A Review and Case Study of Genital and Extragenital Human Papillomavirus Type 6 and 11 Infections in Men Who Have Sex with Men Accompanied by Human Immunodeficiency Virus Infection.

Extragenital warts caused by HPV types 6 and 11 are rarely reported. However, major risk factors for anogenital warts (AGW) include men who have sex with men (MSM) and Human Immunodeficiency Virus (HIV) infection. The incidence of extragenital warts among these populations has not been reported. This study presented a case report of a 33-year-old male with high-risk sexual behavior who showed symptoms of flesh-colored and hyperpigmentation papules. Furthermore, verrucous surfaces were observed at genital and extragenital. The patient had a history of using the same razor for pubic and armpit hair, bathing with a mesh scrub, and scratching the anal area. The histopathological result showed koilocytes, while polymerase chain reaction (PCR) examination for both genital and extragenital lesions confirmed HPV type 6 and 11. This represented the first reported case describing the incidence of extragenital and AGW caused by HPV types 6 and 11. The transmission of extragenital warts was facilitated through fomites autoinoculation, particularly in the immunocompromised condition induced by HIV, which was common among MSM. Extragenital warty-like lesions were considered as warts caused by HPV type 6/11, in HIV-infected persons, specifically MSM.

The Importance of p16 and p53 Immunohistochemical Staining in Diagnosing Vulvar Lichen Simplex Chronicus Mimicking Vulvar Intraepithelial Neoplasia with False-Positive Human Papillomavirus Type 66.

Vulvar intraepithelial neoplasia (VIN), the precursor lesion of vulvar squamous cell carcinoma (VSCC), may present as pruritic or asymptomatic lichenified plaques surrounded by single or multiple discrete or confluent macules or papules. VIN is divided into high-grade squamous intraepithelial lesion (HSIL), which is human papillomavirus (HPV)-driven, and differentiated VIN (DVIN), which develops independently of HPV. Histopathological examination and HPV genotyping polymerase chain reaction (PCR) tests should be performed to distinguish between HSIL and DVIN. Lichenified plaques surrounded by multiple papules are found not only in VIN but also in vulvar lichen simplex chronicus (LSC). This chronic inflammatory skin disease mostly appears in labia majora and is triggered by sweating, rubbing, and mental stress. IHC staining of p16 and p53 are recommended as the most commonly used biomarkers for VIN in diagnostically challenging cases. IHC staining is also beneficial to confirm the accuracy of the HPV detection technique, as p16-negative staining may also represent a false-positive result. We report a case of the importance of p16 and p53 IHC staining in diagnosing vulvar LSC mimicking VIN with false-positive HPV-66. The patient was previously diagnosed with VIN based on clinical examination. HPV-66 was detected by PCR from a vulvar biopsy sample. Histopathological examination revealed stromal lymphocytic infiltration with non-specific chronic dermatitis; neither atypia nor koilocyte was observed. Both p16 and p53 IHC staining were negative. The patient was diagnosed and treated as vulvar LSC with 10 mg cetirizine tablet, emollient, and 0.1% mometasone furoate cream. Clinical improvement was observed as the lesions became asymptomatic hyperpigmented macules in the 4 weeks of follow-up, without recurrence after 3 years of follow-up. Both p16 and p53 IHC staining might help distinguish HSIL and DVIN mutually and from other vulvar mimics in diagnostically challenging cases.

Successful treatment of anogenital warts with single dose Bacillus Calmette Guerin vaccine without prior sensitization in tuberculosis endemic country: Two case report.

Anogenital Warts (AGWs) are benign proliferations caused by Human Papillomavirus (HPV) infection on the genital or anal areas. Various therapeutic options are available for the treatment of AGWs but there is no best or ideal therapy, and the recurrence of AGWs is significantly high. A promising new therapy that is currently being evaluated is immunotherapy with the intralesional Bacillus Calmette-Guérin (BCG) vaccine. Two cases of a 23-year-old woman and a 41-year-old man were presented with manifestations of condyloma acuminata type AGWs. The patients were immunocompetent and received single dose intralesional BCG vaccine on the largest lesion. Clinical improvements of AGWs lesions were noted starting on the 14th day after receiving therapy by the disappearance of some lesions with no recurrence and side effects. Intralesional BCG vaccine activates the immune system, treats other AGWs lesions that do not receive an intralesional injection, and also prevents recurrence. Although the intralesional BCG vaccine is effective for treating AGWs, further evaluation is still needed for its recurrence.

Success of Intralesional Purified Protein Derivative Immunotherapy in the Treatment of Anogenital Warts: A Case Report.

Anogenital warts (AGW) are among the most common sexually transmitted infections worldwide. The condition may be persistent, increase in size and number, and have a high recurrence rate. There are many therapeutic options of AGW, but none of them prevented recurrence, only yielded partial responses and have the propensity to cause scars. Immunotherapy by purified protein derivative (PPD) is one of the therapeutic options for AGW, which effectively reduces the number of lesions until complete clearance, with minimal side effects and less recurrence rate. This case report aims to demonstrate the effectiveness, safety, and low recurrence rate of intralesional PPD injection as an alternative therapy for AGW. We reported one case of AGW in an immunocompetent 30-year-old homosexual man who was given 3 doses of 0.2 mL PPD injected intralesionally. As a result, clinical improvement was observed starting from the 18th day, with some of the lesions decreasing in size, and on the 46th day, all of the lesions disappeared. There was no significant side effect. Within two years of follow-up, no recurrence was observed. Intralesional injection of PPD can stimulate the immune response against human papillomavirus (HPV) infection both on the injection site and distant from the injection site. Previous studies have shown promising results of intralesional PPD, with low recurrence in over six-month follow-up and no side effects. Intralesional injection of PPD can be considered as an alternative therapy due to its minimal side effects and its long-term low recurrence rate.

Detection of A2058G and A2059G on the 23S rRNA Gene by Multiplex Nested PCR to Identify Treponema pallidum Resistance to Azithromycin in Indonesia.

Azithromycin is an antibiotic used to treat syphilis, especially in the context of penicillin allergy. Although resistance to azithromycin has been widely reported to be associated with one- and/or two-point mutations on the 23S rRNA gene, it has yet to be described in Indonesia. Specimens were collected from 220 patients diagnosed with secondary syphilis. A multiplex nested polymerase chain reaction (PCR) testing system using the 23S rRNA target gene of Treponema pallidum was designed using three primer pairs. The first step involved the use of PCR primer pairs to detect T. pallidum. In the second step, two PCR primer pairs were constructed to identify azithromycin-resistant T. pallidum based on A2058G and A2059G point mutations. T. pallidum detected in samples from Jakarta or Bandung were not resistant to azithromycin. However, azithromycin-resistant T. pallidum were found in samples from Makassar, Medan, and Bali. Specimens from heterosexual males and patients with HIV accounted for the majority of azithromycin resistance noted in the study. This study demonstrated that the azithromycin-resistant T. pallidum detected in Indonesia appear to be a novel variant of resistance, containing both the A2058G and A2059G mutations found in Medan and Makassar.

Two Cases of Giant Molluscum Contagiosum on the Eyelids of HIV Patients Successfully Treated with Adjuvant Self-Applied Topical 20% Potassium Hydroxide Solution.

Molluscum contagiosum (MC) is an infectious disease caused by the MC virus. In human immunodeficiency virus (HIV) patients, MC has an atypical predilection and prominence, sometimes measuring more than 1 cm in diameter, known as giant MC. Giant MC lesions on the eyelids are rare. There is no standardized therapy for eyelids MC in HIV patients. Antiretroviral (ARV) administration is recommended as the primary treatment for MC in HIV patients along with other treatment modalities, such as potassium hydroxide (KOH). The 20% KOH solution is a keratolytic agent with good efficacy as MC therapy. Two cases of giant MC on the eyelids of stage 2 HIV patients with respective CD4+ of 31 cells/µL and 46 cells/µL were reported. The lesions consisted of multiple confluent papules with central umbilication, and Tzanck smear revealed Henderson-Patterson bodies. Both patients were treated with ARV and self-applied 20% KOH solution once daily. The lesions improved after four weeks of therapy in both patients with most of the lesions diminished. The successful treatment with 20% KOH solution for giant MC on the eyelids of HIV patients observed in the current study provides evidence that treatment with this solution yielded prompt results, is non-toxic, and can be self-applied.

A Successful Defect Closure After Total Excision of Seborrheic Keratoses with Atypical Clinical Presentation Using Island Pedicle Flap in an Elderly Patient.

Seborrheic keratoses (SK) are benign skin tumor characterized by well-demarcated and skin-colored to pigmented papules, plaques, or nodules with stuck-on appearance. Typical SKs are normally treated for cosmetic reasons. However, total excision and histopathological examination have to be considered in SK with unusual properties. The island pedicle flap (IPF) is a method of flap for defect closure, especially on the cheek. It has the capability to maintain the vascularization, thus it is also suitable in the elderly. We report a case of an SK with atypical clinical presentation in a 69-year-old female, with a solitary enlarging, hyperpigmented, verrucous, and bleeding tumor. The dermoscopic examination did not show characteristic features of SK. Total excision was performed due to its clinical properties. The histopathological examination revealed hyperkeratosis, acanthosis, hyperplasia, and papillomatosis, along with intercellular pseudo-horn cyst which confirmed the diagnosis of SK. The patient underwent total excision of the skin lesion which left a primary defect. We performed IPF procedure to reconstruct the defect after total excision of the skin lesion. After a year of follow-up, no meaningful complication was detected. The final result of the procedure was satisfying due to its ability to restore the natural contour and texture match by utilizing cheek laxity, without interfering the nasolabial fold. In conclusion, IPF is an appropriate method for defect closure in an elderly patient after facial total tumor excision.

A Case Series: Experience of Using 20% Potassium Hydroxide Solution to Treat Adult Sexually Transmitted Molluscum Contagiosum.

BACKGROUND: Molluscum contagiosum (MC) is a benign disease of the skin and mucous membrane caused by a poxvirus. To date, there is no standard therapy used for the treatment of MC. Using 10% of potassium hydroxide (KOH) once or twice a day and 20% KOH once a day are often applicable to MC lesions both in children and adults. Nevertheless, the usage of 20% KOH twice a day still has not been reported. PURPOSE: This case series aimed to show the efficacy and side effects of once- or twice-daily application of 20% KOH solution for MC lesions due to sexually transmitted infections (STIs) in adults. PATIENTS AND METHODS: Three cases of MC on the genital were applied once or twice daily and one case of MC on the face was applied twice daily using 20% KOH solution. RESULTS: As a result, the application of 20% KOH twice daily showed the improvement of MC lesions on the face on day 7 and MC lesions on the genital on day 20. Meanwhile, once-daily application of 20% KOH showed diminished MC lesions on genital on day 25-31 after treatment. There were tolerable side effects that occurred in this treatment, such as stinging and burning sensation several minutes after application, erosions, and post-inflammatory hypo- and hyper-pigmentation. CONCLUSION: The 20% KOH solution twice daily on MC lesions in adults is effective, practical, and inexpensive.

A Successful Treatment of Ostraceous Psoriasis Associated with Psoriatic Arthritis in Children: A Case Report.

Psoriasis may manifest as severe hyperkeratotic lesions resembling an oyster shell called ostraceous psoriasis (OP). This type of psoriasis is extremely rare and is often associated with psoriatic arthritis (PA). Cases of OP associated with PA in children have never been reported before. We reported a 9-year-old girl with hyperkeratotic lesions resembling an oyster shell all over the body accompanied with swelling on joints of both fingers, knee joints, and ankle. Histopathological examination supported the diagnosis of OP. The diagnosis of PA was established according to the Classification Criteria for Psoriatic Arthritis (CASPAR). Significant improvements of the skin lesions and joints involved were observed within 44 days after the beginning of treatment with cyclosporine and a combination of high potent topical steroid with emollient. OP associated with PA is uncommonly seen in children. High potent corticosteroid combined with emollient showed good result in skin improvement with low side effects. In addition, cyclosporine can be a good choice of systemic therapy for OP with PA in children.

Skin disorders in HIV-infected patients from West Java.

AIM: to describe the spectrum of HIV-related skin disorders as well as their prevalence and relation to CD4-cell counts among HIV-seropositive patients from West Java, Indonesia. METHODS: all HIV-positive patients presenting in 2008 at the HIV-clinic, Hasan Sadikin Hospital, were included in a cross-sectional study. Patients who had a skin complaint were examined by a dermatologist. Skin diseases were classified based on ICD 10. RESULTS: among 843 patients, 121 (14.4%) had a skin complaint, consisting of skin manifestations (73.3%), drug eruptions (30.5%), and sexually transmitted infections (15.7%), some of them had more than one diseases. The most common skin manifestations were drug eruptions, pruritic papular eruptions, seborrhoeic dermatitis, herpes zoster, dermatophytosis, and bacterial skin infections. Among patients who started nevirapine, 6.4% (95%CI: 3.9% - 8.9%) developed any kind of drug eruption, and 1.4% (95%CI 0.2%-2.6%) developed a severe drug eruption. No cases of Kaposi sarcoma, penicilliosis, eosinophilic folliculitis were seen, however one case of histoplasmosis was diagnosed. CONCLUSION: this is the first report describing the prevalence and characteristic of skin manifestation in HIV-positive in Indonesia. Indonesian physicians should be alert about HIV when patient presents with certain skin manifestations. The rate of severe drug eruptions following treatment with nevirapine is a cause of concern that needs further study.