Search

Climate change, exemplified by higher average global temperatures resulting in more frequent extreme weather events, has the potential to significantly impact human migration patterns and health. The consequences of environmental catastrophes further destabilize regions with pre-existing states of conflict due to social, political, and/or economic unrest. Migrants may carry diseases from their place of origin to their destinations and once there may be susceptible to diseases in which they had not been previously exposed to. Skin diseases are among the most commonly observed health conditions observed in migrant populations. To improve awareness among dermatologists of the burden of skin diseases among migrants, the group searched the English language scientific literature to identify articles linking climate change, migration, and skin disease. Skin diseases associated with human migration fall into three major categories: (i) communicable diseases, (ii) noncommunicable diseases, and (iii) environmentally mediated diseases. Adopting comprehensive global strategies to improve the health of migrants requires urgent attention.

A 28-year-old Filipina presented with a 20-year history of multiple hyper- and hypopigmented macules on the face, trunk and extremities. The lesions, noted to be nonpruritic and nontender, simultaneously appeared, initially on the trunk and spread gradually to the upper and lower extremities. Involvement of the face was noted 1 year prior to consult. Previous treatment with topical miconazole and oral itraconazole proved futile. She was also diagnosed clinically as a case of hypopigmented mycosis fungoides in another dermatology clinic, for which she underwent narrow band UVB phototherapy for 20 sessions. The patient was born to non-consanguineous parents. Similar skin lesions were also present in her two (maternal) aunts, an uncle and two male cousins (Fig. 14.1).

A 58-year-old Filipino female consulted at the clinic because of a 1-year duration of hyperpigmented patches on both cheeks. On physical examination, she presented with a symmetrical grayish-black hyperpigmentation on both cheeks, extending to the zygomatic areas, mandible, nostrils, upper lip and eyebrow regions; skin texture was coarse. Closer examination revealed telangiectasias and confetti-like depigmentation on both malar areas.

Ashy dermatosis (AD), lichen planus pigmentosus (LPP), erythema dyschromicum perstans (EDP), and idiopathic eruptive macular pigmentation are several acquired macular hyperpigmentation disorders of uncertain etiology described in literature. Most of the published studies on these disorders are not exactly comparable, as there are no clear definitions and different regions in the world describe similar conditions under different names. A consensus on the terminology of various morphologies of acquired macular pigmentation of uncertain etiology was a long-felt need. Several meetings of pigmentary disorders experts were held to address this problem. A consensus was reached after several meetings and collation of e-mailed questionnaire responses and e-mail communications among the authors of publications on the above conditions. This was achieved by a global consensus forum on AD, LPP, and EDP, established after the 22nd International Pigment Cell Conference held in Singapore in 2014. Thirty-nine experts representing 18 countries participated in the deliberations. The main focus of the deliberations was terminology of the conditions; as such, we present here the consensus statement of the forum and briefly review the available literature on the subject. We have not attempted to discuss treatment modalities in detail.

Studies show frequent usage but low adherence rates and poor satisfaction from topical therapy for psoriasis. These were attributed to low efficacy, inconvenience of application, and poor cosmetic quality for different body parts. Multicenter surveys on patients suggest a two-way holistic approach, where patients convey what bothers them most and doctors explain how products address specific concerns. New rapid response targeted topical agents, in cosmetically acceptable preparations, applied less often, are undergoing efficacy and safety studies, ideally on large populations up to 1 year or more. Until available, this review addresses gaps in knowledge on how to maximize effects of emollients, used alone, with physiologic lipids, or as base for active topical therapy. Updates—on how psoriasis skin becomes itchy, red, dry, thick, and scaly from inflammation and barrier defects—explain clinical responses to the physical, chemical, and functional properties of psoriasis topical therapies.

Climate change contributes to the increase in severity and frequency of flooding, which is the most frequent and deadly disaster worldwide. Flood-related damage can be very severe and include health effects. Among those health impacts, dermatological diseases are one of the most frequently encountered. Both infectious and noninfectious dermatological conditions are increasing after flooding. We searched PubMed using the search term climate change OR global warming OR rainfall OR flooding OR skin. Articles published in the English-language literature were included. We also searched the International Society of Dermatology website library on climate change for additional articles. There is an increased risk of trauma during the course of a natural disaster. The majority of post-tsunami wound infections were polymicrobial, but gram-negative bacteria were the leading causes. Infectious diseases with dermatological manifestations, such as impetigo, leptospirosis, measles, dengue fever, tinea corporis, malaria, and leishmaniasis, are important causes of morbidity among flood-afflicted individuals. Insect bites and stings, and parasite infestations such as scabies and cutaneous larva migrans are also frequently observed. Inflammatory conditions including irritant contact dermatitis are among the leading dermatological conditions. Dermatological conditions such as alopecia areata, vitiligo, psoriasis, and urticaria can be induced or exacerbated by psychological conditions post disaster. Prevention is essential in the management of skin diseases because of flooding. Avoiding exposure to contaminated environments, wearing protective devices, rapid provision of clean water and sanitation facilities, prompt vector controls, and education about disease risk and prevention are important.

Summary Cnidarian envenomations are common occurrences in the tropics that can affect holidaymakers. The cutaneous reactions are classified as immediate or delayed types. Delayed allergic reactions are persistently recurring dermatitis, which can occur within 1–4 weeks from the initial sting, and may last for several months. Hypertrophic scar-like or keloid-like reactions are rare, and are believed to be a type IV hypersensitivity reaction to sequestered antigens from stinging filaments. We report an unusual case of delayed allergic dermatitis with keloid-like presentation caused by Physalia utriculus.

Acquired macular pigmentation of uncertain etiology(AMPUE) has certain characteristic hyperpigmentation patterns; they include ashy dermatosis(AD), erythema dyschromicum perstans (EDP), lichen planus pigmentosus (LPP), and idiopathic eruptive macular pigmentation(IEMP). The clinical and histopathological features overlap, and presently there is no consensus on effective treatment. Riehl’s melanosis and IEMP with papillomatosis are two other distinctive pigmentary disorders for which the exact aetiology is not known. All other cases, where the pattern of pigmentation is not characteristic, are best kept under the umbrella of AMPUE until more disease-defining features develop or the etiology becomes clearer. There is a pressing need to fully understand and properly define these skin conditions as patchy hyperpigmentation creates both cosmetic and psychological problems for the darker-skinned populations.

Racial variations exist in the distribution of melanin and melanosomes in the epidermis; however, no racial differences are observed in melanocyte density and concentration. Melanosomes in pigmented skin are distributed in the entire epidermis unlike in fair skin where only few melanosomes are found in the basal and malpighian layers. Studies on melasma in brown skin consistently show increased epidermal melanocytes and melanin in all the layers of the epidermis accompanied by solar elastosis and mild perivascular infiltrate. The presence of melanophages is a variable observation and raises the question whether there is indeed a “dermal” type of melasma. Important clinical differential diagnoses include ochronosis, dermal melanocytosis, ashy dermatosis (AD), erythema dyschromicum perstans (EDP), lichen planus pigmentosus (LPP), Riehl’s melanosis, and minocycline pigmentation, which are conditions mostly observed in Fitzpatrick skin type IV brown skin. A skin biopsy is indispensable when melasma presents with unusual clinical features or has become recalcitrant to treatment. It may be useful to establish the nature and pathology of facial hyperpigmentation and determine changes in the underlying dermis which may provide clues to the diagnosis.

Vitiligo is characterized histopathologically by loss of melanocytes in the basal layer which eventually results in the absence of melanin in the epidermis. Only few studies have been conducted in brown skin, and most of our knowledge on the pathologic changes in the epidermis and dermis are based on studies done involving an assortment of races and skin phototypes. The role of cellular immunity in vitiligo pathogenesis has been pointed out by the use of immunohistochemistry to identify the cellular components of vitiligo lesions. Common clinical and histological differential diagnosis of vitiligo in brown skin includes diseases presenting with hypo- and depigmentation. These include idiopathic guttate hypomelanosis, pityriasis alba, postinflammatory pigmentary alteration, hypopigmented mycosis fungoides (MF), and tuberculoid leprosy. More studies on the histopathology of vitiligo in brown skin should be conducted to identify prominent features and further highlight the cellular immune elements which potentially drive the unique inflammatory responses.

Mucinous cutaneous adnexal tumors are an uncommon occurrence. We describe three cases of mucinous hidradenoma characterized by diffuse and prominent mucinous cell proliferation and discuss the relevant literature. The patients (two men and one woman) ranged in age from 32 to 72 years. The lesions were completely excised, and all patients were alive without evidence of disease (follow-up interval 3-4 years). Case 1 presented as a 1.3-cm eyelid nodule and histology showed a mucinous apocrine hidradenoma with a proliferation of mucinous cells and apocrine glands. Case 2, from the shoulder of a 40-year-old man, was a 2.5-cm well-circumscribed nodule composed of hyperplastic villoglandular proliferation of mucinous cells with focal squamous whorls and focal columnar glandular cells showing decapitation secretion. The tumor was also interpretated as a mucinous hidradenoma, most likely of follicular-apocrine origin. Case 3 was a 3.0-cm scalp nodule. The histology showed a mucinous clear-cell hidradenoma composed of numerous mucinous glands amidst small squamous cells with clear cytoplasm and a hyalinized fibrovascular stroma.

Summary Background Controversy exists about the relationship of borrelia infection with B-cell lymphomas because B-cell clonality has been identified in infiltrates that contained borrelia-specific DNA. Systematic clinicopathological, immunophenotypical and molecular pathological studies of early borreliosis are lacking. Objectives (i) To clarify whether clonal B-cell populations are present already in early borreliosis of the skin (erythema migrans); (ii) to re-evaluate clinicopathological, immunophenotypical and molecular pathological criteria for diagnosis of erythema migrans. Methods Study of 34 patients with erythema migrans confirmed by polymerase chain reaction (PCR). Infiltrates were analysed by histopathological and immunohistochemical methods and multiplex PCR for clonal IgH rearrangements. Results Erythema migrans shows a broad spectrum of changes including sparse infiltrates of T lymphocytes, dense interstitial granulomatous infiltrates (CD68+), and pseudolymphomatous patterns with germinal centre formation. There were accompanying epidermal changes in 59% of patients, and plasma cells were an inconsistent finding. B cells were few when infiltrates were sparse, but increased disproportionately when infiltrates were dense. IgH rearrangement studies revealed one pseudo-oligoclonal, three pseudoclonal and three clonal infiltrates. Pseudoclonality was encountered when infiltrates contained only few B lymphocytes. Conclusions Infiltrates in erythema migrans are dominated by T cells followed by CD68+ histiocytes and B lymphocytes. Plasma cells are an inconsistent finding. Pseudoclonality of IgH rearrangement is a result of infiltrates being sparse in B lymphocytes and represents a pitfall in molecular pathological diagnosis that can only be avoided by duplicate or triplicate tests. Incidental B-cell clonality may be encountered in patients with unequivocal erythema migrans and should not be interpreted as a malignant lymphomatous process induced by borrelia.

Eccrine porocarcinoma is an uncommon sweat gland malignancy. To the best of our knowledge, there has been no report in the English literature of porocarcinoma with predominantly undifferentiated sarcomatous change. We present two cases of sarcomatoid eccrine porocarcinoma associated with a benign poroma. Case 1 pertained to an 82-year-old woman with an ulcerated chest wall tumor, and Case 2 was that of a 74-year-old woman who presented with an ulcerated plaque in the lower leg. Case 1 showed an unusual pseudo-angiosarcomatous morphology with spindle cells dissecting through collagen bundles and forming vascular like channels. Case 2 revealed high-grade malignant spindle cells with focal evidence of ductal differentiation. In both the cases, benign poromatous elements were histologically evident. Immunohistochemistry performed showed pancytokeratin positivity in spindle cells of both lesions. Epithelial membrane antigen and carcino-embryonic antigen positivity in the malignant ductal elements and focal smooth muscle actin staining of the spindle cells were demonstrated in Case 2. A brief review of relevant literature is presented.

The warm tropical climate of the Philippines and its interaction with cultural practices, occupation and immune responsiveness contribute to the increased susceptibility of Filipinos to fungal infections. An investigation to determine the prevalence of fungal infections in dermatology training institutions over a 4-year period was conducted. The results showed that fungal infections rank as the second leading cause of consultation with a prevalence of 12.98%. Pityriasis versicolor (25.34%), tinea corporis (22.63%), tinea cruris (16.7%) and tinea pedis (16.38%) were the most frequently encountered cases. Fungal culture yield is low and Candida sp. is the most common isolate, obtained predominantly from specimens taken from the oral mucosa and nails. Candidiasis is still the most common opportunistic infection followed by coccidioidomycosis, cryptococcosis and aspergillosis. Imidazoles are the most commonly prescribed systemic and topical treatment by Filipino dermatologists. Initial data collected would serve as reference for future research and may be used to compare with epidemiologic data obtained from other Asian countries.

Background: We describe a series of previously unreported, distinctive, polypoid solitary T-cell-rich cutaneous pseudolymphomas. Methods: The clinicopathologic features were examined in 17 cases. Results: Patient ages ranged from 16 to 71 years (mean = 38.5) with a female predominance (female : male = 14 : 3). All lesions, clinically diagnosed most often as pyogenic granuloma, presented as a solitary, polypoid, erythematous, papule ranging in size from 2.5 to 7.5 mm (mean = 5.8). Most occurred on the head and neck (7) and trunk (6) with other sites including the thigh (1), shoulder (1) and knee (1). A dense dermal infiltrate composed of mildly atypical lymphocytes with variable numbers of admixed plasma cells and histiocytes was prototypical. Commonly, there was an associated epidermal collarette (16/17), Grenz zone (11/17) or admixed eosinophils (8/17). Prominent vessels lined by plump endothelial cells, reminiscent of high endothelial venules of lymph nodes, were universal and some degree of telangiectasia was also common (12/17). CD3-positive T-cells consisted of an admixture of CD4-positive and CD8-positive forms (15/16). Multiple studies suggested polyclonality (seven cases). No recurrences after lesional excision were noted in the 17 patients with a follow-up range from 24 to 120 months (mean = 46.6). Conclusion: Although these lesions share histopathologic features of the so-called acral pseudolymphomatous angiokeratoma of children (APACHE), they occur in a completely different clinical setting, present in solitary and polypoid fashion and are T-cell rich. We propose the diagnostic label T-cell-rich angiomatoid polypoid pseudolymphoma for this distinctive but presumably reactive lesion. Dayrit JF, Wang W-L, Goh SGN, Ramdial PK, Lazar AJF, Calonje E. T-cell-rich angiomatoid polypoid pseudolymphoma of the skin: a clinicopathological study of 17 cases and a proposed nomenclature.

Symplastic hemangioma is characterized by degenerative atypia of vascular smooth muscle and interstitial cells within a pre-existing vascular lesion with minimal endothelial cell atypia. We describe an additional two cases of this distinctive but poorly recognized entity. On histology, both lesions revealed a cirsoid aneurysm-type appearance with thick-walled and variably dilated blood vessels. The vascular endothelial cells showed mild nuclear hyperchromasia with no multilayering or mitoses. The atypical cells, either located within the vascular smooth muscle wall or within the interstitium, were spindle or epithelioid with varying degrees of hyperchromasia, nuclear enlargement, pleomorphism, and multinucleation. Perivascular hemorrhage, vascular thrombosis, and focal papillary endothelial hyperplasia were uniformly present. The variably fibrous to edematous stroma showed hemosiderin deposits and a mononuclear inflammatory infiltrate. Clusters of adipocytes were present within the superficial dermis. Rare atypical mitoses and occasional bizarre lipoblast-like stromal cells were identified in one tumor. Immunohistochemistry showed focal smooth muscle actin positivity in the pleomorphic cells of the vascular walls. CD68 and CD34 stained occasional stromal cells in the interstitial location. Both the cases showed no recurrence. The bizarre cytologic changes are interpreted as degenerative in nature and probably akin to that observed in ancient schwannoma and uterine symplastic leiomyoma.