
out that their primary care physicians were not properly pre- this, the respondents of the study were found to have average to
pared to manage the common skin diseases in Aden, Yemen. low confidence in their ability to diagnose and manage skin dis-
The authors mentioned that their findings call for providing eases as shown in their self-perception of competency ratings.
continuous medical education for primary care physicians in This may mean that more often than not they are indeed unsure
skin diseases.4 Similarly, our results show that majority of our of their dermatologic diagnosis and management.
primary care physicians can be classified as having insufficient
knowledge on common skin diseases. The implications of these These findings highlight the need to augment training, pro-
results are that these physicians assigned to geographically vide guidelines, and improve the referral system to make the
isolated low-income municipalities, who are sometimes being delivery of skin-related health care services more efficient and
solely relied upon for consultation, are inadequately equipped accessible in the country.
in terms of knowledge in diagnosing and managing common
skin diseases. LIMITATIONS
Due to incomplete attendance of the physicians during their
Al-Zahrani et al. (2017) has also recognized that as medical CME classes and distant areas of assignments, there was a dif-
knowledge expands, family physicians face an ever-increasing ficulty getting all targeted respondents, however, we were able
challenge in diagnosis and treatment of skin disorders. Because to recruit more than the minimum number of respondents com-
of this, they did a study on the knowledge, attitude, and practice puted for this study. Majority of the respondents completed the
of primary health care providers regarding common derma- survey, however, there is a certain number of missing data due
tologic problems, and they correlated their level of knowledge to items that were not answered which may introduce bias.
and practice gap with their background characteristics. They
found out in the study that primary health care providers had CONCLUSION
insufficient knowledge regarding management of common skin
disorders and that more than half of the primary health care Skin-related diseases make up a significant proportion of the
physicians strongly agreed that they should have a role in the respondents’ weekly consults, however, a lack of basic knowl-
managing of common dermatological disorders.3 The common- edge in the diagnosis and treatment of skin diseases was not-
ly reported barriers mentioned for proper diagnosis and man- ed. Majority of the respondents believe in the importance of
agement were lack of guidelines and training in dermatology. having adequate knowledge on dermatological diseases and
Similarly, our study results showed that our respondents have they are interested in learning more about skin diseases. Most
recognized the importance of being knowledgeable in the man- of them also recognize the importance of having access to der-
agement of common skin diseases as primary care physicians matologists.
and they have shown interest in learning more about these skin
conditions. This can be attributed to the fact that they do play a Almost half of the DTTBs always refer to dermatologists when
major role in managing dermatological disorders in their own they are unsure of the diagnosis and a few of them never seek refer-
municipalities. The barriers to the management of skin diseas- ral and proceed to treatment even when unsure of the diagnosis.
es mentioned in the study of Al-Zahrani et al. were also the top Medications for common skin diseases are only sometimes avail-
barriers identified by our respondents. These top 2 barriers, the able to most of the DTTBs. In terms of their self-perception of com-
lack of training and the lack of experience, may have resulted to petency, the respondents have rated themselves average to bad in
lack of medications since without the knowledge on how to treat diagnosing and managing common skin diseases.
these diseases, our primary care physicians would not know
In this study, we were able to achieve more than the min-
imum number of respondents needed which strengthens the
generalisability of our results. The findings of this study can

29 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

therefore be applicable to the other physicians in the group that graphically isolated areas, is recommended for generalizability
we have sampled. However, at this point, we cannot say that of the data for the whole country. Municipal health officers and
these conclusions can be applicable to all primary care physi- rural health physicians in other provinces and cities, even those
cians in the entire country. that are not under the Doctors to the Barrios (DTTB) program
may also be included. It is also recommended to improve the
RECOMMENDATIONS questionnaires and to develop a more standardized and validat-
Further research to cover more municipalities, especially geo- ed tool for data gathering.

REFERENCES

1. Hay RJ, Johns NE, Williams HC, Bolliger IW, Dellavalle RP, Margolis DJ, et al. The global burden of skin disease in 2010: an analysis of the
prevalence and impact of skin conditions. J Invest Dermatol [Internet]. 2014;134(6):1527–34. Available from: http://dx.doi.org/10.1038/
jid.2013.446

2. Castillo-Arenas E, Garrido V, Serrano-Ortega S. Skin conditions in primary care: an analysis of referral demand. Actas Dermosifiliogr
[Internet]. 2014;105(3):271–5. Available from: http://dx.doi.org/10.1016/j.adengl.2013.10.005

3. Al-Zahrani DMAA, Shamsun Nahar P, Al-Zahrani DSA, Al-Zahrni DRA. Knowledge, attitude, and practice of primary care physicians regarding
common dermatological disorders in Abha city, kingdom of Saudi Arabia. IOSR J Pharm [Internet]. 2017;07(02):89–110. Available from: http://
dx.doi.org/10.9790/3013-07020189110

4. Bahelah SO, Bahelah R, Bahelah M, Albatineh AN. Primary care physicians’ knowledge and self-perception of competency in dermatology:
An evaluation study from Yemen. Cogent Med [Internet]. 2015;2(1):1119948. Available from: http://dx.doi.org/10.1080/2331205x.2015.1119948

5. Goldsmith LA, Katz SI, Gilchrest BA, Paller A, Leffell DJ, Wolff K. Fitzpatrick’s dermatology in general medicine, eighth edition, 2 volume set.
8th ed. New York, NY: McGraw-Hill Medical; 2012.

6. James, WD. Andrew’s Diseases of the Skin: Clinical Dermatology (12th Ed.). Philadelphia: Elsevier. 2016
7. Bolognia, J, Schaffer J, Cerroni L. Dermatology (3rd Ed). Elsevier; 2012.
8. Peacock JL, Peacock PJ. Oxford handbook of medical statistics. 2nd ed. London, England: Oxford University Press; 2020.
9. Ishish S, El-Wahed M, Abd El-Azim A. Pattern of dermatologic care by family physicians versus dermatologists. Menoufia Med J [Internet].

2015;28(2):583. Available from: http://dx.doi.org/10.4103/1110-2098.163922

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 30

JPDS ORIGINAL ARTICLE
Journal of the Philippine
Dermatological Society

Skin cancer in a public tertiary hospital in Manila,
Philippines from 2015 to 2019: A retrospective study

Aizlynn Anne J. Robledo, MD,1 Krisinda Clare C. Dim-Jamora, MD, FPDS1

ABSTRACT

INTRODUCTION The true incidence of skin cancer, as well as the clinico-demographic and histopathologic profile of skin cancer patients in the
Philippines, has not been established. To the authors’ knowledge, no similar studies have been published in recent years.

OBJECTIVES To determine the clinico-demographic and histopathologic characteristics of histopathologically-proven skin cancer Filipino pa-
tients in a Philippine public tertiary hospital.

METHODS This study included 121 patients with histopathologically-proven skin cancers from January 2015 to December 2019 in the dermatology
and pathology departments of a public tertiary hospital in Manila, Philippines. Retrospective chart review and descriptive data analysis were
conducted for this study.

RESULTS Of the 121 cases, the common skin cancers included basal cell carcinoma (54%), squamous cell carcinoma (27%), cutaneous lymphoma
(7%), and melanoma (6%). The mean age was 63 ±16 years. There was a slight female preponderance (56%). The most commonly affected area was the
head and neck region (73%). Most cases (54%) were clinically diagnosed by dermatologists, while the remaining patients were seen by non-derma-
tologists. Thus, the concordance between clinical diagnosis and histopathologic confirmation was 62% in basal cell carcinoma, 50% in cutaneous
lymphoma, 29% in melanoma, and 24% in squamous cell carcinoma. Overall, the skin cancer lesions amongst the patients were significant at the
time of diagnosis, with a median length of 20 mm and a median width of 18.5 mm.

CONCLUSION Basal cell carcinoma is the most common skin cancer (54%), followed by squamous cell carcinoma (27%). The head and neck was the
most commonly affected region at 73%. Due to the low concordance of clinical and histopathologic confirmation, referral to a dermatologist is
necessary to improve clinical accuracy. In the public tertiary hospital setting, whole-body skin examination should be a part of the initial derma-
tology screening to catch small skin cancers. A system to ensure regular follow-up of skin cancer patients should be initiated to optimize early
detection of recurrence and subsequent treatment as necessary.

KEYWORDS skin cancer; basal cell carcinoma, squamous cell carcinoma, melanoma

1Skin and Cancer Foundation, Inc., San INTRODUCTION squamous cell carcinoma (SCC) (319 or 19%) and
Miguel Avenue, San Antonio Village, Pasig melanoma (214 or 12%). BCC and melanoma were
City, Manila, Philippines Nonmelanoma skin cancer (NMSC) in Southeast more common in females than in males (~1.9:1
Asia is 2.1 per 100,000 reported cases. Among and ~1.5:1, respectively), while SCC was more fre-
Corresponding author these cases, males have a higher risk of devel- quent in males than in females (~1.2:1).3
Aizlynn Anne J. Robledo, MD oping NSMC with an incidence rate of 2.5 per
100,000 compared to females with 1.8 per 100,000 The true incidence of skin cancer, as well
Conflict of interest cases. In addition, the mortality rate in South- as the clinico-demographic and histopatholog-
None east Asia is 0.10 per 100,000 in males and 0.06 per ic profiles of skin cancer patients in the Philip-
100,000 in females.1 pines, has not been established. Moreover, to the
Source of funding authors’ knowledge, no similar national or local
This study is partly funded by the In the Philippines, melanoma ranked 26th studies have been published in recent years.
Philippine Dermatological Society among the most common skin cancer types, with
418 cases reported in 2020. In addition, it ranked METHODOLOGY
24th among the highest number of deaths, with
251 reported deaths and a 5-year prevalence of A retrospective, descriptive, and observational
1,131 reported cases.2 study was conducted in Quirino Memorial Med-
ical Center (QMMC), Philippines, based on the
The Philippine Dermatological Society - 2015 to 2019 data from the hospital records. A to-
Health Information System revealed 1,719 skin tal of 121 patients histopathologically diagnosed
cancer cases from 2015 to 2019. Based on the with skin cancer were included in the study.
data, the most common skin cancer was basal Personal, family and psychosocial history were
cell carcinoma (BCC) (1,166 or 68%), followed by

31 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

obtained to determine the clinico-demographic profiles. Biopsy Table 2. Clinico-demographic features of patients (n=121)
results were gathered to identify the histopathologic diagnosis
and the presence of metastasis. Data regarding the treatment Median (Range); Mean ± SD; Frequency (%)
modalities and disease outcomes were also retrieved. All valid
data, including data from patients with incomplete medical re- Age (years) 65 (1–87); 62.74 ± 15.96
cords, were integrated into the analysis. Missing variables were 1 (0.83)
neither replaced nor estimated. STATA 15.0 was used for data 0-9 1 (0.83)
analysis. 10-19 4 (3.31)
20-29 4 (3.31)
RESULTS 30-39 8 (6.61)
40-49 23 (19.01)
Included in the study were 121 patients with histopathologic con- 50-59 32 (26.45)
firmation of skin cancer. The highest recorded incidence was in 60-69 36 (29.75)
2018, with 31 new diagnoses (Table 1). More than half (54%) of 70-79 12 (9.92)
the patients were clinically diagnosed by dermatologists. ≥80

The mean age of patients was 63 ±16 years. There was a Sex 53 (43.8)
slight female preponderance (56%). Very few had data on occu- Male 68 (56.2)
pation (n=5) and risk factors (n=4) (Appendix 1). The most com- Female
mon site of skin lesions was the head and neck (73%). In com-
parison, fewer were found on the trunk (10%), lower extremities Occupation 2 (1.65)
(6%), upper extremities (3%), and genitalia (3%). One patient had Indoor 1 (0.83)
lesions on both the trunk and lower extremities (0.83%). The 1 (0.83)
most common presumptive diagnosis was BCC (34%). The most Laundry worker 1 (0.83)
common diagnostic technique was plain incision biopsy (60%) Domestic helper 2 (1.65)
(Table 2). Outdoor (construction worker) 116 (95.87)
Mixed (driver)
Overall, the skin cancer lesions had a median length of 20 Unspecified
(range 3-130) mm and a width of 18.5 mm (range 2-85) (Table 3).
Site 88 (72.73)
Patients had a median of 3 (range 0.06-50) years from the Head and neck 12 (9.92)
onset of the lesions to receiving a histopathologic diagnosis of Trunk 7 (5.79)
skin cancer and a median of 1 (range 0.17-21) year from histo- Lower extremities 4 (3.31)
pathologic diagnosis to treatment initiation. Basal cell carcino- Upper extremities 4 (3.31)
ma was histopathologically confirmed in 54% of patients. The Genitalia 1 (0.83)
other significant diagnoses were SCC (27%), cutaneous lympho- Trunk + lower extremity 5 (4.13)
Unspecified

Table 1. Annual census of skin cancer (n=121) Clinical diagnosis 41 (33.88)
Basal cell CA 10 (8.26)
Frequency Proportion (95% CI) Squamous cell CA 4 (3.31)
Cutaneous lymphoma 3 (2.48)
Year of diagnosis 20 16.53 (10.40–24.37) Basal cell vs. squamous cell CA 3 (2.48)
2015 23 19.01 (12.45–27.14) Melanoma 13 (10.74)
2016 27 22.31 (15.25–30.78) Other 47 (38.84)
2017 31 25.62 (18.12–34.35) Unspecified
2018 20 16.53 (10.40–24.37)
2019 Diagnostic technique 73 (60.33)
53.72 (44.43–62.83) Incision biopsy 29 (23.97)
Department 23.97 (16.68–32.57) Excision biopsy 14 (11.57)
18.18 (11.76–26.22) Incision + excision biopsies 1 (0.83)
Dermatology 65 Incision + total penectomy with biopsy 1 (0.83)
1.65 (0.20–5.84) Percutaneous biopsy 1 (0.83)
Surgery 29 1.65 (0.20–5.84) MRM with biopsy 1 (0.83)
0.83 (0.02–4.52) Lip and cheek reconstruction with biopsy 1 (0.83)
ENT 22 Wound debridement with biopsy
CA, carcinoma; vs, versus; MRM, modified radical mastectomy
OB-GYN 2

Ophthalmology 2

Orthopedics 1

ENT, ears, nose, and throat; OB-GYN, obstetrics-gynecology

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 32

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

Table 3. Lesion dimensions in millimeters Table 4. Diagnosis, treatment, and outcome

Length Width Years from onset to histopathologic diagnosis Frequency (%); Median (Range)

All n Mean ± SD; Median (Range) (n=62) 3 (0.06–50)
76 31.23 ± 27.99 20 (3–130) 23.75 ± 19.75 18.5 (2–85) <1 14 (22.58)
Basal cell CA ≥1 48 (77.42)
35 27.97 ± 18.27 25 (3–80) 22.15 ± 14.47 20 (2–64)
Squamous cell CA Years from histopathologic diagnosis to 1 (0.17–21)
27 34.26 ± 34.45 18 (3–105) 26.41 ± 26.09 13 (2–85) treatment 5 (45.45)
Cutaneous lymphoma 6 (54.55)
2 17.5 ± 3.54 17.5 (15–20) 17 ± 4.24 17 (14–20) (n=11)
Melanoma <1 65 (53.72)
5 43.4 ± 49.95 25 (7–130) 19 ± 18.17 10 (5–50) ≥1 33 (27.27)
Dermatofibrosarcoma 8 (6.61)
protuberans 2 51 ± 55.15 51 (12–90) 32 ± 25.46 32 (14–50) Histopathologic diagnosis 7 (5.79)
2 (1.65)
Paget's disease, 2 14 ± 8.49 14 (8–20) 15 ± 7.07 15 (10–20) Basal cell CA 2 (1.65)
mammary Squamous cell CA 1 (0.83)
1 20 - 20 - Cutaneous lymphoma 1 (0.83)
Basosquamous CA, Melanoma 1 (0.83)
moderately 0- - - - Dermatofibrosarcoma protuberans 1 (0.83)
differentiated Paget’s disease, mammary
1 70 - 70 - Basosquamous CA, moderately differentiated 8 (6.61)
Langerhans cell 1 10 - 10 - Langerhans cell histiocytosis 6 (4.96)
histiocytosis Malignant eccrine CA 107 (88.43)
Mucoepidermoid CA, high grade
Malignant eccrine CA 32 (26.45)
Metastasis 14 (11.57)
Mucoepidermoid CA, 18 (14.88)
high grade No 3 (2.48)
Yes 1 (0.83)
CA, carcinoma Unspecified 1 (0.83)
1 (0.83)
ma (7%), and melanoma (6%). Metastatic status was largely un- Treatment 1 (0.83)
specified (88%). The most commonly performed treatment strat- 1 (0.83)
egy was excision, either as sole management (26%) or combined Excision 1 (0.83)
with skin grafting (2%) or chemotherapy (0.8%). Unfortunately, Wide excision 1 (0.83)
one patient had a recurrence of skin cancer (Table 4). Unspecified 79 (65.29)

The skin cancer types for the years 2015 (n=20), 2016 (n=23), Excision with skin grafting 21 (17.36)
2017 (n=27), 2018 (n=31), and 2019 (n=20) are presented in Table Excision + chemotherapy 5 (4.13)
5.1. Basal cell CA was most frequently seen in 2018 (68%), while Lip & cheek reconstruction 1 (0.83)
squamous cell CA was most commonly seen in 2017 (48%). Modified radical mastectomy 94 (77.69)
NB-UVB + topical corticosteroids
The skin cancer types were clinically diagnosed by the fol- Mohs micrographic surgery
lowing services: dermatology (n=65), ENT (n=22), OB-GYN (n=2), Total penectomy
ophthalmology (n=2), orthopedics (n=1) and surgery (n=29) (Ta- Wound debridement
ble 5.2). Unspecified

The histopathologic readings diagnosed by dermatopathol- Outcome
ogy or general pathology are given in Table 5.3.
Resolution
BCC was more common in females (66% vs. 34%), whereas Lost to follow-up
SCC (64% vs. 36%) and melanoma (71% vs. 29%) were more com- Recurrence
mon among males (Table 5.4). Unspecified

The 60s and 70s age groups comprised a third of all those CA, carcinoma; NB-UVB, narrowband UVB therapy
with basal cell carcinoma. Squamous cell carcinoma was most
common among patients in their 50s (30%) and was likewise eccrine carcinoma was seen in an elderly patient. Mucoepider-
prevalent among those in their 60s (21%) and 70s (24%). Cuta- moid carcinoma was caught in a patient in his 40s (Table 5.5).
neous lymphoma was primarily diagnosed in patients in their
20s (38%). Melanoma was only seen in patients 50 years old and For basal cell carcinoma, there was a median of 5 years
above. A patient in his 30s (50%) and another in his 70s (50%) had from the onset of lesions to histopathologic diagnosis and an-
dermatofibrosarcoma protuberance. Paget’s disease was seen other 6 years from histopathologic diagnosis to treatment. For
in patients in their 50s (50%) and 60s (50%). Basosquamous car- squamous cell carcinoma, there was a median of 2 years from
cinoma was only seen in a patient in his 60s. One case of Lang- the onset to histopathologic diagnosis but less than a year from
erhans cell histiocytosis was diagnosed in a child. Malignant histopathologic diagnosis to treatment. For the four cutaneous
lymphoma patients, it took less than a year from the onset to
histopathologic diagnosis on average. For the one melanoma
case with data, it took half a year from the onset to histopatho-
logic diagnosis and half a year from histopathologic diagnosis to

33 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Table 5.1. Skin cancer types by year of diagnosis 2015 2016 Year 2018 2019
(n=20) (n=23) (n=31) (n=20)
Skin cancer 2017
Basal cell CA 11 (55) 11 (47.83) (n=27) 21 (67.74) 11 (55)
Squamous cell CA 4 (20) 8 (34.78) 6 (19.35) 2 (10)
Cutaneous lymphoma 2 (10) Frequency (%) 1 (3.23) 5 (25)
Melanoma 2 (10) 0 (0) 11 (40.74) 1 (3.23) 0 (0)
Dermatofibrosarcoma protuberans 0 (0) 2 (8.7) 13 (48.15) 1 (3.23) 1 (5)
Paget's disease, mammary 0 (0) 0 (0) 0 (0) 1 (3.23) 0 (0)
Basosquamous CA, moderately differentiated 0 (0) 0 (0) 2 (7.41) 0 (0)
Langerhans cell histiocytosis 0 (0) 1 (4.35) 0 (0) 0 (0) 0 (0)
Malignant eccrine CA 1 (5) 1 (4.35) 1 (3.7) 0 (0) 0 (0)
Mucoepidermoid CA, high grade 0 (0) 0 (0) 0 (0) 0 (0) 1 (5)
CA, carcinoma 0 (0) 0 (0) 0 (0)
0 (0)
0 (0)

Table 5.2. Skin cancer types clinically diagnosed per department

Department

Dermatology ENT OB-GYN Ophthalmology Orthopedics Surgery
(n=65) (n=22) (n=2) (n=2) (n=1) (n=29)

Skin cancer 45 (69.23) 9 (40.91) Frequency (%) 0 (0) 9 (31.03)
Basal cell CA 9 (13.85) 10 (45.45) 0 (0) 14 (48.28)
Squamous cell CA 7 (10.77) 1 (4.55) 1 (50) 1 (50) 0 (0)
Cutaneous lymphoma 2 (3.08) 1 (100) 0 (0)
Melanoma 1 (1.54) 0 (0) 0 (0) 0 (0) 0 (0) 3 (10.34)
Dermatofibrosarcoma protuberans 0 (0) 0 (0) 1 (3.45)
Paget's disease, mammary 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (3.45)
Basosquamous CA, moderately differentiated 0 (0) 1 (4.55) 0 (0)
Langerhans cell histiocytosis 1 (1.54) 0 (0) 0 (0) 1 (50) 0 (0) 0 (0)
Malignant eccrine CA 0 (0) 0 (0) 0 (0) 0 (0)
Mucoepidermoid CA, high grade 0 (0) 1 (4.55) 0 (0) 0 (0) 1 (3.45)
CA, carcinoma; ENT, ears, nose, and throat; OB-GYN, obstetrics-gynecology 0 (0)
1 (50) 0 (0)

0 (0) 0 (0)

0 (0) 0 (0)

0 (0) 0 (0)

0 (0) 0 (0)

Table 5.3. Skin cancer types histopathologically diagnosed per department

Dermatopathology General Pathology Table 5.4. Sex distribution per skin cancer type

(n=65) (n=56) Skin cancer Male Female
Basal cell CA (n=65)
Skin cancer Frequency (%) Squamous cell CA (n=33) Frequency (%)
Basal cell CA Cutaneous lymphoma (n=8)
Squamous cell CA 45 (69.23) 20 (35.71) Melanoma (n=7) 22 (33.85) 43 (66.15)
Cutaneous lymphoma Dermatofibrosarcoma protuberans (n=2)
Melanoma 9 (13.85) 24 (42.86) Paget's disease, mammary (n=2) 21 (63.64) 12 (36.36)
Dermatofibrosarcoma protuberans Basosquamous CA, moderately differentiated (n=1)
Paget's disease, mammary 7 (10.77) 1 (1.79) Langerhans cell histiocytosis (n=1) 4 (50) 4 (50)
Basosquamous CA, moderately differentiated Malignant eccrine CA (n=1)
Langerhans cell histiocytosis 2 (3.08) 5 (8.93) Mucoepidermoid CA, high grade (n=1) 5 (71.43) 2 (28.57)
Malignant eccrine CA CA, carcinoma
Mucoepidermoid CA, high grade 1 (1.54) 1 (1.79) 0 (0) 2 (100)
CA, carcinoma
0 (0) 2 (3.57) 0 (0) 2 (100)

0 (0) 1 (1.79) 0 (0) 1 (100)

1 (1.54) 0 (0) 0 (0) 1 (100)

0 (0) 1 (1.79) 0 (0) 1 (100)

0 (0) 1 (1.79) 1 (100) 0 (0)

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 34

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

Table 5.5. Age distribution per skin cancer type 0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 ≥80

Skin cancer 0 (0) 0 (0) 1 (1.54) 1 (1.54) Frequency (%) 8 (12.31) 22 (33.85) 22 (33.85) 8 (12.31)
Basal cell CA (n=65) 0 (0) 0 (0) 0 (0) 2 (6.06) 3 (4.62) 10 (30.30) 7 (21.21) 8 (24.24) 3 (9.09)
Squamous cell CA (n=33) 0 (0) 1 (12.50) 3 (9.09) 1 (12.50) 1 (12.50) 1 (12.50)
Cutaneous lymphoma (n=8) 0 (0) 0 (0) 3 (37.50) 0 (0) 1 (12.50) 3 (42.86) 0 (0) 3 (43.86)
Melanoma (n=7) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (14.29) 0 (0)
Dermatofibrosarcoma protuberans (n=2) 0 (0) 0 (0) 0 (0) 1 (50) 0 (0) 0 (0) 1 (50) 0 (0)
Paget's disease, mammary (n=2) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0)
Basosquamous CA, moderately differentiated (n=1) 1 (100) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (50) 0 (0) 0 (0)
Langerhans cell histiocytosis (n=1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (100) 0 (0) 0 (0)
Malignant eccrine CA (n=1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (100) 0 (0)
Mucoepidermoid CA, high grade (n=1) 0 (0) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0) 0 (0)
CA, carcinoma 0 (0)

Table 5.6. Diagnosis and treatment interval per skin cancer type Onset to diagnosis (years) Diagnosis to treatment (years)

Skin cancer n=62 Median (Range) n=11 Median (Range)
Basal cell CA 42 5 (0.17–50) 4 6 (0.75–21)
Squamous cell CA
Cutaneous lymphoma 11 2 (0.06–40) 4 0.54 (0.17–1)
Melanoma
Dermatofibrosarcoma protuberans 4 0.17 (0.08–15) 0-
Paget's disease, mammary
Basosquamous CA, moderately differentiated 1 0.5 1 0.5
Langerhans cell histiocytosis
Malignant eccrine CA 2 4.38 (0.75–8) 18
Mucoepidermoid CA, high grade
CA, carcinoma 15 15

0- 0-

1 0.33 0-

0- 0-

0- 0-

Table 5.7. Histopathologic findings per lesion site

H&N (n=88) Trunk (n=12) LE (n=7) Genital (n=4) UE (n=4) Trunk + LE (n=1) Unspecified
(n=5)
3 (25) 2 (28.57) Frequency (%) 1 (25)
Skin cancer 3 (25) 2 (28.57) 0 (0) 0 (0)
2 (16.67) 4 (100) 2 (50)
Basal cell CA 57 (64.77) 1 (8.33) 0 (0) 0 (0) 0 (0) 0 (0) 2 (40)
0 (0) 3 (42.86) 0 (0) 1 (25) 0 (0) 0 (0)
Squamous cell CA 24 (27.27) 2 (16.67) 0 (0) 0 (0) 1 (100) 2 (40)
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (20)
Cutaneous lymphoma 1 (1.14) 1 (8.33) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Melanoma 2 (2.27) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 0 (0) 0 (0)
Dermato-fibrosarcoma protuberans 1 (1.14) 0 (0) 0 (0) 0 (0)
0 (0) 0 (0)
Paget's disease, mammary 0 (0)

Basosquamous CA, moderately differentiated 1 (1.14)

Langerhans cell histiocytosis 0 (0)

Malignant eccrine CA 1 (1.14)

Muco-epidermoid CA, high grade 1 (1.14)

CA, carcinoma; H&N, head and neck; LE, lower extremities, UE, upper extremities

35 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Table 5.8. Histopathologic outcomes per diagnostic technique

Incision biopsy Excision biopsy Incision + excision Incision biopsy + Lip & cheek MRM + biopsy Percutaneous Wound
(n=73) (n=29) biopsy total penectomy + reconstruction + (n=1) biopsy debridement +
(n=14) (n=1)
17 (58.62) biopsy biopsy 0 (0) biopsy
8 (27.59) (n=1) (n=1) 0 (0) 0 (0) (n=1)
0 (0) 1 (100)
Skin cancer 36 (49.32) 0 (0) 10 (71.43) Frequency (%) 0 (0) 0 (0) 1 (100)
Basal cell CA 20 (27.4) 2 (6.9) 0 (0) 1 (100) 0 (0) 0 (0) 0 (0)
Squamous cell CA 8 (10.96) 1 (3.45) 1 (100) 0 (0) 0 (0)
Cutaneous lymphoma 5 (6.85) 0 (0) 3 (21.43) 1 (100) 0 (0) 0 (0) 0 (0) 0 (0)
Melanoma 1 (1.37) 0 (0) 0 (0) 0 (0) 0 (0)
Dermatofibrosarcoma protuberans 1 (1.37) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Paget's disease, mammary 1 (3.45) 0 (0) 0 (0) 0 (0)
Basosquamous CA, moderately differentiated 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Langerhans cell histiocytosis 1 (1.37) 0 (0)
Malignant eccrine CA 0 (0) 0 (0) 0 (0) 0 (0)
Mucoepidermoid CA, high grade 0 (0)
CA, carcinoma; MRM, modified radical mastectomy 1 (1.37) 0 (0) 0 (0) 0 (0)

1 (7.14) 0 (0) 0 (0)

0 (0) 0 (0) 0 (0)

0 (0) 0 (0) 0 (0)

0 (0) 0 (0) 0 (0)

Table 5.9. Metastasis per skin cancer type No Yes Unspecified ry Paget’s disease and four patients with SCC (Table 5.9).
Basal cell carcinoma patients underwent excision, excision
Skin cancer 3 (4.62) Frequency (%) 62 (95.38)
Basal cell CA (n=65) 4 (12.12) 0 (0) 25 (75.76) with skin grafting, lip and cheek reconstruction, Mohs micro-
Squamous cell CA (n=33) graphic surgery, and wound debridement. Squamous cell carci-
Cutaneous lymphoma (n=8) 0 (0) 4 (12.12) 8 (100) noma patients underwent excision, excision with skin grafting,
Melanoma (n=7) 1 (14.29) 0 (0) 6 (85.71) and total penectomy. Most patients had an unspecified entry for
Dermatofibrosarcoma protuberans (n=2) 0 (0) 2 (100) management (Table 5.10).
Paget's disease, mammary (n=2) 0 (0) 0 (0)
Basosquamous CA, moderately differenti- 0 (0) 2 (100) 0 (0) Resolution was documented in 13 BCC, 6 SCC, 1 melanoma,
ated (n=1) 0 (0) 0 (0) 1 (100) and 1 Paget’s disease case. Recurrence was reported in one SCC
Langerhans cell histiocytosis (n=1) patient. The rest of the patients were either lost to follow-up or
Malignant eccrine CA (n=1) 0 (0) 0 (0) 1 (100) had an unspecified outcome in the registry (Table 5.11).
Mucoepidermoid CA, high grade (n=1) 0 (0) 0 (0) 1 (100)
CA, carcinoma 0 (0) 0 (0) 1 (100) The concordance between clinical diagnosis and histo-
pathologic confirmation is presented in Table 6. There was 62%
treatment. Clinical intervals per skin cancer type are enumer- concordance for basal cell carcinoma, 24% for squamous cell
ated in Table 5.6. carcinoma, and 50% for cutaneous lymphoma.

Most lesions on the head and neck regions (n=88) were di- DISCUSSION
agnosed as BCC (65%). All four patients with skin lesions on the
genitalia had SCC. Most (43%) of those with lower extremity le- This study included 121 biopsy proven skin cancer cases. The
sions (n=7) received a diagnosis of melanoma. Lesions confined incidence increased annually from 2015 to 2018, with a sudden
to the trunk mainly were BCC (25%) or SCC (25%). Two of the decrease in 2019, probably due to a reduction in skin cancer
four patients with upper extremity lesions, as well as one pa- screening (Table 5.11).
tient with lesions on both the trunk and lower extremities, had
cutaneous lymphoma (Table 5.7). 10 types of skin cancers were observed in the study. The
most common skin cancers were basal cell carcinoma (54%),
Incision biopsy (73, or 60.3%) was the primary histopatho- squamous cell carcinoma (27%), cutaneous lymphoma (7%), and
logic technique used. It revealed basal cell carcinoma (36/65, or melanoma (6%). Although melanoma is the third most common
49.3%), squamous cell carcinomas (20/33, or 27.4%), cutaneous type of skin cancer, a systemic review and meta-analysis study
lymphoma (8/8, or 11.0%), melanoma (5/7, or 6.9%), Paget’s dis- revealed that cutaneous T-cell lymphoma (CTCL) might be un-
ease (1/2, 1.4%), Langerhans cell histiocytosis (1/1, 1.4%), and derdiagnosed. The same study stated that CTCL is 15% more
mucoepidermoid CA (1/1, or 1.4%) (Table 5.8). frequent in Asians. CTCL was also linked to lymphoma-associ-
ated viruses such as the human T-lymphotropic virus (HTLV)-1,
Metastasis was documented in two patients with mamma- which is endemic in Asia, and Epstein-Barr virus (EBV).4 A study
by Veemer revealed a relatively stable incidence in well-de-
scribed cutaneous lymphoma subtypes such as mycosis fun-
goides and lymphomatoid papulosis over time and an increase

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 36

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

Table 5.10. Management per skin cancer type

Excision (n=32) Excision + skin Excision + Lip & Cheek MRM NB-UVB + MMS Total Wound Unspecified
grafting Chemotherapy Reconstruction (n=1) topical CS (n=1) Penectomy Debridement (n=79)
(n=3)
(n=1) (n=1) (n=1) (n=1) (n=1)

Skin cancer Frequency (%)

Basal cell CA (n=65) 17 (26.15) 1 (1.54) 0 (0) 1 (1.54) 0 (0) 0 (0) 1 (1.54) 0 (0) 1 (1.54) 44 (67.69)
1 (3.03) 0 (0) 20 (60.61)
Squamous cell CA (n=33) 10 (30.3) 2 (6.06) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 7 (87.5)
0 (0) 0 (0) 5 (71.43)
Cutaneous lymphoma (n=8) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 1 (12.5) 0 (0) 0 (0) 0 (0)
0 (0) 1 (50)
Melanoma (n=7) 2 (28.57) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
0 (0) 0 (0) 0 (0)
Dermatofibrosarcoma protuberans 1 (50) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
0 (0)
(n=2) 0 (0) 0 (0) 1 (100)
0 (0) 0 (0) 0 (0)
Paget's disease, mammary (n=2) 0 (0) 0 (0) 1 (50) 0 (0) 1 (50) 0 (0) 0 (0) 0 (0) 1 (100)

Basosquamous CA, moderately 1 (100) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

differentiated (n=1)

Langerhans cell histiocytosis (n=1) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

Malignant eccrine CA (n=1) 1 (100) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

Mucoepidermoid CA, high grade 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)

(n=1)

CA, carcinoma; MRM, modified radical mastectomy; NB-UVB, narrowband ultraviolet B therapy; CS, corticosteroids; MMS, Mohs micrographic surgery

Table 5.11. Outcome per skin cancer type minimal histopathologic changes pose a challenge for general
pathologists. They are often signed out as “no specific diagno-
Skin cancer Lost to Recurred Resolved Unspecified sis.” A study by Alhumidi et al. showed that 81 similar cases
follow-up 0 (0) were reviewed and diagnosed by dermatopathologists. 53% of
Basal cell CA (n=65) 13 (20) 50 (76.92) these biopsies had a specific diagnosis, 47% remained nonspe-
2 (3.08) 1 (3.03) 6 (18.18) 24 (72.73) cific, and the remaining were due to inadequate biopsy, inactive
Squamous cell CA (n=33) 2 (6.06) 0 (0) 7 (87.5) skin lesions, or inadequate clinical data.7
1 (12.5) 0 (0) 0 (0) 6 (85.71)
Cutaneous lymphoma (n=8) 0 (0) 1 (14.29) Basal cell carcinoma was more common in females (66%)
0 (0) 2 (100) than in males (34%). Older studies focusing more on Caucasians
Melanoma (n=7) 0 (0) 0 (0) 0 (0) revealed a higher incidence in males than females. However,
recent literature showed an increasing incidence of BCC in fe-
Dermatofibrosarcoma 0 (0) 0 (0) 1 (50) 1 (50) males.8,9 The increase in female incidence was associated with
protuberans (n=2) changes in clothing and sun exposure behavior.9 In addition, a
0 (0) 0 (0) 0 (0) 1 (100) 2016 retrospective study revealed that NMSCs, including SCC,
Paget's disease, mammary were more common in Asian females than males. The same
(n=2) 0 (0) 0 (0) 0 (0) 1 (100) study concluded that females are more likely to notice lesions
0 (0) on the face and, thus, seek consult more often than males.10
Basosquamous CA, moderately 0 (0) 0 (0) 1 (100)
differentiated (n=1) 0 (0) 0 (0) 1 (100) In this study, SCC and melanoma were more common in
males than females. This was consistent with previous studies.
Langerhans cell histiocytosis The male predominance was attributed to more frequent occu-
(n=1) pational sun exposure.8

Malignant eccrine CA (n=1) The mean age of patients in this study was 63 ±16 years.
The majority of the cases were diagnosed at ages 70-79. This was
Mucoepidermoid CA, high consistent with previous studies that found a higher risk in older
grade (n=1) age groups with an increase in incidence during their 40s and a
significant rise beginning in their 50s.9,11 A decline in cases was
CA, carcinoma seen in ages 80 and above, probably due to senile mortality.

in other cutaneous lymphoma subtypes such as folliculotropic In this study, the most commonly affected area was the
mycosis fungoides.5 head and neck (72.73%). This was congruent with previous lit-
erature, which stated that sun-exposed areas are more likely
The cases were clinically diagnosed by various physicians. to develop skin cancer. All four skin cancers of the genital area
Most of the patients (54%) were from the dermatology depart- (3.31% of all skin cancer cases) were SCC. This coincided with
ment. The remaining cases were diagnosed by surgery (24%), previous studies indicating an increased risk of HPV-associated
ENT (18%), OB-GYN (2%), ophthalmology (2%), and orthopedics
(1%) departments. A 2014 study revealed that skin cancer detec-
tion via visual whole-body examination by non-dermatologists
had a sensitivity rate of only 29%, implying an accuracy increase
if skin cancers were clinically diagnosed by dermatologists.6

Of the 121 cases, 65 (54%) were histopathologically diag-
nosed by a single dermatologist, while only 56 (46%) were an-
alyzed by a single general pathologist. Skin biopsies that show

37 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

Table 6. Clinicopathologic concordance among different skin cancer types

Histopathologic findings Number Proportion of Misdiagnosed diseases (cases)
Basal cell CA 65 concordance with
clinical diagnosis Basal cell CA vs squamous cell CA – 2
Dysplastic nevus, rule out basal cell carcinoma – 1
40 (61.54) Irritated seborrheic keratosis vs pigmented basal cell CA – 1

Squamous cell CA 33 8 (24.24) Squamous cell CA – 1
Trichoepithelioma vs basal cell CA – 1
Cutaneous lymphoma 8 4 (50)
No clinical diagnosis – 19
Melanoma 7 2 (28.57)
Anterior mediastinal wall mass – 1
Dermatofibrosarcoma protuberans 2 0 (0) Basal cell CA – 1

Paget's disease 2 1 (50) Basal cell CA vs squamous cell CA – 1
Basosquamous CA 1 0 (0) Basal cell CA vs superficial spreading melanoma – 1
Langerhans cell histiocytosis 1 0 (0)
Malignant eccrine CA 1 0 (0) Maxillary mass, probably malignant – 1
Mucoepidermoid CA 1 0 (0) Melanoma – 1
CA, carcinoma; vs, versus
Penile cancer – 1
No clinical diagnosis – 18

Exfoliative dermatitis – 1
Leukemia cutis – 1

Squamous cell CA – 1
No clinical diagnosis – 1

Soft tissue mass – 1
No clinical diagnosis – 4

Xanthogranuloma vs dermatofibroma – 1
No clinical diagnosis – 1

No clinical diagnosis – 1

No clinical diagnosis

No clinical diagnosis

No clinical diagnosis

No clinical diagnosis

SCC in this body region. Other sites include the trunk (9.92%), (range 3-130) mm and a width of 18.5 (range 2-85) mm (Table
upper extremities (3.31%), and lower extremities (3.31%). Previ- 3). Depending on the body site, BCC and SCC are considered
ous literature revealed a decreased risk for skin cancer on the high risk if the largest diameter is ≥10-20 mm.15 A 2020 study
extremities, especially on the hands and feet, possibly due to revealed an increased risk for distant metastasis for melanomas
skin hardening.12 ≥42mm.16 Mycosis fungoides (MF) comprise most of the cutane-
ous lymphoma in this study. However, size is only one of the fac-
Consistent with most studies, hypertension (9.92%) was the tors to determine MF prognosis.17
most common comorbidity in this study. In addition, it was also
associated with various cancers. Other comorbidities included In this study, the time from the onset of lesions to histo-
asthma (4.13%), pulmonary tuberculosis (PTB) (4.13%), diabetes pathologic diagnosis was three years and the time from histo-
mellitus (DM) (2.48%), and systemic lupus erythematosus (SLE) pathologic diagnosis to treatment was one year. A study in Italy
(2.48%). The association of DM and diabetic drugs with skin can- revealed that a delay in histopathologic diagnosis and treatment
cers is controversial but is often investigated. PTB is endemic for SCC was associated with a lack of time for consult and ur-
in the Philippines, which may partly explain the association in gency, as most patients did not consider the primary lesions
this study. In addition, a study from China revealed that skin dangerous. Based on the highest quartile percentile, the same
cancer was the 7th most common cancer associated with PTB study defined long total delay as more than 18 months from the
in an endemic area in China. Some studies also associated skin appearance of lesion to removal.18 Among the five melanoma
cancer with immunosuppression, such as SLE. Most risk factors cases, only one had data from the onset to histopathologic diag-
from this study included sun exposure. This was consistent with nosis (6 months). According to a 2021 study, the most common
previous studies discussing the role of sun exposure in cutane- reasons for a delay in seeking consultation or treatment for BCC
ous carcinoma.13,14 Data on occupation from this study was inad- were avoidance behavior, misconceptions and banalization of
equate to make a conclusion. symptoms, and fear of treatment.19 Although BCC is correlated
with a good prognosis, urgent treatment is imperative to prevent
Overall, the skin cancer lesions had a median length of 20

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 38

ORIGINAL JPDS
ARTICLE Journal of the Philippine
Dermatological Society

complications. A 2017 study revealed that a treatment delay of cancer patients to optimize early detection of recurrence and
more than 90 days (3 months) was associated with a decrease in subsequent treatment as necessary.
overall survival for melanoma.20
During this study, the patient data were in the traditional
According to previous studies, the most common biopsy paper-based record system, resulting in missing data. Current-
techniques used were excisional, incisional, shave, and punch ly, the institution is transitioning to an electronic health record
biopsy. However, some studies consider shave and punch biop- system for better record keeping.
sies as types of incisional biopsy, hence the subclassification for
this study. There are no clear-cut guidelines to guide clinicians LIMITATIONS
on which technique to use. The choice of technique should be First, although most data needed for the study was available, a
based on the lesion's character and the biopsy's intent.21 large part of the data from different categories was missing ei-
ther due to lost and irretrievable patient charts or improper and
Concordance between clinical diagnosis and histopatho- incomplete documentation by physicians attributed to the bulk
logic confirmation was high in basal cell carcinoma (62%), of patients seen in the public tertiary hospital. Second, many
cutaneous lymphoma (50%), and melanoma (29%). However, cases were initially clinically diagnosed by non-dermatolo-
squamous cell carcinoma had a relatively low concordance rate gists, thus affecting the proportional concordance rate between
(24%), implying that SCC is more challenging to diagnose. There- clinical and histopathologic diagnosis. Almost half of the skin
fore, a second opinion is recommended to increase diagnostic cancer cases were histopathologically diagnosed by general pa-
accuracy. In addition, an adequate number of slides should be thologists with a different histopathologic approach compared
provided to the pathologist to improve result reproducibility.22 to dermatopathologists.

Diagnostic interventions used in this study were incision RECOMMENDATIONS
biopsy (n=73), excision biopsy (n=29), incision and excision biop- The authors suggest improvement of hospital record keeping
sy (incision biopsy supported or confirmed by excision biopsy) using the electronic health record system; the creation of a uni-
(n=14), incision biopsy and total penectomy with biopsy (n=1), form hospital guideline for proper diagnosis and management
percutaneous biopsy (n=1), lip and cheek reconstruction with of cutaneous carcinomas; the conduct of multicenter studies to
biopsy (n=1), MRM with biopsy (n=1), and wound debridement increase sample size and strengthen future research results;
with biopsy (n=1). The study was conducted in a public tertiary and the establishment of a skin cancer central database in the
hospital with a high volume of patients and limited medical and Philippines to determine the true incidence and clinico-demo-
financial resources. Hence, physicians often choose a treatment graphic and histopathologic profile of skin cancer patients. In
modality that can also serve as a diagnostic intervention, such the public tertiary hospital setting, a system to ensure regular
as an excision biopsy. follow-up of skin cancer patients should be initiated to opti-
mize early detection of recurrence and subsequent treatment as
The most common treatment modalities were excision necessary. A skin cancer central database in the Philippines is
(n=32), excision with skin grafting (n=3), excision with chemo- needed to improve patient management and provide accurate
therapy (n=1), and lip and cheek reconstruction (n=1). Other data for future research.
treatments included MRM (n=1), NB-UVB and topical cortico-
steroids (n=1), MMS (n=1), total penectomy (n=1), and wound CONCLUSION
debridement (n=1). Unfortunately, most cases (n=79) either had
missing data or were lost to follow-up. The use of the different Skin cancer incidence is increasing annually and is more com-
treatment modalities in this study might be due to the prefer- mon in the elderly. BCC and SCC were the most common skin
ence of the leading service handling the cases. At the same time, cancers. The head and neck area was the most commonly af-
some could be incidental findings from surgical procedures fected region. A female preponderance could be due to the
done by the different departments. changes in clothting and sun-seeking behaviors. To increase
diagnostic accuracy, a second opinion with a dermatologist or
Among the six cases with metastasis, four were SCC, and two a dermatopathologist is recommended for clinically suspicious
were mammary Paget’s disease. The remaining cases were un- lesions or inadequate histopathologic findings, respectively.
specified. The majority of 94 (77.69%) patient outcomes were also Screening and patient education are essential for the timely
unspecified. Only 21 (17.36%) cases were resolved, five (4.13%) were management of skin cancers and the prevention of progression
lost to follow-up, and one (0.83%) had a recurrence of skin cancer. and complications. Proper documentation and a central data-
base are needed to improve patient management and aid future
Table 5.11 shows that the outcomes of the majority of the research.
skin cancer cases were unspecified. 76.92% for basal cell car-
cinoma, 72.73% for squamous cell carcinoma, 87.5% for cuta-
neous lymphoma, and 85.71% for melanoma. There is a need
to stress the importance of regular follow-up in managing skin

39 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS ORIGINAL
Journal of the Philippine ARTICLE
Dermatological Society

ACKNOWLEDGMENTS

This study is partly funded by the Philippine Dermatological Society. The authors would also like to recognize Dr. Venus Oliva Cloma-Rosales and
her research team at 101 Health Research for helping with the statistical analysis and interpretation of the data in the study.

REFERENCES

1. World Health Organization (WHO) – International Agency for Research on Cancer, Global Cancer Observatory. Non-melanoma skin cancer
[Internet]. Iarc.fr. Available from: https://gco.iarc.fr/today/data/factsheets/cancers/17-Non-melanoma-skin-cancer-fact-sheet.pdf

2. World Health Organization (WHO) – International Agency for Research on Cancer, Global Cancer Observatory. Philippines skin cancer fact
sheet 2020. Iarc.fr. Available from: https://gco.iarc.fr/today/data/factsheets/populations/608-philippines-fact-sheets.pdf

3. Philippine Dermatological Society - Health Information System (PDS-HIS). Data on basal cell carcinoma, squamous cell carcinoma, and
melanoma. 2015-2019. Philippine dermatological society: PDS [Internet]. . Available from: https://pds.org.ph

4. Dobos G, Pohrt A, Ram-Wolff C, Lebbé C, Bouaziz J-D, Battistella M, et al. Epidemiology of cutaneous T-cell lymphomas: A systematic review
and meta-analysis of 16,953 patients. Cancers (Basel) [Internet]. 2020;12(10):2921. Available from: http://dx.doi.org/10.3390/cancers12102921

5. Vermeer M. Epidemiology of cutaneous lymphoma. Br J Dermatol [Internet]. 2021;184(6):993–4. Available from: http://dx.doi.org/10.1111/
bjd.19829

6. Breitbart EW, Choudhury K, Anders MP, Volkmer B, Greinert R, Katalinic A, et al. Benefits and risks of skin cancer screening. Oncol Res Treat
[Internet]. 2014;37 Suppl 3(Suppl. 3):38–47. Available from: http://dx.doi.org/10.1159/000364887

7. Alhumidi A, Alshamlan N, Alfaraidi M, Mohajer K. Invisible dermatosis, diagnostic discrepancy between the general pathologist and
dermatopathologist. J Cutan Pathol [Internet]. 2019;46(12):905–12. Available from: http://dx.doi.org/10.1111/cup.13554

8. Ciążyńska M, Kamińska-Winciorek G, Lange D, Lewandowski B, Reich A, Sławińska M, et al. The incidence and clinical analysis of non-
melanoma skin cancer. Sci Rep [Internet]. 2021;11(1):4337. Available from: http://dx.doi.org/10.1038/s41598-021-83502-8

9. Peris K, Fargnoli MC, Garbe C, Kaufmann R, Bastholt L, Seguin NB, et al. Diagnosis and treatment of basal cell carcinoma: European
consensus-based interdisciplinary guidelines. Eur J Cancer [Internet]. 2019;118:10–34. Available from: http://dx.doi.org/10.1016/j.
ejca.2019.06.003

10. Loh TY, Ortiz A, Goldenberg A, Brian Jiang SI. Prevalence and clinical characteristics of nonmelanoma skin cancers among Hispanic and
Asian patients compared with white patients in the United States: A 5-year, single-institution retrospective review: A 5-year, single-
institution retrospective review. Dermatol Surg [Internet]. 2016;42(5):639–45. Available from: http://dx.doi.org/10.1097/DSS.0000000000000694

11. Oh CC, Jin A, Koh W-P. Trends of cutaneous basal cell carcinoma, squamous cell carcinoma, and melanoma among the Chinese, Malays, and
Indians in Singapore from 1968-2016. JAAD Int [Internet]. 2021;4:39–45. Available from: http://dx.doi.org/10.1016/j.jdin.2021.05.006

12. Sun L, Lu J, Zhang M, Yang X, Wu W, Liu Q. Clinical and pathological characteristics of 755 patients with skin cancers in Hainan, China: A 12-
year retrospective study. Clin Cosmet Investig Dermatol [Internet]. 2022;15:43–50. Available from: http://dx.doi.org/10.2147/CCID.S343274

13. Mendes AL, Miot HA, Haddad V Junior. Diabetes mellitus and the skin. An Bras Dermatol [Internet]. 2017;92(1):8–20. Available from: http://
dx.doi.org/10.1590/abd1806-4841.20175514

14. Chen GL, Guo L, Yang S, Ji DM. Cancer risk in tuberculosis patients in a high endemic area. BMC Cancer [Internet]. 2021;21(1):679. Available
from: http://dx.doi.org/10.1186/s12885-021-08391-6

15. Kim JYS, Kozlow JH, Mittal B, Moyer J, et al. Guidelines of care for the management of cutaneous squamous cell carcinoma. J Am Acad
Dermatol [Internet]. 2018;78(3):560–78. Available from: http://dx.doi.org/10.1016/j.jaad.2017.10.007

16. Ma Q, Suo H, Zhu L, Qian Y, Sun X, Xie J, et al. Prognostic significance of tumor size for primary invasive cutaneous melanoma: A population-
based study, 2004-2016. Cancer Med [Internet]. 2020;9(13):4561–71. Available from: http://dx.doi.org/10.1002/cam4.3065

17. Mehta-Shah N, Horwitz SM, Ansell S, Ai WZ, Barnes J, Barta SK, et al. NCCN Guidelines Insights: Primary cutaneous lymphomas, version 2.2020:
Featured updates to the NCCN guidelines. J Natl Compr Canc Netw [Internet]. 2020;18(5):522–36. Available from: http://dx.doi.org/10.6004/
jnccn.2020.0022

18. Renzi C, Mastroeni S, Mannooranparampil TJ, Passarelli F, Caggiati A, Potenza C, et al. Delay in diagnosis and treatment of squamous cell
carcinoma of the skin. Acta Derm Venereol [Internet]. 2010;90(6):595–601. Available from: http://dx.doi.org/10.2340/00015555-0966

19. Legrand A, Quintard B, Garrouteigt C, Beylot-Barry M, Broc G. From neglect to earlier diagnosis: a qualitative meta-synthesis of psycho-
social factors associated with consultation delay in advanced basal cell carcinoma. Psychol Health Med [Internet]. 2022;27(8):1793–804.
Available from: http://dx.doi.org/10.1080/13548506.2021.1952281

20. Conic RZ, Cabrera CI, Khorana AA, Gastman BR. Determination of the impact of melanoma surgical timing on survival using the National
Cancer Database. J Am Acad Dermatol [Internet]. 2018;78(1):40-46.e7. Available from: http://dx.doi.org/10.1016/j.jaad.2017.08.039

21. Fahradyan A, Howell AC, Wolfswinkel EM, Tsuha M, Sheth P, Wong AK. Updates on the management of non-melanoma skin cancer (NMSC).
Healthcare (Basel) [Internet]. 2017;5(4). Available from: http://dx.doi.org/10.3390/healthcare5040082

22. Gamble M, Kaufman B, Bhawan J, Dugan E, Radfar A, Venna S. Rate of concordance amongst pathologists in diagnosis of cutaneous
melanoma. Is there value in a second opinion? J Am Acad Dermatol [Internet]. 2015;72(5):AB174. Available from: http://dx.doi.org/10.1016/j.
jaad.2015.02.713

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 40



JPDS CASE REPORT
Journal of the Philippine
Dermatological Society

An atypical case of a 14-year-old Filipino female with
non-classical congenital adrenal hyperplasia presenting

with alopecia universalis

Erwin John R. Aquino, MD,1 Aira Monica R. Abella, MD,1 Ma. Teresita G. Gabriel, MD, FPDS1

ABSTRACT

INTRODUCTION Non-classical congenital adrenal hyperplasia (CAH) represents a group of inherited, autosomal recessive disor-
ders that typically presents with androgenetic alopecia, but may present with alopecia universalis on rare occasions.

CASE REPORT We report a case of a 14-year-old Filipino female with non-classical congenital adrenal hyperplasia presenting with
alopecia universalis, treated with a combination of Tretinoin and Minoxidil solution, low dose prednisone and an oral supplement
containing zinc gluconate, nicotinamide, superoxide dismutase, vitamin E and selenium, with noted gradual hair regrowth and
improvement in Dermatology Life Quality Index (DLQI).

CONCLUSION Alopecia universalis in a patient diagnosed with non-classical congenital adrenal hyperplasia is a rare and atypical
manifestation, with no case reports available to describe its occurrence. Due to its rarity, there is no standard treatment for pa-
tients with this condition. However, the combination of tretinoin and minoxidil solution, low dose prednisone and an oral supple-
ment containing zinc gluconate, nicotinamide, superoxide dismutase, vitamin E and selenium shows promising results.

KEYWORDS alopecia universalis, minoxidil, tretinoin,

1Department of Dermatology, INTRODUCTION two-year history of generalized gradual hair loss.
Research Institute for Tropical Her hair loss started as few, hairless patches on
Medicine, Research Drive, Alabang, Congenital adrenal hyperplasia (CAH) represents the scalp that eventually became multiple, even
Muntinlupa City a group of inherited autosomal recessive disor- involving the eyebrows, eyelashes, and axillary
ders affecting 1 in 15,000 live births.1 Majority and pubic hair. There was no associated fever,
Corresponding author of cases are caused by 21-hydroxylase deficiency weight loss, or other systemic symptoms. More-
Erwin John R. Aquino, MD (21-OHD) with mutations found on the CYP21A2 over, the patient has no other known co-morbid-
gene, leading to dysfunctional steroidogenesis. ities at the time of consult and has no allergies to
Conflict of interest CAH comes in two major forms: 1) classical CAH, food or medications. She further claims to have
None with manifestations such as severe adrenal crisis family members with hair loss from the paternal
and androgen excess leading to ambiguous geni- side. Upon consult with our institution, patient
Source of funding talia in female infants and 2) non-classical CAH, was diagnosed as alopecia universalis.
None which is a milder form of the condition that also
presents during late childhood with symptoms Physical examination revealed complete
of androgen excess such as precocious puberty, loss of hair on the scalp, eyebrows, and eye lash-
menstrual irregularities, and hirsutism. Patients es (Figure 1), as well as axillary and pubic hair.
with non-classical CAH may also present with Dermatology Life Quality Index (DLQI) was also
hair loss but limited studies have been report- obtained with a score of 8 signifying a moderate
ed to describe its prevalence and characterize effect on the patient’s life. Biopsy was not done.
its occurrence. In this case report, we present Patient was initially treated with minoxidil 5%
an atypical case of a 14-year-old Filipino female + tretinoin 0.05% combination spray solution,
with non-classical CAH presenting with alopecia to be applied on the scalp twice daily for two (2)
universalis. weeks, prednisone 25 mg/day (0.5mkd), to be tak-
en per orem for two (2) weeks and a supplement
CASE SUMMARY containing zinc gluconate, nicotinamide, super-
oxide dismutase, vitamin E, and selenium - to
We are presented with a 14-year-old female with a

42 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS CASE REPORT
Journal of the Philippine
Dermatological Society

be taken orally twice daily for two (2) weeks. The patient was appears to be ethnicity-based with an increased incidence
also referred to Endocrinology service for further workup and of 1/1000 among Caucasians and other minority and ethnic
co-management. Biochemical tests showed normal cortisol lev- groups.3
el, normal thyroid hormone levels, low dehydroepiandrosterone
sulfate (DHEAS) and elevated 17-OH progesterone, which were CAH can be of the classical type, with 75% of patients pre-
diagnostic of non-classical CAH. The patient was advised by En- senting upon birth or in infancy with severe-salt wasting phe-
docrinology service to take prednisone 5 mg (0.5mkd) once daily nomena as a result of aldosterone deficiency leading to dehydra-
for four (4) months. The patient also continued to follow-up with tion, hypovolemia, and shock. Moreover, female infants with
Dermatology service where she was asked to continue applying CAH may also present with ambiguous genitalia, premature
topical medications and to continue taking the oral supplement puberty, and growth abnormalities. On the other hand, female
for a total of three (3) months with noted gradual hair regrowth patients with non-classical CAH present with milder symptoms
on the frontal and occipital scalp, with vellus hair growth on the consisting of menstrual irregularities, premature development
parietal scalp and vertex. Hair regrowth was also noted on the of pubic hair, abnormal growth, and signs of androgen excess
eyebrows (Figure 2) and DLQI improved with a score of 5, signi- such as hirsutism and virilization.4 These manifestations are
fying a small effect on the patient’s life. usually present at birth and only become apparent in late child-
hood or early adolescence. A small number of patients may also
DISCUSSION manifest with hair loss secondary to increased androgen sen-
sitivity. In a multicenter cohort study by Moran et al. involving
Congenital adrenal hyperplasia (CAH) refers to a group of in- 220 female patients with non-classical CAH, the researchers
herited autosomal recessive disorders, majority of which is aimed to determine the most common clinical features of 21-hy-
characterized by 21-hydroxylase deficiency from mutations in droxylase-deficient non-classical CAH in various age groups.
the CYP21A2 gene. The resulting dysfunctional process of ste- Results of the study showed that in patients aged 10-19 years of
roidogenesis is characterized by glucocorticoid and mineralo- age (n=64), the most common manifestations were: hirsutism
corticoid underproduction and androgen excess.2 (59%), oligomenorrhea (54%), acne (33%), infertility (13%), cli-
toromegaly (10%), androgenetic alopecia (8%), primary amen-
About 1/15,000 births in the general population develop orrhea (4%), and premature pubarche (4%).5 The hair loss as-
classic CAH. Meanwhile, the frequency of non-classical CAH sociated with non-classical CAH is that of a male pattern type
of androgenetic alopecia and variations in presentation corre-
Figure 1. Physical examination showed generalized hair loss affecting the entire scalp and spond to the degree of enzyme deficiency.6,7 In the hair follicle,
eyebrows. excess androgen exerts its effects leading to follicular minia-
turization because of a prolonged anagen phase; thus resulting
Figure 2. Physical examination after three (3) months of treatment show areas of hair regrowth in the characteristic hair loss. Only a handful of studies exist
on the frontal, and occipital scalp with vellus hair growth on the parietal scalp and vertex. describing the pattern of hair loss in patients with non-classi-
cal CAH and interestingly, none of these describe a pattern that
could be seen in our patient.

A diagnosis of non-classical CAH in children is made based
on 17-hydroxyprogesterone (17-OHP) values. A 17-OHP level
great than 2 ng/mL is highly suggestive of non-classical CAH.
Our patient’s 17-OHP level is 3.81 ng/mL. For hair loss, the diag-
nosis of alopecia in patients with non-classical CAH is the same
as alopecia universalis, with clinical history and physical exam-
ination as essential tools for a proper assessment of the patient’s
condition.

Treatment of non-classical CAH is usually not indicated
unless the patient presents with symptomatic disease in the
form of symptomatic hyperandrogenism. Treatment generally
consists of low dose oral glucocorticoids until symptoms abate.
Standards have not been established regarding the duration of
treatment for these patients but it is prudent that concentrations
of 17-hydroxyprogesterone, androstenedione, and testosterone
be monitored regularly. Our patient was initially given predni-
sone 25 mg/day (0.5mkd) for two (2) weeks before she was re-
ferred to Endocrinology service. With this, she was advised to

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 43

CASE REPORT JPDS
Journal of the Philippine
Dermatological Society

watch out for side effects of oral corticosteroids such as weight topical solution response, resulting in regimens combining the
gain, bone changes, and increased susceptibility to infections two medications which produced better outcomes in the man-
among many others. Eventually, the patient was maintained on agement of androgenetic alopecia.10 However, clinicians should
a lower dose of prednisone at 5 mg/day (0.5mkd) for a duration prescribe with caution because of the risk of systemic absorp-
of four (4) months with eventual hair growth, specifically in the tion. Finally, there are only a few studies to support the role of
frontal and occipital area of the scalp and improvement in DLQI. vitamins and supplements for the treatment of alopecia. How-
ever, these supplements may still be used off-label as adjunctive
At present, there are no established guidelines for the treatment.
treatment of alopecia among patients with CAH, particularly
among the pediatric population other than oral glucocorticoids. CONCLUSION
Information regarding the safety and use of conventional hair
regrowth treatment products in children are still insufficient.8 Alopecia universalis in a patient diagnosed with non-classical
However, therapeutic agents that are being used to treat adults congenital adrenal hyperplasia is a rare and atypical manifesta-
have been tested in the pediatric population with promising re- tion, with no case reports available to describe its occurrence.
sults. In one retrospective study, topical 5% minoxidil was re- Due to its rarity, there is no standard treatment guideline for
portedly used for a duration of six (6) months in patients aged patients with this condition. However, the combination of treti-
11-18 with noted cessation of hair loss and thicker hair reported noin and minoxidil spray solution, low dose prednisone, and an
at six (6) months upon initiation of therapy and stabilization of oral supplement containing zinc gluconate, nicotinamide, su-
hair loss after one (1) year of use.9 In another study by Sharma et peroxide dismutase, vitamin E, and selenium shows promising
al., topical 0.1% tretinoin was shown to augment minoxidil 2% results.

REFERENCES

1. Y au M, Gujral J, New MI. Congenital Adrenal Hyperplasia: Diagnosis and Emergency Treatment. MDText.com, Inc; 2019.
2. Glass AR, Jackson SG, Perlstein RS, Wray HL. Adrenal insufficiency in a man with non-classical 21-hydroxylase deficiency: consequence or

coincidence? J Endocrinol Invest [Internet]. 1994;17(8):665–70. Available from: http://dx.doi.org/10.1007/BF03349683
3. Speiser PW, Dupont B, Rubinstein P, Piazza A, Kastelan A, New MI. High frequency of nonclassical steroid 21-hydroxylase deficiency. Am J Hum

Genet. 1985;37(4):650–67.
4. Y au M, Khattab A, Yuen T, Maria New. Congenital Adrenal Hyperplasia. In: Endotext [Internet]. MDText.com; 2022.
5. Moran C, Azziz R, Carmina E, Dewailly D, Fruzzetti F, Ibañez L, et al. 21-Hydroxylase-deficient nonclassic adrenal hyperplasia is a progressive

disorder: a multicenter study. Am J Obstet Gynecol [Internet]. 2000;183(6):1468–74. Available from: http://dx.doi.org/10.1067/mob.2000.108020
6. Livadas S, Bothou C. Management of the female with non-classical congenital adrenal hyperplasia (NCCAH): A patient-oriented approach.

Front Endocrinol (Lausanne) [Internet]. 2019;10:366. Available from: http://dx.doi.org/10.3389/fendo.2019.00366
7. Witchel SF, Azziz R. Nonclassic congenital adrenal hyperplasia. Int J Pediatr Endocrinol [Internet]. 2010;2010:625105. Available from: http://

dx.doi.org/10.1155/2010/625105
8. G onzalez ME, Cantatore-Francis J, Orlow SJ. Androgenetic alopecia in the paediatric population: a retrospective review of 57 patients: AGA in

the paediatric population: a retrospective review. Br J Dermatol [Internet]. 2010;163(2):378–85. Available from: http://dx.doi.org/10.1111/j.1365-
2133.2010.09777.x
9. Griggs J, Burroway B, Tosti A. Pediatric androgenetic alopecia: A review. J Am Acad Dermatol [Internet]. 2021;85(5):1267–73. Available from:
http://dx.doi.org/10.1016/j.jaad.2019.08.018
10. S harma A, Goren A, Dhurat R, Agrawal S, Sinclair R, Trüeb RM, et al. Tretinoin enhances minoxidil response in androgenetic alopecia patients
by upregulating follicular sulfotransferase enzymes. Dermatol Ther [Internet]. 2019;32(3). Available from: http://dx.doi.org/10.1111/dth.12915

44 J Phil Dermatol Soc · November 2022 · ISSN 2094-201X

JPDS CASE REPORT
Journal of the Philippine
Dermatological Society

Childhood bullous pemphigoid: A case report

Gemma Theresa C. David-Corpuz, MD, DPDS,1 Cathrine B. Ang, MD, DPDS,1
Camille B. Angeles, MD, FPDS,1 Maria Jasmin J. Jamora, MD, FPDS,1,2
Lian C. Jamisola, MD, FPDS, APSV1

ABSTRACT

INTRODUCTION Bullous pemphigoid (BP) is an acquired autoimmune subepidermal bullous disease characterized by linear depo-
sition of IgG and C3 along the basement membrane. It rarely occurs in childhood, especially in adolescence, with only 14 cases
identified in literature. Treatment of choice is systemic corticosteroids but other treatment options such as anti-inflammatory
antibacterials and methotrexate are available.

CASE REPORT A 16-year-old Filipino girl presented with a three-month history of generalized vesicles and bullae. Nikolsky and
Asboe-Hansen signs were negative. Histopathology and direct immunofluorescence were consistent with BP. ELISA to BP180 au-
toantibody levels was elevated at 135 IU (normal <9 IU). Complete blood count showed leukocytosis with increase in neutrophils.
Chest x-ray revealed pulmonary tuberculosis. The patient was given quadruple anti-Koch’s medication (pyrazinamide, rifampi-
cin, ethambutol, isoniazid), prednisone, oral erythromycin and topical clobetasol propionate. Complete remission was attained
at 10 months and is sustained at the time of writing.

CONCLUSION To establish a definitive diagnosis and appropriate management, BP requires clinical, histopathologic, and immuno-
logical correlation. Childhood BP has good prognosis and rapid treatment response, with rare relapses.

KEYWORDS Bullous pemphigoid, immunodermatology, pediatric dermatology

1Section of Dermatology, INTRODUCTION ed spontaneous appearance of severely pruritic,
Department of Medicine, erythematous macules on her left volar wrist,
University of the East Ramon Bullous pemphigoid (BP) is an autoimmune sub- rapidly evolving into vesicles within the day. In-
Magsaysay Memorial Medical epidermal blistering disease with predominant volvement of the neck was noted the following
Center Incorporated (UERMMMCI), eosinophil infiltration of the blister cavity.1 Au- day. Prior to lesion onset there was no trauma,
Aurora Blvd, Quezon City, toantibodies, mainly IgG, are directed against vaccinations, nor new medications. Initial as-
Philippines the basement membrane.2 BP is commonly seen sessment by another physician was herpes infec-
2Skin and Cancer Foundation, Inc., in the elderly.1 It rarely affects the pediatric tion. She was given prednisone 15 mg daily for
Medical Plaza Ortigas, San Miguel population and there are less than 100 cases re- one week tapered to 10 mg daily for another week
Avenue, San Antonio Village, Pasig ported in literature up to 2015.3 Majority of cases and unrecalled creams resulting to complete res-
City, Metro Manila, Philippines are in infancy, followed by the next peak among olution. Two months later, pruritic erythematous
elementary students.4 Locally, there are a total macules evolving into vesicles and bullae devel-
Corresponding author of 50 newly diagnosed cases of childhood BP ob- oped on both arms and the entire upper trunk for
Gemma Theresa C. David-Corpuz, tained from the Philippine Dermatological Soci- which similar treatment was unsuccessful. One
MD, DPDS ety Health Information System (PDS HIS) from month later, the lesions spread to the entire body,
2011 to 2019.5 In the adolescent age group, which prompting consult at our institution.
Conflict of interest ranges from 10 to 21 years,6 BP has an even rarer
None occurrence with only 14 cases identified in liter- Past medical history revealed varicella in-
ature from 1970 to 2015,6 with a female to male fection at age 10. There was no family history of
Source of funding ratio of 2:1.4 autoimmune blistering nor autoinflammatory
None disease. Immunization history including BCG
CASE REPORT vaccination was unrecalled. Physical exam-
ination showed generalized tense vesicles and
A 16-year-old Filipino female presented with a bullae filled with clear-yellowish fluid on nor-
three-month history of generalized vesicles and mal and erythematous skin. There were yellow,
bullae. Five months prior to consultation, she not-

J Phil Dermatol Soc · November 2022 · ISSN 2094-201X 45