Introduction: Subcutaneous mycosis (SM) is a fungal infection involving dermis and subcutaneous tissue, which can disseminate slowly through systemic blood or lymphatic circulation. The subacute or chronic infection usually found in workers of rural tropical and subtropical area. SM occurs due to trauma along with other predisposing factors such as sex, genetic and occupation. Aim: To identify the types of SM, its clinical findings, laboratory work-up and the treatment at the Dermatomycology Division, Department of Dermatology and Venereology dr. Cipto Mangunkusumo National Hospital between the year 1989 and 2013. Method: This retrospective study collected data from medical records and case reports of patients with SM who came at Department of Dermatology and Venereology dr. Cipto Mangunkusumo National Hospital (1989-2013). Results: We found 16 cases of SM, i.e. subcutaneous mucormycosis (5 cases), eumycetoma (4 cases), actinomycetoma (4 cases) and chromoblastomycosis (3 cases). There was a greater number of male than female patients ratio (3:1) and mostly were in the age group of 25-44 years. The direct microscopic examination did not reveal any fungal element, except for black spora in chromoblastomycosis (1 case). The culture revealed Basidiobolus ranarum in subcutaneous mucormycosis (5 cases), Nocardia transvalensis in actinomycetoma (1 case) and Phialophora sp. in 1 case of chromoblastomycosis. On histopathological examination, we found fine granules of actinomycetoma, sulphuric granules of actinomycetoma, coenocytic hyphae of subcutaneous mucormycosis, eosinophilic granule in 1 case of mycetoma and hyphae with black spore in chromoblastomycosis. Conclusion: SM is still a rare disease, comprehensive management of SM needs supporting laboratory work-up, particularly the histopathological examination.

The use of dermoscopy in non-pigmented skin disorders includes dermoscopy as a diagnostic tool for non-pigmented skin tumors, inflammatory diseases (inflammoscopy) and/or infectious disease (entomodermoscopy), lesions on nail fold and as a tool to monitor skin reaction as a response to treatment and/or side effect. The diagnosis becomes easier, faster and less expensive with dermoscopy without the need for invasive procedures. Knowledge on vascular pattern and its architectural arrangement; which is coupled with additional dermoscopic features, can aid clinicians to the diagnosis. Dermatoscopy can also predict, monitor and evaluate therapeutical response and/or side effect of skin disorders. Nonetheless, dermoscopy has its limitations. Many of various non-pigmented disorders have more specific clinical features than dermoscopic ones, for clinicians to rely on to establish a diagnosis.

Disability is one of problems in leprosy or Morbus Hansen (MH), which can cause the patient loose his autonomy and may affect his social relationship with family and community. Disability occurs due to neurological inflammation that can manifest as silent neuritis (which develops without any pain). Silent neuritis can be recognized early with a routine prevention of disability (POD) assessment. A 19-year-old male patient was referred from a District General Hospital with a history of numbness and stiffness of his 4th and 5th fingers of his left hand since 1 month before admittance. The patient was refered by Community Health Center (CHC or PUSKESMAS) after a one year treatment and RFT. During his treatment at the CHC, no assessment of peripheral nerve or POD had ever been performed. The POD assessment at our hospital demonstrated sensory deficit at some points of assessment on both palms and reduced muscle strength of the first and 5th fingers in both hands. Nerve conduction velocity (NCV) performed at the outpatient of Neurology Department, showed multiple mononeuropathy MH with irreversible damage. Nerve damage is still considered reversible when it occurs less than 6 months. In this case, the silent neuritis was not detected early and there was delayed treatment; as showed by NCV which revealed a manifestation of irreversible nerve damage. Routine POD assessment may detect the condition and appropriate treatment may overcome the nerve damage.

Atopic dermatitis (AD) is a recurrent skin inflammation accompanied by itching. The incidence of AD is increasing worldwide. AD, which persists until elderly or with an onset during elderly, is known as senile AD. It has different prevalence and clinical features from other AD stages. Senile atopic dermatitis affects males more than females, which is different from other stages of AD. Skin manifestation of senile AD is similar with the adult stage of Hanifin-Rajka criteria, but can be atypical. The typical feature of senile AD is eczematous dermatitis around a free-lesion fossa. Other common clinical manifestations are erythroderma and non-specific chronic dermatitis. In the management of senile AD, changes related to aging process should be considered. Management of senile AD is complex, involves combined pharmacological treatment consists of topical and systemic agents, and nonpharmacological aspects. Appropriate treatment considering effectiveness and safety will improve the quality of life of patients with senile AD.

Atypical mycobacterial (AM) infection is caused by Mycobacterium species other than M.tuberculosis. AM skin infection has clinical manifestations that resemble M. tuberculosis infection and deep fungal infection. Laboratory workup is necessary to confirm the diagnosis. An 83-year old female came with a painful lump and swelling on her right lower extremity since three months before admission. Physical examination revealed a plaque consisting, of multiple erythematous and hyperpigmented papules and nodules, diffuse erythematous lesion, and shallow ulcers partially covered with pus and crust. Histopathological features showed tuberculoid granuloma. Direct test and periodic acid-Schiff (PAS) staining of the skin biopsy found no fungal element nor acid-fast bacilli (AFB). Culture and polymerase chain reaction (PCR)of M. tuberculosis were negative. The working diagnosis was atypical mycobacterial infection and treatment with 450 mg rifampicin and 100 mg minocycline daily were administered accordingly. In two months observation following the treatment, the pain was no longer exist, the ulcers were completely healed, and some nodules were in the process of healing Among other Mycobacterium spp, M.marinum is the most common cause of AM infrections. Clinical manifestation of M. marinum infection may present as solitary or multiple nodules on the hands, feet, elbows and knees with sporotrichoid spreading patern. The diagnosis of AM was established based on clinical and laboratory examination. The diagnosis was also confirmed by good clinical response to minocycline and rifampicin.

Vulvar lymphangioma is a rare case and often being misdiagnosed as genital wart. This acquired disorder manifests as dilatation of superficial lymph vessel due to obstruction. It is caused by urogenital infection and most often occurs following surgery and radiotherapy of cervical cancer. The diagnosis is established based on clinical and histopathological features. Treatment aimed to eliminate the cause of obstruction. This article reports two cases of vulvar lymphangioma found in our Hospital. First case was a 43-year-old female with a history of surgery and radiation for cervical cancer 10 years ago presented with vesicular skin lesion in genital area, oozing copious clear fluid since 4 years ago. There are multiple lenticular vesicles containing clear fluid in vulvar area accompanied with bilateral lymphedema of lower extremities. Histopathological features demonstrated dilated superficial lymph vessels. Second case was a 44-year-old female with enlargement of lower abdomen with vesicular lesion containing clear fluid in genital area since 3 years ago. Abdominal USG showed enlarged inguinal lymph node. Histopathological features demonstrated dilated superficial lymph vessels. The treatment for both cases were gradual electrosurgery. In both cases, vulvar dermis’ superficial lymph node dilatation caused the skin lesions. Obstruction of lymph vessel due to radiation and surgery for cervical cancer in the first case and of inguinal lymph node in the second case lead to increased lymphatic pressure in the dermis and later on the dilatations. The treatment in both cases using electrical excision produced good responses; however, we should be attentive on recurrent case.

Occupational skin cancer and precancerous lesions are skin disorders caused by exposure to chemical carcinogens such as polycyclic hydrocarbons and arsenic, or radiation, such as ultraviolet light and ionizing light in the workplace. Annual increase in skin cancer incidence is believed to be related to various factors such as frequent intense sunlight exposure (i.e. at work, recreational activities, and sun-tanning habit), ozone depletion, an increase in number of geriatric population, and an increase of public awareness in skin cancer. The most common occupational skin cancers are basal cell carcinoma, squamous cell carcinoma, and melanoma. Examples of occupational precancerous lesion of the skin are actinic keratosis and Bowen’s disease. Particular diagnostic criteria to diagnose occupational diseases has been developed. Early detection of occupational skin cancer and precancerous lesion is necessary. An effective prevention program consists of primary prevention such as prevention of hazardous material exposure, secondary prevention such as early detection of disease for early intervention, and tertiary prevention such as minimizing long-term impact of the disease.

Introduction: Subcutaneous mycosis (SM) is a fungal infection involving dermis and subcutaneous tissue, which can disseminate slowly through systemic blood or lymphatic circulation. The subacute or chronic infection usually found in workers of rural tropical and subtropical area. SM occurs due to trauma along with other predisposing factors such as sex, genetic and occupation. Aim: To identify the types of SM, its clinical findings, laboratory work-up and the treatment at the Dermatomycology Division, Department of Dermatology and Venereology dr. Cipto Mangunkusumo National Hospital between the year 1989 and 2013. Method: This retrospective study collected data from medical records and case reports of patients with SM who came at Department of Dermatology and Venereology dr. Cipto Mangunkusumo National Hospital (1989-2013). Results: We found 16 cases of SM, i.e. subcutaneous mucormycosis (5 cases), eumycetoma (4 cases), actinomycetoma (4 cases) and chromoblastomycosis (3 cases). There was a greater number of male than female patients ratio (3:1) and mostly were in the age group of 25-44 years. The direct microscopic examination did not reveal any fungal element, except for black spora in chromoblastomycosis (1 case). The culture revealed Basidiobolus ranarum in subcutaneous mucormycosis (5 cases), Nocardia transvalensis in actinomycetoma (1 case) and Phialophora sp. in 1 case of chromoblastomycosis. On histopathological examination, we found fine granules of actinomycetoma, sulphuric granules of actinomycetoma, coenocytic hyphae of subcutaneous mucormycosis, eosinophilic granule in 1 case of mycetoma and hyphae with black spore in chromoblastomycosis. Conclusion: SM is still a rare disease, comprehensive management of SM needs supporting laboratory work-up, particularly the histopathological examination.

The use of dermoscopy in non-pigmented skin disorders includes dermoscopy as a diagnostic tool for non-pigmented skin tumors, inflammatory diseases (inflammoscopy) and/or infectious disease (entomodermoscopy), lesions on nail fold and as a tool to monitor skin reaction as a response to treatment and/or side effect. The diagnosis becomes easier, faster and less expensive with dermoscopy without the need for invasive procedures. Knowledge on vascular pattern and its architectural arrangement; which is coupled with additional dermoscopic features, can aid clinicians to the diagnosis. Dermatoscopy can also predict, monitor and evaluate therapeutical response and/or side effect of skin disorders. Nonetheless, dermoscopy has its limitations. Many of various non-pigmented disorders have more specific clinical features than dermoscopic ones, for clinicians to rely on to establish a diagnosis.

Atypical mycobacterial (AM) infection is caused by Mycobacterium species other than M.tuberculosis. AM skin infection has clinical manifestations that resemble M. tuberculosis infection and deep fungal infection. Laboratory workup is necessary to confirm the diagnosis. An 83-year old female came with a painful lump and swelling on her right lower extremity since three months before admission. Physical examination revealed a plaque consisting, of multiple erythematous and hyperpigmented papules and nodules, diffuse erythematous lesion, and shallow ulcers partially covered with pus and crust. Histopathological features showed tuberculoid granuloma. Direct test and periodic acid-Schiff (PAS) staining of the skin biopsy found no fungal element nor acid-fast bacilli (AFB). Culture and polymerase chain reaction (PCR)of M. tuberculosis were negative. The working diagnosis was atypical mycobacterial infection and treatment with 450 mg rifampicin and 100 mg minocycline daily were administered accordingly. In two months observation following the treatment, the pain was no longer exist, the ulcers were completely healed, and some nodules were in the process of healing Among other Mycobacterium spp, M.marinum is the most common cause of AM infrections. Clinical manifestation of M. marinum infection may present as solitary or multiple nodules on the hands, feet, elbows and knees with sporotrichoid spreading patern. The diagnosis of AM was established based on clinical and laboratory examination. The diagnosis was also confirmed by good clinical response to minocycline and rifampicin.

Atopic dermatitis (AD) is a recurrent skin inflammation accompanied by itching. The incidence of AD is increasing worldwide. AD, which persists until elderly or with an onset during elderly, is known as senile AD. It has different prevalence and clinical features from other AD stages. Senile atopic dermatitis affects males more than females, which is different from other stages of AD. Skin manifestation of senile AD is similar with the adult stage of Hanifin-Rajka criteria, but can be atypical. The typical feature of senile AD is eczematous dermatitis around a free-lesion fossa. Other common clinical manifestations are erythroderma and non-specific chronic dermatitis. In the management of senile AD, changes related to aging process should be considered. Management of senile AD is complex, involves combined pharmacological treatment consists of topical and systemic agents, and nonpharmacological aspects. Appropriate treatment considering effectiveness and safety will improve the quality of life of patients with senile AD.

Disability is one of problems in leprosy or Morbus Hansen (MH), which can cause the patient loose his autonomy and may affect his social relationship with family and community. Disability occurs due to neurological inflammation that can manifest as silent neuritis (which develops without any pain). Silent neuritis can be recognized early with a routine prevention of disability (POD) assessment. A 19-year-old male patient was referred from a District General Hospital with a history of numbness and stiffness of his 4th and 5th fingers of his left hand since 1 month before admittance. The patient was refered by Community Health Center (CHC or PUSKESMAS) after a one year treatment and RFT. During his treatment at the CHC, no assessment of peripheral nerve or POD had ever been performed. The POD assessment at our hospital demonstrated sensory deficit at some points of assessment on both palms and reduced muscle strength of the first and 5th fingers in both hands. Nerve conduction velocity (NCV) performed at the outpatient of Neurology Department, showed multiple mononeuropathy MH with irreversible damage. Nerve damage is still considered reversible when it occurs less than 6 months. In this case, the silent neuritis was not detected early and there was delayed treatment; as showed by NCV which revealed a manifestation of irreversible nerve damage. Routine POD assessment may detect the condition and appropriate treatment may overcome the nerve damage.

Vulvar lymphangioma is a rare case and often being misdiagnosed as genital wart. This acquired disorder manifests as dilatation of superficial lymph vessel due to obstruction. It is caused by urogenital infection and most often occurs following surgery and radiotherapy of cervical cancer. The diagnosis is established based on clinical and histopathological features. Treatment aimed to eliminate the cause of obstruction. This article reports two cases of vulvar lymphangioma found in our Hospital. First case was a 43-year-old female with a history of surgery and radiation for cervical cancer 10 years ago presented with vesicular skin lesion in genital area, oozing copious clear fluid since 4 years ago. There are multiple lenticular vesicles containing clear fluid in vulvar area accompanied with bilateral lymphedema of lower extremities. Histopathological features demonstrated dilated superficial lymph vessels. Second case was a 44-year-old female with enlargement of lower abdomen with vesicular lesion containing clear fluid in genital area since 3 years ago. Abdominal USG showed enlarged inguinal lymph node. Histopathological features demonstrated dilated superficial lymph vessels. The treatment for both cases were gradual electrosurgery. In both cases, vulvar dermis’ superficial lymph node dilatation caused the skin lesions. Obstruction of lymph vessel due to radiation and surgery for cervical cancer in the first case and of inguinal lymph node in the second case lead to increased lymphatic pressure in the dermis and later on the dilatations. The treatment in both cases using electrical excision produced good responses; however, we should be attentive on recurrent case.