An evaluation of the early effects of a combination antiretroviral therapy programme on the management of AIDS-associated Kaposi's sarcoma in KwaZulu-Natal, South Africa.

Roll-out of combination antiretroviral therapy (cART) in South Africa should impact on AIDS-associated Kaposi's sarcoma (KS). Government provision began in 2003, with 23% coverage for World Health Organization (WHO) stage IV AIDS in 2006. To assess the effect of cART availability on KS management, we evaluated records from 701 KS patients seen at a tertiary oncology centre in KwaZulu-Natal, South Africa, from 1995 to 2006. Associations between cART use and measures of KS care were evaluated. cART availability was 0% prior to 2001, 9.6% (2001-2003) and 44% (2004-2006). Documentation of HIV status increased incrementally from 65% to 92%. cART was associated with chemotherapy administration: 56% on cART versus 17% not on cART (P < 0.001); and less loss to follow-up, 13% on cART versus 38% not on cART (P < 0.001). cART availability improves the care of AIDS-associated KS. Further increases in cART availability for this population are needed in South Africa.

Guideline on the management of psoriasis in South Africa.

UNLABELLED: BACKGROUND; Psoriasis vulgaris is a chronic, relapsing, immune-mediated, potentially devastating disease, influenced by genetic and environmental factors, that can cause substantial morbidity and psychological stress and have a profound negative impact on patient quality of life. OBJECTIVE: These guidelines for the management of psoriasis have been developed in an attempt to improve the outcomes of treatment of this condition in South Africa. Psoriasis has a major impact on the quality of life of sufferers, and it is expected that these guidelines, if implemented, will play a role in achieving improved outcome. SCOPE: These guidelines were developed to address the diagnosis and treatment of psoriasis, of differing degrees of severity and in patients of all ages, by all health care professionals involved with its management. RECOMMENDATIONS: All health care workers involved in the management of psoriasis should take note of these guidelines and try to implement them in clinical practice as far as possible. All treatment methods and procedures not substantiated by evidence from the literature should be discontinued and avoided to decrease the financial burden of psoriasis treatment. VALIDATION: These guidelines were developed through general consensus by a group of 8 South African dermatologists (the 'Working Group') sanctioned by the Dermatological Society of South Africa (DSSA), by adaptation for the South African situation of the current guidelines used in the USA, the UK, Germany, Canada and Finland. Draft documents were made available for comment to the dermatological community as a whole via the official website of the DSSA, and the guidelines were presented and discussed at the annual congress of the DSSA in 2008. All input from these sources, where appropriate, were then incorporated into these guidelines. GUIDELINES SPONSOR: Schering-Plough initiated the project and sponsored the meetings of the working group and all costs generated by these meetings. PLANS FOR GUIDELINE REVISION: The field of biologicals and cytokine modulators is in a rapid phase of development, and revision of the scope and content of these guidelines will be ongoing as longer-term data emerge.

Corticosteroid/cyclophosphamide pulse treatment in South African patients with pemphigus.

BACKGROUND: Treatment of pemphigus remains a challenge. Corticosteroid/cyclo-phosphamide pulse treatment has been used to reduce the morbidity associated with long-term treatment with high-dose corticosteroids. We describe our experience with pulse treatment in South African patients with pemphigus. OBJECTIVES: To assess, in patients who achieved remission of pemphigus, the number of pulses, time and total amounts of steroid and cyclophosphamide required to achieve remission of pemphigus, any side-effects and the long-term outcome. METHODS: Patient charts were reviewed retrospectively. In those who had remission of disease (resolution of cutaneous lesions and no new mucosal lesions), details of medication were analysed. The relationships between medication, disease severity, type of disease and patient demographics were investigated. RESULTS: Of the 70 patients, 35 achieved remission as defined in the study criteria; 43% of them with < 6 treatment pulses. Neither the type nor severity of pemphigus correlated with the number of treatment pulses or time to remission. However, 73% of patients who presented with severe disease did receive additional oral corticosteroids between treatment pulses. Lymphopenia occurred in 80% of patients, who needed more treatment pulses (P = 0.002) and thus larger total amounts of oral (P = 0.006) and intravenous (P = 0.02) cyclophosphamide to eventually achieve remission. Of the 35 patients who achieved remission, 94% remained in remission, although seven patients required retreatment to achieve this. CONCLUSIONS: Pulse treatment in our setting was associated with minimal morbidity. In the nine patients who relapsed, the regimen was not strictly followed, emphasizing the importance of compliance. Our use of low-dose oral corticosteroids between treatment pulses, early in the management of poorly controlled patients, supports the current modified recommendation of Pasricha.

Kaposi's sarcoma in sub-Saharan Africa: a current perspective.

PURPOSE OF REVIEW: The aim of this review is to summarize the most recent published literature on HIV/AIDS Kaposi's sarcoma in sub-Saharan Africa (SSA). We attempted to update readers on the epidemiology of Kaposi's sarcoma herpesvirus infection and HIV Kaposi's sarcoma in SSA, as well as clinical features, therapy and immune reconstitution inflammatory syndrome associated with HIV Kaposi's sarcoma. RECENT FINDINGS: Seroprevalence rates of Kaposi's sarcoma herpesvirus differ across SSA; it is low in South African children as compared to endemic areas like Uganda. The major route of transmission in SSA is horizontal rather than sexual. The incidence of Kaposi's sarcoma has increased exponentially with the HIV/AIDS pandemic with a shift in trend demonstrating a dramatic increase in females and occurrence in younger individuals. Kaposi's sarcoma specific therapy is underutilized due to poor access to highly active antiretroviral therapy and financial constraints in SSA. As highly active antiretroviral therapy becomes available, clinicians treating HIV/AIDS in SSA need to have a high index of suspicion of Kaposi's sarcoma immune reconstitution inflammatory syndrome events. SUMMARY: Kaposi's sarcoma is a public health concern in SSA. More studies appropriate to therapy for Kaposi's sarcoma in resource-poor environments like SSA are imperative. We are hopeful that with the increased availability of highly active antiretroviral therapy, the incidence of HIV Kaposi's sarcoma will decrease and management will improve, as it has in the West.

Increasing incidence of Kaposi's sarcoma in black South Africans in KwaZulu-Natal, South Africa (1983-2006).

The aim of the study was to describe the temporal trends in the incidence of Kaposi's sarcoma (KS) in black South Africans in KwaZulu-Natal (KZN). The study was designed as a retrospective record review. The incidence of Kaposi's sarcoma was estimated using administrative records for patients receiving care for KS through public sector oncology clinics in KZN, 1983-2006. Annual age-standardized incidence rates were calculated using provincial census data for the denominator. Age-specific rates were calculated for the pre-AIDS (1983-1989) and for the generalized AIDS epidemic eras (2006). Age-standardized incidence of KS increased in KZN from <1:100,000 in 1990 to at least 15:100,000 in 2006; this increase was observed in both men and women. There was a shift in the peak age-specific incidence rates from the sixth decade of life in the pre-AIDS era to the fourth and fifth decades in the AIDS era. In conclusion, KS is a growing public health problem in KZN, South Africa. These data reinforce the need for comprehensive national access to and roll-out of antiretroviral drugs, given their success in prevention and treatment of KS in first-world settings.

Characteristics of HIV-1-associated Kaposi's sarcoma among women and men in South Africa.

Despite the increase of HIV-1-associated Kaposi's sarcoma (KS), little is known about HIV-associated KS in the African setting, particularly among women. A descriptive study of the demographic, clinical, immunological and virological features of AIDS-associated KS from KwaZulu-Natal, South Africa was undertaken. Consecutively, recruited patients were clinically staged; CD4/CD8 cell counts, HIV-1 viral loads and clinical parameters were evaluated. Of the 152 patients (77 male and 75 female) 99% were black. Females were significantly younger (P = 0.02) and had poorer disease prognosis (odds ratio [OR] = 2.7, 95% confidence interval [CI] = 1.4-5.4, P = 0.003) and were more likely to have extensive cutaneous KS when compared with males (OR = 3.1, 95% CI = 1.4-6.7, P = 0.003). One-third of patients had coexisting HIV-related disease, most commonly tuberculosis, and these were more frequent in females (56.7 vs. 43.3%). In conclusion, HIV-associated KS in South Africans has an equal female-to-male ratio. Females are younger and have more severe disease than males.

Quality of life issues for South Africans with acne vulgaris.

The adverse effects of acne on the psyche have been established in patients from 'first world' countries. There has been no in depth study in predominantly black patients from Africa addressing this issue. This was a prospective cross-sectional study of acne patients attending a dermatology unit in KwaZulu-Natal, South Africa. A questionnaire was completed and acne graded by the Global Acne Grading scale. Psychological morbidity and quality of life (QOL) were assessed by the General Health Questionnaire and Dermatology Specific Quality of Life Questionnaires, respectively. We found that clinical severity was not associated with patient perception or psychological distress. The QOL measures such as feelings, social activities, performance at work or school, activities of daily living and overall mental health were found to be associated with distress with associated P-values of 0.0002, 0.0168, 0.0032, 0.033 and < 0.0001, respectively. The severity of acne was not associated with psychological distress. Painful and bleeding lesions were associated with distress levels; P = 0.042 and P = 0.019, respectively. In conclusion, South African patients with acne vulgaris suffer significant psychological distress, which affects the quality of their lives.

Therapeutic options for the treatment of tinea capitis caused by Trichophyton species: griseofulvin versus the new oral antifungal agents, terbinafine, itraconazole, and fluconazole.

Tinea capitis is a relatively common fungal infection of childhood. Griseofulvin has been the mainstay of management. However, newer oral antifungal agents are being used more frequently. A multicenter, prospective, randomized, single-blinded, non-industry-sponsored study was conducted in centers in Canada and South Africa to determine the relative efficacy and safety of griseofulvin, terbinafine, itraconazole, and fluconazole in the treatment of tinea capitis caused by Trichophyton species. The regimens for treating tinea capitis were griseofulvin microsize 20 mg/kg/day x 6 weeks, terbinafine [> 40 kg, one 250 mg tablet; 20-40 kg, 125 mg (half of a 250 mg tablet); < 20 kg, 62.5 mg (one-quarter of a 250 mg tablet)] x 2-3 weeks, itraconazole 5 mg/kg/day x 2-3 weeks, and fluconazole 6 mg/kg/day x 2-3 weeks. Patients were asked to return at weeks 4, 8, and 12 from the start of the study. Griseofulvin was administered for 6 weeks and the final evaluation was at week 12. Terbinafine, itraconazole, and fluconazole were administered for 2 weeks and the patient evaluated 4 weeks from the start of therapy. At this time, if clinically indicated, one extra week of therapy was given. There were 200 patients randomized to four treatment groups (50 in each group). At the final evaluation at week 12, the number of evaluable patients were griseofulvin, 46; terbinafine, 48; itraconazole, 46; and fluconazole, 46. Patients who discontinued therapy or were lost to follow-up were griseofulvin, 1/3; itraconazole, 0/4; terbinafine, 0/4; and fluconazole, 0/4. The causative organisms were Trichophyton tonsurans and T. violaceum species. Patients were regarded as effectively treated at week 12 if there was mycologic cure and either clinical cure or only a few residual symptoms. Effective treatment was recorded in, intention to treat, griseofulvin (46 of 50, 92.0%), terbinafine (47 of 50, 94.0%), itraconazole (43 of 50, 86.0%), and fluconazole (42 of 50, 84.0%) (p=0.33). Adverse effects were reported only in the griseofulvin group (gastrointestinal effects in six patients). Discontinuation from therapy due to adverse effects occurred only in the griseofulvin group (nausea in one patient). For the treatment of tinea capitis caused by the Trichophyton species, in this study, griseofulvin given for 6 weeks is similar in efficacy to terbinafine, itraconazole, and fluconazole given for 2-3 weeks. Each of the agents has a favorable adverse-effects profile.

Pemphigus in South Africa.

BACKGROUND: Pemphigus is an autoimmune disease characterized by intraepidermal blistering. We describe the demography, prevalence, clinical features, response to treatment, and human leukocyte antigen (HLA) characteristics of pemphigus in Kwa-Zulu Natal, South Africa. METHODS: All patients with pemphigus were prospectively recruited over 12 years from January 1987 to December 1999. The demography, clinical features, histology, and immunofluorescence (IF) were recorded. In a subset of patients, HLA tests were performed. RESULTS: One hundred and twelve patients had pemphigus. Pemphigus foliaceus (PF) was the commonest variant seen (62 patients) and 80% of these patients were black. The mean age was 43 years (12-93 years) and the male to female ratio was 1 : 1.4. Fifty patients had pemphigus vulgaris (PV), of whom 82% were Indian. The mean age of presentation of PV was 48 years (21-82 years). The male to female ratio was 1 : 1.7. There was no mucosal involvement in PF. PV patients had painful oral lesions. The mortality rate was 14% in the total sample (six in PV and two in PF). HLA-B8 was positive in 41% of patients with PF (P < 0.001). CONCLUSIONS: PF occurs more commonly in black people, while most cases in Indians present with the PV subtype. Pemphigus patients present with severe and extensive disease, and PV patients share features in common with patients from their land of origin (India), suggesting a genetic link.

Once weekly fluconazole is effective in children in the treatment of tinea capitis: a prospective, multicentre study.

In an open, multicentre evaluation carried out in Brazil, Canada and South Africa we have demonstrated that fluconazole 8 mg kg-1 once weekly is effective in tinea capitis caused by Trichophyton and Microsporum species. There were 61 children, aged (mean +/- SE) 5.0 +/- 0.3 years; weight (mean +/- 5.6) 20.0 +/- 0.9 kg; 41 males, 20 females; one Asian, 57 Black, one Caucasian and two Hispanic. The organisms were Trichophyton violaceum (33 patients), T. tonsurans (11) and Microsporum canis (17). The extent of tinea capitis at pretherapy was: mild (18 patients), moderate (30) and severe (13). Patients with tinea capitis due to Trichophyton species were initially treated for 8 weeks with an extra 4 weeks of fluconazole if clinically indicated. All 44 patients with tinea capitis due to Trichophyton species were completely cured (clinically and mycologically) when evaluated 8 weeks after completion of active treatment, following 8 weeks of once weekly dosing in 35 patients and 12 weeks of once weekly dosing in nine patients. In Microsporum canis tinea capitis, an extra 4 weeks was administered at week 12 in patients where it was clinically indicated at the time. Sixteen of 17 patients with M. canis tinea capitis were completely cured (clinically and mycologically) when evaluated 8 weeks following the end of treatment when given for 8, 12 and 16 weeks in 12, one and three patients, respectively. Overall, complete cure (clinical and mycological) occurred in 60 of 61 patients at follow-up 8 weeks from the end of therapy. The duration of once weekly fluconazole in the 60 patients was 8 weeks (47 patients), 12 weeks (10 patients) and 16 weeks (three patients), respectively. Clinical adverse effects consisted of a mild, reversible gastrointestinal complaint in three (4.9%) of 61 children. A laboratory abnormality with elevated liver function tests was observed in one (5.9%) of 17 patients; this was asymptomatic, and reversible. No patient discontinued therapy. The data suggest that once weekly fluconazole dosing is effective, safe and associated with high compliance when used to treat tinea capitis.

Childhood Lichen scrofulosorum revisited.

Lichen scrofulosorum (LS), an uncommon cutaneous tuberculous reaction, has been described in children and young adults. In the last three decades, there has been a dearth of literature on the entity in children, despite a global increase in tuberculosis. It is usually associated with localized cervical, hilar, or mediastinal lymphadenopathy or with osseous tuberculosis. The occurrence of LS in association with pulmonary tuberculosis is rare and its occurrence with generalized lymphadenopathy is unrecognized. We report LS in two children and highlight its occurrence with pulmonary tuberculosis and generalized lymphadenopathy.

Intermittent short duration therapy with fluconazole is effective for tinea capitis.

We have demonstrated in an open multicentre investigation that oral fluconazole 6 mg/kg daily for 2 weeks, followed, if clinically indicated four weeks from the start of therapy, by an extra week of treatment at the same dosage, may be effective and safe in the treatment of tinea capitis. Of a total of 48 patients, there were 42 evaluable children < 18 years old (19 boys, 23 girls; mean age 6.2 years, range 1.5-16). The causative organisms were Trichophyton tonsurans (38 subjects) and T. violaceum (four). In the 42 evaluable patients, a 2-week course of fluconazole was administered in 21, with the remainder requiring 1 additional week of therapy. At follow-up 12 weeks from the start of therapy, mycological and clinical cure was recorded in 37 of the 42 evaluable patients (88.1%, 95% confidence interval 83.1-93.1%). The treatment was well tolerated, with no clinical adverse effects. This regimen appears to be effective and safe, and is associated with high compliance. The preliminary results of the investigation need to be evaluated in a larger sample of patients, and in tinea capitis caused by zoophilic species.

HIV-associated eosinophilic folliculitis in an infant.

HIV-associated eosinophilic folliculitis (HIV-EF), which is a well-known entity in adults, has not been described in children. Although Ofuji's disease (OD) or eosinophilic pustular folliculitis (EPF) has been described in children and shares histopathologic features with HIV-EF, it is a distinct entity with characteristic clinical features. We report the occurrence of eosinophilic folliculitis in an 8-month-old HIV-positive patient and discuss the clinical, pathologic and possible pathogenetic aspects thereof. In addition, differences in the clinical manifestations of the present case and that of I-EPF are addressed. Because of clinicopathologic similarities between the present case and HIV-associated eosinophilic folliculitis (HIV-EF) in adults, we believe that eosinophilic folliculitis in this patient represents a cutaneous manifestation of HIV infection, rather than co-incidental occurrence of the infantile form of Ofuji's disease in an HIV-positive patient.

Erythroderma: a comparison between HIV positive and negative patients.

UNLABELLED: Background Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV). OBJECTIVE: To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed. METHOD: One hundred and thirty-eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded. RESULTS: Seventy-five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34. 7 years (range, 1 month to 85 years). Forty-three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P < 0.05) white cell count (7.6 vs. 10.5 x 109 /L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 x 109 /L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 mM/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group. CONCLUSIONS: A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection.

Tinea pedis et unguium in the Muslim community of Durban, South Africa.

BACKGROUND: In a pilot study performed in eight mosques in the Durban area, it was found that the prevalence of tinea pedis et unguium in the adult Muslim male population regularly attending mosques was higher than in the nonMuslim male population. The aims of the present study were: (i) to determine the prevalence of tinea pedis et unguium in the adult Muslim male population regularly attending mosques; (ii) to investigate the role of mosque carpets and ablution areas in the spread of infection; and (iii) to develop strategies to combat the infection. METHOD: Seventy-eight regular worshippers comprising adult Muslim males, chosen at random from five mosques in the Durban area, were examined for clinical evidence of tinea pedis et unguium. Skin scrapings and nail clippings were taken from clinically infected individuals and submitted for microscopy and culture for fungal organisms. A control group, comprising 72 nonMuslim adult male office workers from the administration departments of King Edward VIII Hospital, was similarly examined. In addition, scrapings from high traffic areas of the mosque carpets and swabs from the ablution areas were cultured for fungi. RESULTS: In the mosque group, it was found that the prevalence of tinea pedis et unguium was 85%, taking either microscopy or culture positivity as indicative of infection. In the control group, the prevalence was 41%. Thus a statistical difference of 44% (P < 0.0001) between the two groups was demonstrated. Dermatophytes and yeasts were isolated from the carpets and/or floors of the ablution areas in all the mosques under investigation. CONCLUSIONS: The high prevalence of tinea pedis et unguium among regular male worshippers in the Muslim community can be attributed to the spread of fungal organisms in the communal ablution areas and prayer carpets of the mosques. Strategies to combat this spread of infection are being developed. These strategies are expected to find important practical applications in other communal environments, such as gymnasia, health spas, swimming pools, changing rooms of sports clubs, public showers, and even hotels.

Papulonecrotic tuberculid in a 2-year-old girl: with emphasis on extent of disease and presence of leucocytoclastic vasculitis.

The clinicopathologic features of childhood papular necrotic tuberculid (PNT) have been detailed in 10 patients. PNT is characterized by symmetric, acral papular lesions that undergo necrosis. Despite widespread cutaneous involvement, the number of lesions is usually sparse. The extensor aspects of the limbs are usually involved and trunk involvement is uncommon. Vasculitis, an integral component of PNT, has been documented only once in childhood PNT. We describe PNT in a 2-year-old girl in whom a multitude of lesions were present all over the body, including unusual involvement of flexor surfaces of the limbs, trunk, perineum, and vulva. Biopsied tissue revealed the characteristic features of PNT, including leucocytoclastic vasculitis. There was prompt response to antituberculous therapy. Based on the findings in this patient, we believe that the clinical spectrum of this eminently treatable disease in children must be expanded in terms of distribution and number of lesions to include extensive limb and trunk, perineal, and vulval involvement; the histopathologic spectrum of childhood PNT must include leucocytoclastic vasculitis; and adult and childhood PNT share common histopathologic features, including a common cellular immunohistochemical profile, thereby suggesting a common pathogenesis.

Chronic bullous dermatosis of childhood--clinical and immunological features seen in African patients.

During the period 1985-88, 30 children with a chronic blistering dermatosis were studied. Of these 25 were found to have chronic bullous dermatosis of childhood (CBDC) and five had bullous pemphigoid (BP). No case of dermatitis herpetiformis (DH) was seen in the same period. Except for the difference in immunofluorescence (IMF) there were no definite clinical, histological or therapeutic differences between the two groups. All the children were Africans with the exception of one Indian girl. Their ages ranged from 1 year to 12 years with a mean of 5 years. The females outnumbered the males in a ratio of 3:2. All children had a generalized eruption consisting of large tense blisters arising on normal skin. The blisters were more profuse on the lower trunk, pelvic region and limbs. Face and scalp were also affected. Histological features of BP and DH were seen. Direct IMF in the CBDC patients showed linear deposits of IgA at the basement membrane zone (BMZ) while linear deposits of IgG were seen in the BP group. Complement and IgM were also seen in some cases in both groups. Sixty per cent of the CBDC patients showed IgA BMZ antibodies by indirect IMF. There were no symptoms or signs of malabsorption. Serum vitamin B12 and folate levels were normal. HLA studies showed the B-8 antigen in five of the 20 patients studied. Therapy was difficult in most cases. All patients haemolysed on therapeutic doses of dapsone, sulphapyridine and/or prednisone had to be added. Follow-up was generally poor as six patients failed to return after discharge from hospital.(ABSTRACT TRUNCATED AT 250 WORDS)