We would like to welcome and introduce the newest members of Philippine Academy of Clinical and Cosmetic Dermatology. We wish you all much success in your career.
On June 23,2016 Thursday – PACCD held its third scientific symposium entitled: “Common Bullous Skin Diseases: Clinical Diagnosis Laboratory and Management”. The event was once again mounted at the Occupational Safety and Health Center, North Ave. cor Agham Rd., Diliman, Quezon City. The lecture concentrated on the viral varieties of this subset of diseases, specifically: Pemphigus, Bullous Pemphigoid, Epidermolysis Bullosa Acquisita, Pemphigoid Gestationis and Cicatricial Pemphigoid. The content was specifically targeted at practical approaches in diagnoses and management for the more seasoned dermatological practitioners. Although the academic weight of the lecture is undeniable; the occasion felt more like a guided series of enlightened anecdotes from a wise Professor whose focus is to aid his audience through the intricacies of these diseases. Some tips he imparted were:
- Ramon R. Briones, M.D.
Last Thursday, July 14, 2016 –members of the PACCD Organizing Committee and Board of Trustees gathered at the Gauguin Room of the Novotel Manila Araneta Center to celebrate Dr. Vinson B. Pineda’s 80th Birthday. The latter had been the PACCD President for the past 13 years; thus the organization deemed it appropriate to honor his milestones annually.
The evening started informally, but in high spirits, as guests trickled into the venue at around seven p.m. to greet the youthful octogenarian, who emanated robust health and a rather impish demeanor. Dinner was composed of an ample buffet complete with soup, salad, rice, vegetables, three main courses – and a choice of two pastry deserts. A rather agreeable cabernet sauvignon was also served to fuel the festivities; climaxing in a dry(sec) champagne for the final toast.
The program for the evening was energetically led by Dr. Connie Garcia who opened with a moving prayer which was sung by all, and complemented by an equally heartwarming slide presentation. After this, the entire company held their hands over the celebrant to pray over, wishing for his health and happiness. Toasts were then accomplished by the tinkling of flutes; ending in a slide show presentation of pictures from Dr. Pineda’s 79th Birthday Celebration.
The evening closed with Dr. Pineda’s sage invocation of how one could accomplish worldly success, and divorce from sin, by recognizing Jesus Christ as one’s Savior. A message which has become both traditional, and annual in its frequency.
-Ramon R. Briones, MD
PACCD’s second Scientific Symposium, held last March 3, 2016 Thursday was occasioned in a new venue (please see copy of the invitation), which can be described as classroom-type; but elegant in its practical roominess. Most importantly, the forty attendees were pleased with the new locale.
The topic of Leprosy may surprise some; but informal survey of the members revealed the disease’s persistent presence in the clinics of many; so the choice of topic was rather apt.
Opening the event was Mr. Samuel Sumilang. R.N.,EMT-B,MAN, Chief Nurse of the Dr. Jose N. Rodriguez Memorial Hospital, formerly Tala Leprosarium, who gave the general introduction to the subject matter – composed of history, statistics, general management, side effect of medications and classification of leprosy. Highlights of his lecture were:
1. Prevalence rate is 0.4/ 10,000 population. Rodriguez Hospital still receives 6-7 patients per month. But the trend has gone towards outpatient management.
2. Multi-Drug Therapy (MDT) is still the cornerstone management; with Minocycline and Ofloxacin as alternative options for resistant or allergic cases. Duration of treatment is 6 months to a year.
3. The mnemonic of L-E-P was introduced to aid in diagnosing leprosy: Loss of sensation, Enlargement of peripheral nerves, and Positive skin smear.
4. Transmission of M. Leprae is stops after 1 week of treatment.
The succeeding part of the event was presided over by Dave Elvin G. Sanchez, M.D., MPH,DPCOM,CESE, Head of the Dermatology and Leprosy Services , OIC Medical Center Chief of the Dr. Jose N. Rodriguez Memorial Hospital; who gave a more detailed account of the Disease’s Diagnosis, Differential Diagnosis, Physical Examination, Laboratory – and most importantly, recognition and management of the Reactive Phenomena. Highlights of his lecture were:
1. Constant spurts in incidence rates of the Disease concludes the inability of the local Medical programs to completely eliminate This may be due to hidden and/or unknown pockets within the population housing carriers of said Disease.
2. Reactive Phenomena involves immunological activities; of which complement activation would lead to kidney and liver destruction.
3. Management of reactions utilizes weight-computed corticosteroids and clofazimine.
Conclusively, the event was a success based on the liveliness of the open forum wherein the members of the audience greedily extracted management tips which they would use in their practice. Although the lecturers stated that 3 days may be required to adequately discuss Leprosy; they were sensitive to the requirements of the Dermatology practitioners and gave emphasis to topics which would help the latters’ clinical practice.
Lunch, which was served at the cafeteria, though not haute cuisine proved to be tasty and rather filling. So for members who have never attended a symposium – rest assured, that our program always satisfies the academic, as well as culinary gluttons among the attendees. So do please attend our subsequent events, for PACCD has always been concerned with the intellectual progress of its members.
- Ramon Briones, M.D.
Invitation and Program
PACCD 2nd Scientific Symposium March 3, 2016 Occupational Safety and
Health Center Diliman Quezon City
PACCD 2nd Scientific Symposium March 3, 2016 Occupational Safety and
Health Center Diliman Quezon City
(From L-R) Dr. Oscar Salvador D. Griño, PACCD Asst. Treasurer; Dr. Angelina P. Aquende, PACCD Treasurer; Dr. Dave Elvin G. Sanchez and Mr. Samuel Sumilang, PACCD Lecturers; Dr. Sonia G. Baluyot, PACCD Academic Chairperson
PACCD 2nd Scientific Symposium March 3, 2016
Occupational Safety and Health Center Diliman Quezon City
Delegates and Lecturers
PACCD’s First Scientific Symposium 2016; In Hindsight
Cynthia S. Floro, M.D
At exactly 10 am on January 28,2016, the Conference Room of Sulo Riviera Hotel is filled with no less than 53 PACCD members anticipating the first Scientific Symposium of the year.
Aptly relevant, is the choice of topic selected by our Academic Committee Chair, Dr. Sonia Baluyot, the title of which is “CONNECTIVE TISSUE DISEASES BOTH IN ADULT AND CHILDREN”
Two Specialists in the field of Rheumatology served as our Guest Speakers. They are Dra. Marica A. Lazo, an Adult Rheumatologist and Dra. Leonila F. Dans, a Pediatric Rheumatologist. Both of whom are established practitioners in their Fields.
Dra. Marica Lazo started the Symposium with the in-depth lecture on SLE or Systemic Lupus Erythematosus.
According to her, SLE is one of the Chronic systemic autoimmune diseases with protean manifestations. More than 90% of SLE cases occur in women, most often in the child-bearing age. It may affect any organ system and its presentation and course are highly variable ( indolent or fulminant).
Skin involvement is the second most common manifestation of SLE, next to Arthalgias. She noted that 75% of all SLE patients develop skin lesion in the course of their disease.
This is also one of the most common Connective Tissue disease seen for consutation, with the average of 2-3 patients per day. And on the flipside, one of the diseases often not reported.
Symptoms may vary over time, but commonly include:
• Blood disorder
• Renal disorder
• ANA positive titter
• Immunological disorder
• Neurologic disorder
• Malar “Butterfly” rash
• Discoid rash
There are three forms of Cutaneous Lupus, namely:
1. Acute Cutaneous Lupus- which has the characteristic erythema over the cheeks and nasal bridge, sparing the naso-labial folds, making it appear like a malar “butterfly” rash.
2 . Subcutaneous Lupus – has the characteristic psoriasiform rash and annular polycystic rash
3. Chronic or Discoid Lupus – with lupus penniculitis/ lupus profundus
Other Cutaneous Manifestations may include:
For the treatment, Dra. Lazo, mentions the medications commonly used :
• Antimalarial drugs
She proceeds by discussing four other Connective Tissue Diseases namely:
Psoriasis/ Psoriatic Arthritis
Among these, Psoriasis aroused the most interest in the attendees. Simply because, it is one of the most common immune-mediated inflammatory skin disorder seen by many of us in practice.
The key dermatologic signs in Psoriasis, include, papulosquamous plaques on the scalp and extensor surfaces of the body. Nail dystrophy is not uncommon. And once, a patient has nail pitting with accompanying back pain, it is more likely a case of Psoriatic arthritis, Dra. Lazo notes.
Treatment includes, topical steroids, Phototherapy and DMARDS ( Methotrexate, Cyclosporine and Biogenics, like, Etanercept, Infliximab, Adalimumab and Ustekinumab.
At the end of her lecture, she points out that, a good Medical History and thorough Physical Examination , guides a Physician to a Proper Diagnosis.
In closing, she gives the following Key Points in Diagnosis And Treatment.
• Skin changes occur in a variety of rheumatic diseases and may even be the initial manifesta- tation of a systemic disease
• Skin involvement in a rheumatic disease may serve as an easy-to-access diagnostic and prognostic indicator
• Physicians need to be aware of the impact that chronic and disfiguring skin changes may have on the quality of life of a patient with rheumatic disease.
Immediately after, Dra. Leonila F. Danz, is called on the floor to discuss on ‘” Differentiating Skin Findings of Pediatric Rheumatic Conditions”.
With her warm personality, attendees are able to get back to the momentum of the Lectures right after a good one.
She begins, by mentioning that skin changes in Pediatric Rheumatic Conditions can be very confusing in coming- up with a diagnosis. Like what Dra. Lazo says, a good Clinical history and Physical Examination is the key.
She emphazises the following essential clinical features in ruling out Differential Diagnosis:
Approach to Diagnosis:
• Site of involved joint
• Duration and Frequency of symptoms
• Number of Joints involved
• Associated Extra-articular manifestations
At UP-PGH Pediatric Rhuematology Clinic where she practices, she points 5 case- mixed diseases commonly seen. In the year 2015, statistics show:
• SLE – most common case, about 23%
• Juvenille Idiopathic Arthritis 15%
• Vasculitis 17%
• Rheumatic Fever 12%
• Juvenille Dermatomyositis 3 %
Juvenile Rheumatoid Arthritis, or Juvenile Idiopathic Arthritis, is the most common type of arthritis in children under the age of 17. Like Rheumatic Fever, she says, both have spiking fever and the typical evanescent rash , with joint pains , swelling and morning stiffness.
To rule out other skin diseases rather than Rheumatic Fever, Jones Criteria for Diagnosis of Acute Rheumatic Fever must guide the Physicians. Of courses after an evidence of positive Streptococcal infection. These are:
• Erythema marginatum
• Subcutaneous nodules
• Elevated ESR, CRP
• Prolonged PR
Vasculitis or Henoch Schonlein Purpura, she continues, is the commonest form of vasculitis in children.There is purpura affecting the lower limb or occasionally widespread with fever but is self-limiting. She observes, that children who underwent appendectomy get it more than those who did not.
Juvenile Dermatomyositis, on the other hand, has a characteristic violaceous rash over the eyelids with periorbital edema. It may appear like a child has eye shadow make-up on, she adds. Other findings include Gottron papules, heliotrope rash, calcinosis cutis, and proximal muscle weakness.
Scleroderma or Sytemic Sclerosis, she goes on, is characterized by formation of fibrosis in the skin that leads to the thickness and firmness of involved skin. Reynauld’s phenomenon is an example. There is increase fibroblast activity resulting in abnormal growth of connective tissue, resulting in vascular damage and fibrosis.
Topical steroids, antihistamines and NSAIDs can be used to ease the symptoms. However, oral corticosteroids do not help. Dapsone and methotrexate are also being used, but she cautions that no treatment is uniformly effective.
She concludes her lecture by saying that, a Physician should request for a skin biopsy in case of doubts, but gives us the following guidelines :
• SLE – has malar rash, oral sore, different from Koplik’s spots of Measles
• Henoch Shchonlein Purpura – has palpable purpura
• KAWASAKI Disease – has desquamation, strawberry tongue
• JDM – Gotton’s papules, Heliotrope
• Scleroderma – with distal sclerosis
By the end of the Lectures, attendees have nothing but satisfied look on our faces.
For starting a New Year, this good PACCD Scientific Symposium is a welcome treat . It makes a good anticipation for the coming ones. In addition, it doesn’t only feed our minds with knowledge, but the food served at lunch time, completes the pleasure.
- csf -
PACCD 1st SCIENTIFIC SYMPOSIUM, January 28, 2016 at Sulo Riviera Hotel, Quezon City (from L to R)Dr. Vinson B. Pineda, PACCD President, Dr. Rosario Divina R. Perez, PACCD Auditor, Dr. Isagani C. Cruz, PACCD Asst. PRO, Dr. Leonila F. Dans and Dr. Marica A. Lazo, PACCD Lecturers, Dr. Sonia G. Baluyot, PACCD CME Chairperson
Varicose veins are veins that have become enlarged and tortuous. The term commonly refers to the veins on the leg,although varicose veins can occur elsewhere.When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work. This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides cosmetic problems, varicose veins are often painful, especially when standing or walking. They often itch, and scratching them can cause ulcers. Serious complications are rare. Non-surgical treatments include sclerotherapy, elastic stockings, elevating the legs, and exercise. The traditional surgical treatment (vein stripping) removes the affected veins. Newer, less invasive treatments which seal the main leaking vein on the thigh are available. Alternative techniques, such as ultrasound-guided foam sclerotherapy, radiofrequency ablation and endovenous laser treatment, are available as well. Because most of the blood in the legs is returned by the deep veins, the superficial veins, which return only about 10 per cent of the total blood of the legs, can usually be removed or ablated without serious harm.Varicose veins are distinguished from reticular veins (blue veins) and telangiectasias (spider veins), which also involve valvular insufficiency,by the size and location of the veins.
Signs and symptoms
Aching, heavy legs (often worse at night and after exercise). Appearance of spider veins (telangiectasia) in the affected leg. Ankle swelling. A brownish-blue shiny skin discoloration near the affected veins. Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg. Cramps may develop especially when making a sudden move as standing up. Minor injuries to the area may bleed more than normal and/or take a long time to heal. In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard. Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency. Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche.
Varicose veins are more common in women than in men, and are linked with heredity. Other related factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury, abdominal straining, and crossing legs at the knees or ankles. Less commonly, but not exceptionally, varicose veins can be due to other causes, as post phlebitic obstruction and/or incontinence, venous and arteriovenous malformations.
The symptoms of varicose veins can be controlled to an extent with the following: Elevating the legs often provides temporary symptomatic relief. “Advice about regular exercise sounds sensible but is not supported by any evidence.” The wearing of graduated compression stockings with variable pressure gradients (Class II or III) has been shown to correct the swelling, nutritional exchange, and improve the microcirculation in legs affected by varicose veins.They also often provide relief from the discomfort associated with this disease. Caution should be exercised in their use in patients with concurrent arterial disease. Diosmin/Hesperidine and other flavonoids. anti-inflammatory medication such as ibuprofen or aspirin can be used as part of treatment for superficial thrombophlebitis along with graduated compression hosiery – but there is a risk of intestinal bleeding. In extensive superficial thrombophlebitis, consideration should be given to anti-coagulation, thrombectomy or sclerotherapy of the involved vein.
Active medical intervention in varicose veins can be divided into surgical and non-surgical treatments. Some doctors favor traditional open surgery, while others prefer the newer methods. Newer methods for treating varicose veins such as Endovenous Thermal Ablation (endovenous laser treatment or radiofrequency ablation), and foam sclerotherapy are not as well studied, especially in the longer term.
Several techniques have been performed for over a century, from the more invasive saphenous stripping, to less invasive procedures like ambulatory phlebectomy and CHIVA.
Stripping consists of removal of all or part the saphenous vein main trunk. The complications include deep vein thrombosis (5.3%),pulmonary embolism (0.06%), and wound complications including infection (2.2%). For traditional surgery, reported recurrence rates, which have been tracked for 10 years, range from 5-60%. In addition, since stripping removes the saphenous main trunks, they are no longer available for venous bypass in the future (coronary and/or leg artery vital disease)\
Other surgical treatments are:
Ambulatory phlebectomy Vein ligation Cryosurgery- A cryoprobe is passed down the long saphenous vein following saphenofemoral ligation. Then the probe is cooled with NO2 or CO2 to a temperature of – 850. The vein freezes to the probe and can be retrogradely stripped after 5 sec of freezing.It is a variant of Stripping. The only point of this technique is to avoid a distal incision to remove the stripper. Non-surgical treatment
A commonly performed non-surgical treatment for varicose and “spider” leg veins is sclerotherapy in which medicine is injected into the veins to make them shrink. The medicines that are commonly used as sclerosants are polidocanol (POL), sodium tetradecyl sulphate (STS), Sclerodex (Canada), Hypertonic Saline, Glycerin and Chromated Glycerin. STS and Polidocanol(branded Asclera in the United States) liquids can be mixed with air or CO2 or O2 to create foams. Sclerotherapy has been used in the treatment of varicose veins for over 150 years.Sclerotherapy is often used for telangiectasias (spider veins) and varicose veins that persist or recur after vein stripping.Sclerotherapy can also be performed using foamed sclerosants under ultrasound guidance to treat larger varicose veins, including the great saphenous and small saphenous veins. A study by Kanter and Thibault in 1996 reported a 76% success rate at 24 months in treating saphenofemoral junction and great saphenous vein incompetence with STS 3% solution. A Cochrane Collaboration review concluded sclerotherapy was better than surgery in the short term (1 year) for its treatment success, complication rate and cost, but surgery was better after 5 years, although the research is weak.