Comparison of efficacy of combination of 2 percent Ketoconazole solution wash and topical 1 percent clotrimazole with topical 1percent Clotrimazole alone in C

Objective: Comparison of efficacy of combination comprising 2 percent ketoconazole solution wash plus topical 1 percent clotrimazole versus topical 1 percent clotrimazole alone in management of patients with Pityriasis versicolor

Study Design: Randomized controlled trial

Place and Duration of Study: Dermatology department, Pak Emirates Military Hospital Rawalpindi, from Oct 2016 to Apr 2017

Material and Methods: Sixty patients of Pityriasis versicolor, both male and female were included in study. Diagnosis of Pityriasis versicolor was made clinically and confirmed microscopically by examining skin scrapings for fungal hyphae. Patients with concomitant systemic illnesses or those who had received anti-fungal in last three months were excluded from study. Random number tables were used to allocate patients to the two treatment groups. Group A received 2 percent ketoconazole shampoo twice per week for four weeks plus topical 1 percent clotrimazole twice daily application for 2 weeks. Group B received only topical therapy with 1 percent clotrimazole cream applied twice daily for 2 weeks. Assessment of treatment efficacy was done by clinical examination of patient and microscopy of skin scrapping for fungal hyphaedone at baseline and at end of study [4 weeks of treatment]. A negative clinical examination and negative skin scrapping for fungal hyphae was considered effective therapeutic response

Results: In group A, the mean age of patients was 29.76 +/- 8.89 years and in group B was 27.67 +/- 10.46 years. Efficacy in group A was observed in 22 [73.33 percent] patients while in group B in 14 [46.67 percent] patients

Conclusion: Combination of 2 percent ketoconazole solution wash plus topical 1 percent clotrimazole was found more effective in treatment of patients with Pityriasis versicolor as compared totopical 1 percent clotrimazole alone

Squamous cell carcinoma arising in background of mature cystic teratoma

Mature cystic teratoma of ovary is a common benign adnexal tumor in females. Malignant transformation in a mature cystic teratoma of the ovary occurs in only 1 - 2% of cases. Most common malignant transformation is squamous cell carcinoma [70-80% of cases], occurring mostly in postmenopausal women with large sized cysts. Here, we report a case of 46-year lady who presented with pain in lower abdomen. Ultrasound and CT scan revealed complex adnexal mass measuring 16x9 cm. Size and older age of the patients should be regarded as important predictors of malignant transformation in mature cystic teratoma. Adequate sampling followed by histopathological examination has important role in diagnosis of such rare tumor

Views and practices of dermatologists regarding preventable skin diseases

To find out views and practice of dermatologists regarding prevention of preventable skin diseases. Cross-sectional study. The study was set up in Apr-May 2010 at PAF Hospital Faisal, Karachi, Pakistan. A close-ended questionnaire was sent to 100 dermatologists through resource persons at different places throughout the country. It included basic information about them, their views and practice regarding prevention of these diseases. Data was managed and analyzed using SPSS-17. Fifty dermatologists thought that frequency of preventable skin diseases in their clinical practice is 26-50%. Fifty-six observed educated community as the most important link for prevention, 46 held governments responsible and 42 consider busy schedule as barrier to educate community. Thirty dermatologists delivered talk to general public, 11 at schools, colleges and factories, 07 appeared on mass media and 08 prepared leaflets, pamphlets and brochures regarding preventive aspects of skin diseases at least once during last one year. Dermatologists in Pakistan are aware of magnitude of the problem and understand importance of public education; however only a few dermatologists have endeavored to take up this task

Real time and accelerated stability studies of tetanus toxoid manufactured in public sector facilities of Pakistan

Tetanus is an acute illness represented by comprehensive increased inflexibility and spastic spasms of skeletal muscles. The poor quality tetanus toxoid vaccine can raise the prevalence of neonatal tetanus. WHO has taken numerous steps to assist national regulatory authorities and vaccine manufacturers to ensure its quality and efficacy. It has formulated international principles for stability evaluation of each vaccine, which are available in the form of recommendations and guidelines. The aim of present study was to ensure the stability of tetanus vaccines produced by National Institute of Health, Islamabad, Pakistan by employing standardized methods to ensure constancy of tetanus toxoid at elevated temperature, if during storage/transportation cold chain may not be maintained in hot weather. A total of three batches filled during full-scale production were tested. All Stability studies determination were performed on final products stored at 2-8 Degree C and elevated temperatures in conformance with the ICH Guideline of Stability Testing of Biological Products. These studies gave comparison between real time shelf-life stability and accelerated stability studies. The findings indicate long-term thermo stability and prove that this tetanus vaccine can remain efficient under setting of routine use when suggested measures for storage and handling are followed in true spirit

Multiple disseminated pyogenic granulomas

Pyogenic granulomas [Granuloma telengiectaticum] or tabular capillary haemangioma are classically described as solitary lesions, occurring in young individuals, usually at the site of previous trauma, with a tendency to recur after treatment. We describe an unusual case of multiple disseminated pyogenic granulomas in an elderly male caucasoid of Pakistani origin in whom more than 400 lesions occurred de novo without any antecedent history of trauma or skin disease, responded well to treatment and showed no tendency for recurrence. Multiple eruptive pyogenic granulomas are probably a rare subset of the disease, which can occur at any age, arise de novo or in association with a skin or systemic disease and do not exhibit a tendency to recur after treatment

Adherence of chronic dermatology patients to prescriptions and non-medicinal instructions

To determine frequency of adherence of dermatology patients having chronic diseases to prescriptions and non-medicinal instructions. The study was conducted at dermatology out-patient department of PAF Hospital Faisal, Karachi from July 2009 to September 2009. Patients included those having skin disease of over 6 months duration and visiting hospital repeatedly. A specially designed pro forma was filled for each patient. It included demographic profile and questions regarding written prescription, non-medicinal instructions and follow up dates by the dermatologist and whether patients understood and followed the prescription and non-medicinal instructions and having regular follow ups. Computer program SPSS-15 was used to manage and analyze the data. Of 160 patients, 91 [56.9%] were males and 69 [43.1%] females. Patients' age was 1-90 years [mean 33.08+18.72 years]. Prescription was clearly written for 94 [58.8%] and 84 [52.5%] understood the prescription. Ninety five [59.4%] patients took medicines regularly and in correct dosages and 43 [26.9%] observed non-medicinal instructions. Forty [25.0%] patients were given follow up date in writing and 71 [44.37%] were re-visiting clinic regularly. A considerable number of patients having chronic dermatological diseases are not adhering to the prescriptions and non-medicinal instructions

Clinical pattern of vitiligo

All new cases of vitiligo reporting to Dermatology Outpatient of Combined Military Hospital, Panu Aqil, were included in the study. Of the 230 patients, 124 were male [53.9%] and 106 were female [46.1%]. Males were more commonly affected. The disease affected all age groups. Mean age at presentation was 27.02 +/- 18.34 years and age at presentation ranged from 5.5 months to 82 years. The mean age at onset was 22.03 +/- 16.97 years with majority 30.4% [n=70], developing vitiligo in first decade of life. Generalized vitiligo was the most common type [n=132, 57.4%] followed by focal [n=53, 23%] and aero-facial vitiligo [n=16, 7%]. Head and neck was the most common initial site of onset [n=100, 43.48%]. Koebner phenomenon was observed in 72 patietns [31.3%], family history was present in 64 patients [27.8%] and 16 patients [7%] had associated diseases

Harlequin ichthyosis in two siblings

Harlequin ichthyosis is a rare and extremely severe form of congenital ichthyosis. The affected neonates usually do not survive beyond first few days after birth, but several long-term survivals have been noted. The inheritance is thought to be autosomal recessive. It has recently been shown that the vast majority of affected individuals are homozygous for mutations in the ABCA12 gene, which cause a deficiency of the epidermal lipid transporter and result in hyperkeratosis and abnormal barrier function. Prenatal diagnosis is possible. We report a case of a newborn with Harlequin ichthyosis, a product of consanguineous marriage, with a history of similar disease leading to early neonatal death previously in a sibling

Paraneoplastic Addisonian pigmentation and acquired ichthyosis as presenting features of multiple myeloma

Black brown hyperpigmentation of the mucosae, sunexposed skin, palmar creases and frictional sites [Addisonian pigmentation] is characteristic of Addison disease. However, it can also occur as a paraneoplastic manifestation of tumours like bronchogenic carcinoma. Acquired ichthyosis starts later in life and can also be a paraneoplastic presentation.We report a unique combination of paraneoplastic Addisonian pigmentation and acquired ichthyosis as presenting features in a patient with undiagnosed multiple myeloma. To the best of our knowledge this combination of paraneoplastic dermatosis has not been documented before in multiple myeloma. It is concluded that the presence of more than one suspicious dermatosis may be an indicator of being paraneoplastic requiring necessary work-up

Second opinion and discrepancy in the diagnosis of soft tissue lesions at surgical pathology.

Objective: To determine the frequency and magnitude of discrepancies in the surgical pathological diagnosis of soft tissue lesions on review and second opinion in a histopathology center. Study Design: Cross-sectional, observational. Place and Duration of Study: Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, from April 2006 to May 2007. Materials and Methods: All the cases of soft tissue as well as bone lesions, irrespective of age and gender, which were referred for second opinion or review after being reported elsewhere, were included in the study. A panel of antibodies of soft tissue, epithelial and lymphoid markers was applied according to the requirements of each case. The cases were categorized as category A where there was concurrence between initial diagnosis and diagnosis at review. Category B included cases where there was disagreement in the specific diagnostic entity as per WHO classifications without therapeutic implications. Category C was cases where the category of benign or malignant diagnosis remained the same but there was disagreement in the specific diagnosis with definite therapeutic implications. Category D had diagnosis of benign changed to malignant while category E had cases where diagnosis of malignancy was changed to a benign lesion. Results: During the study period, 34 cases of soft tissue lesions were received for review and second opinion. The mean age of the patients was 39 ΁ 22 years and immunohistochemistry was performed in 21 (62%) of 34 cases. Concurrence between the review and initial diagnosis was seen in 18 (53%) cases (category A). Discrepancy in the diagnosis at review and initial consultation was seen in 16 (47%) cases. There were four (11.8%) cases that were placed in category B as the diagnosis of benign and malignant remained the same but the specific diagnostic entity was changed. Category C included eight (23.5%) cases where the review diagnosis changed the therapeutic modality despite the benign or malignant category remaining unchanged. All the cases in this category required immunohistochemistry as diagnosis of metastatic carcinoma was changed to sarcoma in two cases and diagnosis of sarcoma was changed to carcinoma in three cases. There was only one (2.9%) case in category D where a benign diagnosis was changed to malignant on review and three (8.8%) cases reported as malignant had a revised diagnosis of benign lesion, placing them in category E. Conclusion: In the absence of a quality assurance regulatory body to monitor and overlook the professional competence of practicing surgical pathologists, a mandatory review and second opinion should be undertaken whenever a major therapeutic endeavor is to be undertaken, regardless of the cost for the ultimate benefit of the patient.

Treatment of toxic epidermal necrolysis [TEN] with low dose intravenous immunoglobulin in child

Stevens-Johnson syndrome [SJS] and toxic epidermal necrolysis [TEN, LyeII's disease] are severe, episodic, acute mucocutaneous reaction that may be caused by various factors particularly drugs. Treatment is primarily supportive care and there are no specific therapy regimens. Intravenous immunoglobulin [IVIG] has recently been shown to be a useful and safe therapy in paediatric patients with SJS/TEN, though no such case has so far been reported from Pakistan. The authors report the experience with low dose IVIG [0.1 g/kg/day for four consecutive days for treating a 3 years old boy with toxic epidermal necrolysis with favourable outcome without early complications

Non-dermatophyte moulds and yeasts as causative agents in onychomycosis

Although dermatophytes are the most common pathogens of onychomycosis, yeasts and non-dermatophyte moulds can also be found as causative agents. To find out relative frequency of non-dermatophyte moulds and yeasts as causative agents in onychomycosis. Forty patients of all age groups and either sex suffering from onychomycosis were subjected to fungal cultures. Demographic and clinical features of the patients were recorded. Nail scrapings were inoculated on fungal culture media and growth pattern studied. Out of 40 patients, eight [16%] were positive for fungal culture. Amongst culture positive cases 4 [50%] were dermatophytes, all of them belonging to genus trichophyton, whereas 2 [25%] were positive for Candida spp. and 2 [25%] were positive for non-dermatophyte moulds belonging to Scopulariopsis spp. and Aspergillus spp. each. Dermatophytes remain the most common cause, but the role of yeasts and nondermatophye moulds should receive due consideration in a case of onychomycosis

study of Pakistan hajj medical mission in comparison with six other medical missions during 2008

To describe constitution, capabilities and functioning of Pakistan Hajj Medical Mission [Pak HMM] in comparison with six other medical missions during Hajj-2008. A comparative cross-sectional study. Pak HMM Hospital, Makkah Mukarramah over a period of 06 weeks during Hajj season-2008. Besides Pakistan, six other medical missions were visited and their heads requested to answer a specially designed questionnaire prepared in English. Constitution, capabilities and functioning of Pak HMM was compared with other missions. Data was managed and analyzed using computer programme SPSS-10. Pak HMM was selected 12 weeks, whereas other missions were selected 06-24 weeks [mean=16.33+8.62] prior to Hajj season [p=0.66]. The doctor: hajj ratio at Pak HMM was 1:1650, whereas it was 1:180-1:2188 [mean =1:807.16+708.56] at other missions [p=0.32]. during peak days, average daily out-patient attendance of Pak HMM was 6000, whereas it was 2000-4000 [mean = 2833.33 + 816.49] at other missions [p=0.016]. Six [85.71%] medical missions including Pak HMM had indoor facilities, routine diagnostic facilities and were able to perform minor surgical procedures under local anaesthesia. Number of fully equipped ambulances for critical evacuation of patients in Pak HMM was none whereas in other missions, it ranged from 0 to 16 [mean = 6.33+ 7.45]. Pak HMM is neither selected well in time nor involved in pre-Hajj medical assessment of the intending hujjaj. Although Pak HMM provides health care facilities to Pakistani hujjaj to the best of its capabilities, its indoor facilities, selection and utilization of specialists doctors as well as trained staff and ambulance evacuation of critically sick patients are not adequate

Onset of chilblains in relation with weather conditions

Chilblains or perniosis is a moderately severe form of cold injury, localized to peripheral parts of the body, which occurs after exposure to non-freezing temperatures and damp conditions. Although inter-individual variations exist with respect to susceptibility to develop chilblains, no study has been carried out in this region to determine the role of different weather conditions either alone or in combination, in predisposing the susceptible individuals to chilblains. The objective of this study was to determine the relationship between weather conditions and onset of chilblains at a moderately cold weather station. This study was conducted at the Department of Dermatology, Combined Military Hospital, Abbottabad, from Dec 2004 to Mar 2005. All patients fulfilling the clinical criteria for diagnosis of chilblains were included in the study. These patients were interviewed and examined thoroughly. A specially designed proforma was filled for each patient separately. Meteorological department was contacted for record of weather conditions. Onset of chilblains in each patient was related with weather conditions of that particular month. Computer programme SPSS 10 was used for statistical analysis. Out of 111 patients, 67 [60.4%] were males and 44 [39.6%] were females. Eighty nine [80.2%], 90 [81.1%] and 90 [81.1%] patients had onset in relation with lower temperature [<10 °C], relatively low atmospheric pressure [<1500 kpa] and higher relative humidity [>60%] respectively. There was statistically significant relationship of weather conditions with onset of chilblains when different groups, i.e., elderly and young, males and females, locals and non locals, outdoor workers and those remaining inside most of the time and those having disease of longer or shorter duration were compared. The cold weather conditions that can be endured by humans depend on combination of the duration and the extent of the exposure, in addition to physiological adaptive changes. However, susceptibility to chilblains increases when ambient temperature is less than 10°C and relative humidity is more than 60%. Elderly, females, outdoor workers and those having chronic or recurrent episodes of chilblains are less tolerant to cold weather and develop the disease under lesser ambient cold

Onest of adult varicella in relation to rural or urban origin and its complications

To determine area of origin of adult varicella patients, whether rural or urban, to compare the mean interval between leaving the area of origin and onset of varicella in adults of rural origin in comparison with those of urban origin and to observe its complications. A cross-sectional study. Combined Military Hospital, Abbottabad, from January to December 2006. All patients over the age of 18 years, presenting with acute illness clinically, suggestive of varicella were included in the study. A specially designed proforma was filled for each patient separately, which included demographic features as well as area of origin, whether rural or urban, and the age at which they left the area of origin. These patients were examined, treated and assessed clinically on regular basis for the progress of the disease as well as for its possible local or systemic complications. Data analysis was done by using statistical programme SPSS-10. Out of 9155 adult patients, 156 [1.70%] had varicella, including 128 [82.1%] males and 28 [17.9%] females. Origin was rural in 125 [80.1%] and urban in 31 [19.9%] patients. Mean interval between leaving area of origin and developing varicella in those of rural origin was 01.79+01.78 years and that in patients of urban origin was 03.37+05.72 years [p+0.009]. None of the patients developed any complication of the disease. Varicella in adults is generally a benign illness. It is more common among adult males of rural origin and the interval between leaving the area of origin and onset of varicella in these patients is significantly less as compared to that in adults of urban origin

Localized lesions in secondary syphilis

The clinical manifestations of secondary syphilis are variable and can mimic many skin diseases, mostly being generalized and symmetrical in distribution. Localized lesions of secondary syphilis are rarely seen in dermatology clinics. We report an unusual presentation wherein a patient had localized lesions over face and soles only. There is a need for increased awareness on the part of physicians to recognize new patterns of syphilitic infection, together with a willingness to consider the diagnosis of syphilis in patients with unusual clinical features

Outbreak of cutaneous leishmaniasis in Somniani, Balochistan - implementation of preventive measures for deployed personnel of armed forces

To evaluate the number of cutaneous leishmaniasis [CL] cases reporting from Somniani between years 2001 to 2005 and to explore the preventive measures being used against sandfly bite. This observational study was conducted at the dermatology department of Combined Military Hospital, Malir Cantonment, Karachi from January 2001 to December 2005. Between year 2001 and 2005, suspected cases of CL reporting from Somniani, Balochistan were identified, evaluated, diagnosed and included in this study. Diagnosis was based on clinical examination, slit skin smear for detection of Leishman-Donovan [LD] bodies and skin biopsy for histopathology. Patients were then asked to fill a structured, anonymous, self-administered and close ended questionnaire which included questions about the use of various preventive measures against cutaneous leishmaniasis. A total of 108 patients were diagnosed as CL from Somniani during the study period. The peak was seen in year 2004 [n=58] which coincided with increased troop activity in the area. Nodulo-ulcerative lesions were the commonest mode of presentation. Skin biopsy for histopathology was the most effective method of diagnosis. Overall only 28% personnel were using preventive measures against sand fly bite. Only 15% personnel had disease awareness. Lack of application of preventive measures and knowledge of disease were the reasons for increase in CL cases

clinical study of papular urticaria

To determine the clinical features and demographic profile of the patients having papular urticaria. A case-series. Dermatology Department of Combined Military Hospital, Abbottabad from January to December 2006. Individuals of all age groups and either gender either suspected of or having definite history of insect bite were included in the study. A specially-designed proforma was filled for each patient separately. The proforma included demographic features, information regarding clothing and sleeping habits, personal or family history of atopy and clinical patterns of the lesions. Computer programme SPSS 10 was used to manage and analyze the data. Out of 280 patients, 201 [71.8%] were children upto 12 years of age, 178 [63.6%] were males, 91[32.5%] had atopy, 194 [69.3%] were non-locals, 212 [75.7%] came from urban/pen-urban areas and 173 [61.8%] presented during May-August. Lesions were present over exposed parts of the body in 36 [12.9%], arranged in groups in 152 [54.3%] and were papular urticaria in 185 [66.1%] patients. Children, adult males, non-locals and those belonging to urban/peri-urban areas are more vulnerable to papular urticaria in a particular region. Papular and urticarial lesions arranged in groups over both exposed as well as covered body parts of a single patient is the most common clinical pattern