Successful treatment of proximal white subungual onychomycosis with oral terbinafine therapy

Proximal white subungual onychomycosis [PWSO] is a rare form of onychomycosis of both fingernails and toenails. It occurs when the fungus invades the stratum corneum of the proximal nailfold followed by infection of the deeper parts of the nail plate. The surface of the overlying nail is usually normal. A case of PWSO is described with complete cure by the use of oral terbinafine 250 mg/day for 3 months continuously

Fixed drug eruption and intradermal provocation tests

To determine the role of Intradermal Provocation [IDP] tests in Fixed Drug Eruption [FDE]. Study Design: Quasi-experimental study. Place and Duration of Study: Dermatology Unit, Shaikh Zayed Hospital, Lahore, from August 2004 to July 2006. Methodology: The tests were performed in 96 patients in two stages. At stage I, suspected drugs were given intradermally. Changes at injection site in FDE lesions or any systemic effects were observed. In patients showing no response to IDP, Oral Provocation [OP] was performed [stage II] and its effects in FDE lesions or any systemic effect were observed. The positive response of FDE lesions after IDP and OP were compared with local changes at injection site. Control intradermal tests were repeated in normal persons with drugs and in FDE patients with distilled water on normal skin. At stage I, 46 positive cases had local signs of erythematous indurated nodule with or without hemorrhagic centre, urticarial weal with hemorrhagic centre and erythematous indurated nodule with central vesicle. At stage II, 41 patients had similar local signs. The changes at injection site to those of FDE lesions were compared. Z-test for proportions showed no significant difference between groups [p-value > 0.05]. Control tests were negative. The drug producing erythematous indurated nodule with or without hemorrhagic centre, vesicle or urticarial weal with hemorrhagic centre at injection site was the most likely drug causing fixed eruption

Prevalence of Hepatitis B surface antigen carrier state in patients with Lichen planus-Report of 200 cases from Lahore, Pakistan

To determine the prevalence of hepatitis B surface antigen carrier state in patients with lichen planus. A quasi experimental cross sectional study was done at Department of Dermatology, Shaikh Zayed Federal Postgraduate Medical Institute, Lahore, Pakistan, from April 2003 to March 2005. Two hundred clinically diagnosed cases of LP and equal number of patients with other dermatoses not reportedly associated with hepatitis B virus [HBV] infection [control group] were collected from Skin Out Patient Department. They were screened for hepatitis B surface antigen [HBsAg] by Enzyme Linked Immunosorbent Assay [ELISA]. Statistical analysis was done by using SPSS package version 11. Out of 200 patients of each group, three patients with LP and seven patients from control group were positive for HBsAg. The test of significance for proportions revealed that there was no significant difference [p > 0.1] between two groups. No association between HBsAg carrier state and LP was found in our study

Efficacy and safety of quasi-continuous, frequency-doubled Nd:YAG [532nm] laser therapy of port-wine stains

The quasi-continuous, frequency-doubled neodymium yttrium aluminum garnet [Nd:YAG] 532nm laser has been used for the first time in the treatment of port-wine stain [PWS]. To determine the efficacy and side effects of quasi-continuous Nd: YAG 532nm laser in the treatment of PWS. Twenty patients were enrolled in the study. The site and colour of PWS were recorded and assessed subjectively and by photography both before and after treatment. The patients had test areas treated and followed up after four weeks. Maximally eight treatments were given on any one site or until >75%improvement occurred. Final evaluation was done one month after the last treatment session on a four-point scale. Twenty patients were treated, age range 15-35 years wit 14 females. All the patients had PWS in the head and neck region and achieved >25%improvement.Patients underwent a mean of 7.55 treatment sessions. Overall, fifteen [75%] showed 75-100%improvement. The side effects seen in the study were hyperpigmentation in 65%cases, textural changes in six [30%] and eczematization after laser therapy in four [20%] of patients. Other complications included intraoperative hemorrhage and pyogenic granuloma-like lesions that occurred in two cases [10%] each. We have shown that frequency doubled Nd: YAG 532nm is effective and safe in the treatment of PWS

Topical calcipotriol versus oral psoralen-UVA [PUVA] and topical calcipotriol in thetreatment of vitiligo in type IV skin

The treatment of vitiligo is a challenging task. Several therapeutic modalities have been tried till date. Topical calcipotriol alone and in conjunction with PUVA have shown good results in various international studies in the treatment of type I and II vitiliginous skin. Our aim was to evaluate and compare the efficacy of topical calcipotriol alone and in combination with PUVA in the treatment of vitiligo in type IV skin. Sixty patients of vitiligo [26 males and 34 females], aged 12-60 years and involving < 30% of the body surface area were enrolled and randomly divided into two equal groups. Group I patients were treated with twice daily application of topical calcipotriol for six months. In group II patients, in addition to topical calcipotriol, photochemotherapy [PUVA] was advised thrice a week for the same duration. Response was graded according to the degree of repigmentation. In group I, only one sixth [16.7%] of the cases responded and all of them had less than 50% repigmentation whereas in group II, all the patients responded. Seventy percent of the cases in this group showed excellent response [> 75% of repigmentation]. We conclude that topical calcipotriol alone has no role in the treatment of vitiligo in type IV skin but when combined with PUVA leads to an excellent response in greater than two third of the patients

aetiological study of moderate to severe hirsutism

Hirsutism is a common disorder of females. Most cases are idiopathic, however some studies claim polycystic ovarian syndrome to be the commonest cause. The objective of the present study was to evaluate the etiology of moderate to severe hirsutism and to devise a rational diagnostic approach in these patients depending upon age, severity of the problem and other clinical findings. Seventy four consecutive patients with moderate to severe hirsutism [i.e. Ferriman and Gallwey score of 7 and above] were enrolled and recorded on a standard Proforma. All patients were assessed clinically with particular emphasis on signs and symptoms of virilisation. Hormonal investigation as well as abdominal and pelvic ultrasonography for adrenals and ovaries was done in all patients. Of the 74 patients 35 [47.3%] were labeled as idiopathic hirsutism, while 33 [44.6%] were diagnosed as polycystic ovary syndrome. Other causes identified were hypothyroidism [4%], Cushing"s syndrome [2.7%] and congenital adrenal hyperplasia [1.3%]. Majority of patients belonged to the age group 21-25 years. The commonest cause of hirsutism in our study was idiopathic [47.3%]. This was followed by PCOS which accounted for 44.6% of patients

Food and skin

Food is essential to keep our body healthy and in perfect harmony. The relationship between food and skin is diverse. Food can help to cure certain skin disorders but it can also trigger or aggravate various other dermatoses. This article highlights the role of different food items in dermatological disorders under various headings

Superficial chemical peeling with glycolic acid in melasma

Melasma is an acquired hyperpigmentation of exposed parts of face and neck, for which various treatment options are available. Chemical peeling is an established treatment modality for melasma. The aim of this study was to assess the safety and efficacy of glycolic acid peel in our patients with melasma where the predominant Fitzpatrick skin type is IV and V. A prospective therapeutic trial was carried out in the Department of Dermatology, Mayo Hospital Lahore Pakistan from May 1 999 to February 2000.Twenty adult females [age range 18-38 years] with melasma [epidermal n=1 5, mixed n=3, dermal n=2] were enrolled. Trial was conducted as a series of six fortnightly hospital-based peeling sessions with increasing concentration of glycolic acid [20%-50%], and nightly application of tretinoin, 5% glycolic acid and 2% hydroquinone. Patients were followed up for a period of two months after completion of treatment. The mean pre-peel and post-peel melasma area and severity index [MASI] scores were 16.56 and 3.8 respectively, showing a significant reduction of about 75% [p < 0.05]. Among the two clinical patterns seen in our patients, malar distribution responded better as compared to the centrofacial. Mild and reversible complications noted were erythema [90%], peeling [70%], crusting [55%], post-inflammatory hyperpigmentation [20%] and moist maceration [10%]. Superficial chemical peeling with glycolic acid is safe and effective treatment modality for melasma in our population

Comparative efficacy of topical calcipotriol ointment with betamethasone valerate ointment in chronic plaque psoriasis

Background: Topical steroids are an established therapy for localized psoriasis. Calcipotriol [vitamin D[3] analogue] is a relatively newer addition to the therapeutic armamentarium of psoriasis. We compared the efficacy and safety of calcipotriol 0.005% ointment and betamethasone valerate 0.1% ointment in the treatment of chronic plaque psoriasis

Patients and methods: One hundred diagnosed cases of chronic plaque psoriasis, 50 patients in each group, were enrolled in the study. Age range was 20-55 years for calcipotriol group with a mean of 33.6 years and 15-52 years for betamethasone valerate group with a mean age of 32.6 years. Male to female ratio was 1.17:1 in calcipotriol and 2.13:1 in betamethasone group. Patients in both groups were advised to apply the topical agents twice daily for 6 weeks. They were followed up at 2, 4 and 6 weeks. The assessment was made on the basis of PASI. Overall response was graded as clearance [>70% reduction in PASI], marked improvement [60-70% reduction in PASI], mild improvement [50-60% reduction in PASI], no change and worsening

Results: The mean PASI reduction in calcipotriol group was from 6.33 at week 0 to 1.90 at week 6, whereas betamethasone valerate ointment group showed a decrease in mean PASI from 6.22 at week 0 to 2.26 at the end of treatment. The scores for erythema, infiltration and desquamation at each follow-up i.e. 2, 4 and 6 weeks were comparable in both groups. All the three parameters were effectively reduced by both the topical modalities during six weeks treatment period, but the difference was not significant statistically when compared with each other [p>0.05]. Side effects were observed with both topical agents during 6 weeks of application. Most commonly observed side effects with calcipotriol were persistent lesional erythema in 10 [20%], lesional/perilesional irritation in 7 [14%], pruritus in 4 [8%] and folliculitis in 2 [4%] of the patients. Adverse events noted with betamethasone valerate ointment were atrophy in 6 [12%], folliculitis in 5 [10%], persistent erythema in 4 [8%], pruritus in 2 [4%] and lesional irritation in 1 [2%] of the patients

Conclusion: Topical calcipotriol is as efficacious and safe as betamethasone valerate in the treatment of chronic plaque psoriasis

Quality of life in vitiligo patients

Vitiligo has a considerable impact on Quality of Life [QOL], in a society, like ours with pigmented skin. Dermatology Life Quality Index [DLQI] is a simple and practical tool, which can be used to study the effect of any disease on QOL. To assess the impact of vitiligo on QOL in our patients using DLQI and to corelate DLQI score with age, sex, marital status and sites of involvement. Patients and methods One hundre d patients [52 females and 48 males] of vitiligo were enrolled in the study. Using a ten item DLQI, translated into Urdu, patients were asked to indicate how their lives had been affected over the preceding week. The mean DLQI score was 9.56 ranging from 0 to 29.The difference between mean DLQI score for males [8.17] and females [10.85] was statistically significant. Young females [n=40] had mean DLQI score of 11.2. Unmarried females [n=16] had greater impairment of QOL [mean DLQI score = 8.28]. Patients with involvement of exposed sites of body scored [mean DLQI score= 11.03] higher than patients with disease on covered parts of body. The impact of vit iligo on QOL is greater on young and unmarried females with involvement of exposed parts of body

Itraconazole pulse therapy in the treatment of disto-lateral subungual onychomycosis

To assess the efficacy of itraconazole pulse therapy in disto-lateral subungual onychomycosis. Design: Quasi interventional study. Place and Duration of Study: The study was conducted at the Department of Dermatology, KEMC/Mayo Hospital, Lahore, during the period from 1996-1998. Subjects and Sixty-seven patients, ages ranging from 19 to 55 years, with disto-lateral subungual onychomycosis were enrolled in the study period. Therapy was started with short pulse doses of itraconazole 200 mg twice daily for one week followed by a medicine-free interval of three weeks. Pulses were administered for two consecutive months in fingernail and three months for toenail onychomycosis. Patients were followed upto six months for fingernail onychomycosis and nine months for toenail onychomycosis. Out of 67 cases, there were 62 evaluable patients. Trichophyton rubrum was the most common pathogen, isolated in 42 [67.8%] followed by Candida in 11 [17.8%], T. violaceum in 5 [8%], T. interdigitale in 3 [4.8%] and Epidermophyton floccosum in one [1.6%]. Fingernails were affected in 46 cases whereas 16 had toenail infection. Clinical cure in finger and toenail onychomycosis was seen in 41 [89%] and 13 [81.2%] patients, respectively while mycological cure in 43 [93.5%] and 14 [87.5%] patients, respectively with itraconazole pulse therapy. Itraconazole was found to be effective, well-tolerated and safe therapy for disto-lateral subungual onychomycosis

Frequency of anti - HCV antibodies in patients with lichen planus

To determine the frequency of anti-HCV antibodies, identify risk factors associated with HCV infection and to screen asymptomatic carriers in patients with lichen planus. Design: A prospective study. Place and Duration of Study: This study was carried out in the out patient department of Dermatology, Shaikh Zayed Hospital, Lahore, from October, 1999 to September, 2001. Subjects and A total of 184 clinically diagnosed cases of lichen planus [LP] were selected for the study. Blood samples of all the patients were tested for anti hapatitis C virus antibodies [anti-HCV Ab]. Polymerase chain reaction for hapatitis C virus was done in patients with positive anti-HCV Ab. Transcutaneous liver biopsy was performed in 7 patients with positive HCV-RNA. The histopathological results were evaluated using validated Metavir and Knodell scoring systems. Out of 184 LP patients, 43 [23.4%] were anti-HCV antibodies positive. Females were predominantly affected and male to female ratio was 1:5.1. Maximum positivity for anti-HCV was observed in age group 31-40 years [39.53%] followed by 41-50 years [25.58%]. Eighty-one% patients had history of dental treatment and 63% had received multiple injections for various ailments. Forty% patients had family history of jaundice while 26% had jaundice in the past. Ten out of 16 anti-HCV antibody positive patients, checked for HCV-RNA, had high levels of virus in blood. Transcutaneous liver biopsy done in 7 patients revealed underlying liver disease at various stages. Four patients treated with a-interferon and ribazole therapy for liver disease, showed marked improvement in their skin disease. A high prevalence of HCV infection was detected in patients with lichen planus. Patients with lichen planus should be screened for HCV carrier state

Depression and skin disease

Skin shares a common embryological origin with brain and has a complex relationship with the mind. The emotional factors play a vital role in modulating the skin problems. Whether emotional factors play a primary pathogenic role or cause exacerbation of skin disease secondarily, is difficult to ascertain. This is an Editorial