The Efficacy Of Azithromycin Plus Levamisole Vs Azithromycin Alone In The Treatment Of Moderate To Severe Acne.

BACKGROUND: Acne vulgaris (AV) is an inflammatory disorder of pilosebaceous unit and it affects over 85% of teenagers (peak age 17 years) during some point in their lives. Of these 30% have acne severe enough to require medical treatment. The overall incidence is comparable in both genders. Objective was to compare the efficacy of azithromycin plus levamisole with azithromycin alone in the treatment of moderate to severe acne. It was a single centre randomized controlled trial, conducted at the Department of Dermatology at Military Hospital Rawalpindi. METHODS: We selected 118 patients of acne who fulfilled the inclusion criteria from the dermatology outpatient department. Diagnosis was based on clinical features of acne and severity defined using Acne Global Severity Score. The patients were randomly assigned two treatment groups; Patients in group A received Azithromycin 500 mg per day given for 3 days a week plus oral levamisole 150 mg per day was given for 2 days a week for a total of 08 weeks. Group B patients (n= 59) received Azithromycin 500 mg per day given for 3 days a week for a total of 08 weeks. Patients were followed up fortnightly till they completed their treatment. Response to treatment was graded according to the Acne Global Severity Score. Scoring was done at first visit before therapy and after 08 weeks of therapy in both groups. Therapy was considered efficacious if the patients achieved post-therapy reduction of global score below 19 at the end of 8th week of initiation of therapy. RESULTS: Among our 118 study cases, we had 38 male patients while 80 were female patients. The study cases had mean age of 20.10±2.65 years. Mean global severity was 31.25±3.41 while 56 (47.5%) had moderate acne and 62 (52.5%) had severe acne. Efficacy was found to be higher in patients receiving Azithromycin plus levamisole combination. CONCLUSIONS: Azithromycin plus levamisole was observed as a more effective therapy for the treatment of acne as compared to Azithromycin alone. The study supports the administration of combination therapy for the treatment of Acne to achieve desired outcomes in patients.

The Role of Intraarticular Platelet Rich Plasma (PRP) Injection in Patients with Internal Knee Derangements.

Platelet Rich Plasma (PRP) is an emerging biotechnology which uses patient's own blood components to create healing effect to their own injured tissues. This study was carried out to evaluate the clinical effects, adverse reactions and patient satisfaction after intraarticular injection of platelet rich plasma in a small group of patients with internal derangements of knee at Combined Military Hospital, Panoaqil, Pakistan. In this single center, open study, 10 patients with internal derangements of knee fulfilling the inclusion criteria received two doses of 3 ml of platelet rich plasma as intraarticular knee injection at two weeks interval. All patients were evaluated at 0, 4 and 12 weeks after treatment using IKDC, TEGNER, KOOS and VAS. Adverse events and patient's satisfaction was recorded. There was significant improvement in all scores. Intraarticular PRP injection is safe and effective method in the conservative treatment of internal knee derangements.

Adams-Oliver syndrome.

A new-born male baby with typical features of Adams-Oliver syndrome (AOS) is described. Adams-Oliver syndrome is the association of aplasia cutis congenita with terminal transverse limb reduction defects with or without cutis marmorata telangiectatica congenita. The patient presented with brachydactyly involving all the digits of his hands and shortening of both big toes along with aplasia cutis on the scalp. There was no systemic involvement. The patient was placed on regular follow-up.

Fissure leishmaniasis: A new variant of cutaneous leishmaniasis.

Cutaneous leishmaniasis (CL) may appear at unusual sites or present with atypical morphologies. The lip is considered one of the unusual sites and a fissure of the lower lip is an atypical morphology that has not been described in CL. We report two cases of CL who presented as cutaneous fissures (on lower lip in one patient and dorsum of finger in another). They were diagnosed by demonstrating leishmania parasites in skin smear preparations and were treated accordingly.

Patterns of psoriatic arthritis.

OBJECTIVE: To describe the clinical patterns of arthritis in psoriasis. STUDY DESIGN: Cross-sectional, observational study. PLACE AND DURATION OF STUDY: Combined Military Hospital, Kharian Cantonment, Pakistan, from January to December 2007. METHODOLOGY: One hundred consecutive patients with psoriasis reporting to dermatology outpatient department were included. Pregnant ladies (due to X-ray hazard) and rheumatoid factor positive patients were excluded. The demographic profile of patients was recorded. Psoriatic arthritis was diagnosed on the basis of Moll and Wright criteria. Standardized examination of axial and peripheral joints was made. The severity of psoriasis was assessed by PASI score. The presence of a clinical type of psoriatic arthritis, enthesitis, dactylitis, and nail changes were noted. X-ray films of involved joints were taken. A statistical analysis using chi-square test and student's t-test were done where applicable. RESULTS: The mean age of patients was 39.8+15.8 years. Seventy one percent were males and 29% were females. Forty six percent of the patients gave a history of joint involvement and fulfilled the Moll and Wright criteria. The mean PASI score in non-arthritic patients was 26.8+34.8 and in psoriatic arthritis patients it was 28.4+41.2, p=0.08. Thirteen patients (28.2%) had predominantly axial disease, while the rest had predominantly peripheral disease. Single joint involvement (monoarthritis) was the commonest clinical presentation. Nail involvement was seen in 29% of the patients without arthritis while in patients having arthritis, nail involvement was 74% (p=0.001). CONCLUSION: Joint involvement is common in psoriatic patients. However, the criteria of diagnosis lack consensus.

Rhinophymous leishmaniasis: A new variant.

Cutaneous leishmaniasis is known for its wide clinical spectrum. The nose is one of the usual sites where the disease can present in many forms, such as psoriasiform plaques, furunculoid nodules, lupoid plaques, and erysipeloid or mucocutaneous types. We present a new morphology, i.e. rhinophyma-like plaque in an elderly male patient who presented with a large infiltrated plaque involving his nose and the adjoining area of his upper lip. It appeared to be rhinophyma of the nose but was diagnosed as cutaneous leishmaniasis after the demonstration of leishmania parasites in a skin smear preparation; he was treated satisfactorily with antimonials.

Presentation of early onset psoriasis in comparison with late onset psoriasis: a clinical study from Pakistan.

BACKGROUND: Early onset psoriasis and late onset psoriasis are known to have different clinical patterns in Caucasian population. However, there is paucity of data among Asian patients. AIMS: To compare the clinical presentation of early onset psoriasis with late onset psoriasis in Pakistani population. METHODS: During the study period, participating dermatologists filled a pre-tested questionnaire for each patient with psoriasis on first encounter. The questionnaire incorporated information regarding clinical and demographic features of psoriasis including age of onset, clinical type of psoriasis, nail or joint involvement, and PASI score. Patients were then divided into early onset (age of onset < 30 years, group I) and late onset (age of onset > or =30 years, group II) psoriasis. RESULTS: Five hundred and fifteen questionnaires were filled and returned for evaluation. There was no statistically significant difference in both groups with regards to gender, family history (P = 0.09), nail (P = 0.69) and joint (P = 0.74) involvement, disease severity (P = 0.68), and clinical type of psoriasis (P = 0.06). No significant difference between disease severities measured by PASI score was observed in the two groups (P = 0.68). Presence of nail involvement was associated with joint disease in both groups (odds ratio 2.8, confidence interval 1.9-4.1). CONCLUSION: Patients with early and late onset psoriasis in Pakistani population do not show different clinical and demographic features contrary to the Western patients.

Aplasia cutis congenita associated with azathioprine.

Aplasia cutis congenita is a rare skin condition characterized by the absence of localized or widespread areas of skin at birth. We are reporting a variant aplasia cutis congenita, which involved over 90% of the body surface area, which occurred in a baby born to a mother with pemphigus vulgaris who was on oral prednisolone and azathioprine. A case of extensive aplasia cutis congenita was seen and oral intake of azathioprine by the mother during pregnancy was suspected as an etiologic factor. The parents of the patient did not consent for biopsy or autopsy so the histopathological picture was not available and hence involvement of other systems could not be ascertained. Due, to financial constraints some of the investigations which might have helped in assigning the patient to a particular category of aplasia cutis such as karyotyping and CT scan brain could not be carried out.

Dermatosis neglecta in a case of multiple fractures, shoulder dislocation and radial nerve palsy in a 35-year-old man: a case report.

INTRODUCTION: Dermatosis neglecta is an often misdiagnosed and under-diagnosed condition. In dermatosis neglecta, a progressive accumulation of sebum, sweat, keratin and other dirt and debris, occurs due to inadequate local hygiene resulting in a localized hyperpigmented patch or a verrucous plaque. Vigorous rubbing with alcohol-soaked gauze or soap and water results in a complete resolution of the lesion. This is the first case of dermatosis neglecta reported in a patient with multiple traumatic injuries. CASE PRESENTATION: We report a case of a 35-year-old male Caucasian of Pakistani origin, with multiple fractures, neurological deficit and immobility sustained in a fall, leading to the development of dermatosis neglecta of the left hand. CONCLUSION: Early and prompt clinical recognition of this condition eliminates the need for aggressive diagnostic and therapeutic procedures.

Value of transverse section scalp biopsy in alopecia areata - a clinicopathological correlation.

OBJECTIVE: To correlate the histopathological features of alopecia areata with clinical stage by means of transverse sectioned scalp biopsy specimens, in terms of extent and duration of disease. STUDY DESIGN: Cross-sectional. PLACE AND DURATION OF STUDY: Department of Dermatology, Combined Military Hospital, Kharian Cantonment, Pakistan, from January 2002 to December 2004. PATIENTS AND METHODS: Fifty consecutive patients with alopecia areata were included in the study. Four millimeter punch biopsy was taken and representative horizontal sections from lower and upper dermis were examined. Patients were divided according to disease extent i.e. Group I (<25% of scalp surface area), Group II (25 - 75% of scalp surface area) and Group III (>75% of scalp surface area including alopecia totalis and universalis). Patients were also analyzed according to the disease duration, i.e. 0-6 months, > 6-12 months, > 1-5 years and > 5 years. Follicular unit counts and density / mm2, terminal to vellus hair ratio, anagen to telogen ratio, cellular infiltrate and fibrosis were measured to assess the diagnosis and prognosis of disease. Chi-square test was used to assess statistical significance. RESULTS: Diagnosis of alopecia areata could be made in 82% of biopsies. Follicular unit counts and density per mm2 decreased with the disease duration (p=0.01). Catagen and telogen hair follicle counts increased with disease duration (p=0.0001). Cellular infiltrate decreased and fibrosis increased with the duration of disease (p=0.0001). Anagen telogen ratio and terminal to vellus hair ratio inverted in long-standing disease. CONCLUSION: Transverse section scalp biopsy can help in the diagnosis of alopecia areata and the disease stage can be predicted by analyzing the histopathological findings quantitatively.

Comparison of 30% salicylic acid with Jessner's solution for superficial chemical peeling in epidermal melasma.

OBJECTIVE: To compare the efficacy and safety of Jessner's solution with 30% salicylic acid as superficial chemical peeling agents in treating epidermal melasma in Asian skin. STUDY DESIGN: Double blind, randomized, interventional comparative study. PLACE AND DURATION OF STUDY: Department of Dermatology, Combined Military Hospital, Malir Cantt, Karachi, from January to December 2004. PATIENTS AND METHODS: Sixty consenting patients with epidermal melasma were randomly divided into two groups. Group A was treated with Jessner's solution and Group B with 30% salicylic acid. Baseline Melasma Area Severity Index (MASI) score was noted and peeling started at 2-weekly intervals. Sunscreen in morning and moisturizer at night were prescribed in all patients. MASI score and adverse effects were recorded biweekly. Treatment was stopped at 12 weeks and patients were followed-up at 4 weekly intervals for further 12 weeks. Final MASI score and adverse effects were noted at the end of follow-up period. Mean MASI scores were compared using paired sample t-test and one-way ANOVA. RESULTS: Difference in baseline, treatment end and follow-up end MASI scores was not statistically significant between the two groups (p 0.54, 0.26, and 0.55 respectively). On the other hand, within group analysis of difference between pre and posttreatment MASI score was highly significant in both groups (p<0.0001). Adverse effects were mild and comparable in both groups. CONCLUSION: Jessner's solution and 30% salicylic acid are equally effective and safe peeling agents for use in epidermal melasma in Asian skin.

Treatment of uncomplicated plasmodium falciparum malaria with quinine-doxycycline combination therapy.

OBJECTIVE: To assess the efficacy and tolerability of quinine-doxycycline combination therapy in uncomplicated falciparum malaria in terms of malarial parasite clearance from peripheral blood. METHODS: One hundred adult males were included in the study. Malarial parasite counts in peripheral blood films were determined at the time of admission and then 12 hourly until clearance and thereafter weekly for 28 days (4 weeks). Treatment was started with quinine sulphate 10 mg of salt/kg body weight 8 hourly orally for a minimum period of 3 days and maximum of 7 days along with doxycycline 100 mg 12 hourly orally for 7 days. Primary efficacy outcome measure was early treatment failure, whereas secondary efficacy outcome measure was late treatment failure. Tolerability outcome measure was the development of treatment related adverse effects resulting in discontinuation from the study. RESULTS: The primary efficacy outcome measure of the study i.e. malarial parasite index declined from a mean of 6.34 (SD +/- 2.83) before treatment to zero at day 7 of treatment. Parasite clearance time was 1-7 days (mean 3.58, SD +/- 1.28). Mean duration of quinine treatment till clearance of malarial parasites was 4.63 days (SD +/- 1.38). Mean duration of fever was 2.96 days (range 1 to 6 days). There was no early or late treatment failure. There was no relapse during the 28 days follow up period. Drug related side effects were mild and did not warrant discontinuation of treatment in any patient. CONCLUSION: Quinine-doxycycline combination is effective in southern Pakistan. Randomized controlled trials are needed to further validate the claim.

Recurrent cutaneous leishmaniasis presenting as sporotrichoid abscesses: a rare presentation near Afghanistan border.

Cutaneous leishmaniasis caused by Leishmania tropica and Leishmania major is endemic in Pakistan and is the second most prevalent vector-borne disease in the country (after malaria). We report a case of non-ulcerating, sporotrichoid cutaneous leishmaniasis that recurred 2 years after successful treatment of two typical leishmaniasis ulcers. The patient came from Kohat, a border town in the northwestern region of Pakistan about 50 miles east of Afghanistan. It is important for physicians to be familiar with unusual presentations of this common condition.

Epidemiology of erythema ab igne at a moderately cold weather station.

Erythema ab igne is a localized red brown reticular pigmentation, resulting from chronic, repetitive exposure to sub maximal heat, insufficient to cause burn. A study was carried out at the dermatology outpatient department of Combined Military Hospital, Abbottabad during January-April 2005 with the purpose to see frequency of erythema ab igne. Fourteen patients were identified, interviewed and examined in detail. Nine were females, eight of them housewives, and five were males. Age of the patients ranged from 9 to 60 years with a mean of 36.5 +/- 14.8 years. Body Mass Index (BMI) of the patients ranged from 13.5 to 33.5, six of them were in the BMI range of between 25.1 and 30. Nine patients belonged to rural areas. Erythema ab igne was not associated with thyroid disease or any other systemic or psychiatric illness.

Knowledge, attitude and practice regarding dandruff among soldiers.

OBJECTIVE: To assess the knowledge, attitude and practice regarding dandruff among soldiers. DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Departments of Dermatology at Combined Military Hospitals, Abbottabad, Malir and Gujranwala from January 2006 to March 2006. PATIENTS AND METHODS: Serving male soldiers posted at Abbottabad, Malir and Gujranwala Cantonments were included in the study. Convenience sampling was used to distribute the questionnaire. All soldiers included in the study were asked or assisted by the trained staff to fill the close-ended questionnaire in Urdu, which included information about demographic profile and questions relevant to the objectives of the study. The ethical requirements for the study were fulfilled. SPSS-10 was used for data management. RESULTS: A total of 800 serving male soldiers were surveyed. Five hundred and twenty-one soldiers (65.1%) answered yes to dandruff, whereas 279 (34.9%) replied in negative. Dandruff was considered a disease by 433 (83.1%) respondents. Hair fall (n=392, 75.2%) and scalp itching (n=380, 72.9%) were the common symptoms and 330 (63.3%) respondents were embarrassed by dandruff. Bad water (n=93, 17.8%), winter (n=40, 07.6%) and lack of sleep (n=30, 05.7%) were considered the most common causes of dandruff. Majority of the individuals (n=487, 93.4%) used different hair oils and household remedies for the treatment of dandruff. One hundred and fourteen (21.9%) and 50 (09.6%) participants consulted doctors and traditional healers respectively for their dandruff. Advertisements in electronic or print media and wall hoardings etc. influenced 213 (40.9%) respondents to use various anti-dandruff shampoos, hair tonics and oils. CONCLUSION: Dandruff is a common problem and there is a need for education programmes and formulation of a policy regarding the positive role of media on health matters.

Progressive symmetrical erythrokeratoderma with perioral involvement.

Erythrokeratodermas are inherited or sporadic disorders of keratinization, with many variants. Progressive symmetrical erythrokeratoderma presents as large, erythematous or hyperpigmented, hyperkeratotic, fixed symmetrical plaques over various parts of the body along with many other inconsistent features. Periorificial keratotic lesions have very rarely been reported in progressive symmetrical erythrokeratodermas. We report a 9 years old boy with progressive symmetrical erythrokeratoderma having perioral involvement besides fixed hyperpigmented, keratotic plaques. He was started with oral etretinate but he stopped the treatment due to no-response after two weeks and is presently using topical keratolytics without marked improvement.

Simultaneous onset of herpes zoster in a father and son.

The Varicella Zoster virus persists in sensory nerve ganglion cells after chicken pox and gets reactivated to cause herpes zoster after variable periods of time as a result of waning of specific cellular immunity. Susceptible contacts of herpes zoster can develop chicken pox and very rarely herpes zoster. We report an interesting case of a father and his son who developed herpes zoster simultaneously without any obvious common predisposition and discuss the possible underlying mechanism.

Scrofuloderma neck with chest wall abscess.

Cutaneous tuberculosis (TB) is among the uncommon varieties of tuberculosis but it is also on the rise, commensurate with the general resurgence of the disease. A case of scrofuloderma of neck with tuberculous abscess of anterior chest wall is, hereby, reported. The patient presented with a non-healing ulcer of neck with swelling of anterior chest wall, which responded to antituberculous treatment. This complication of scrofuloderma neck is very rare and should be kept in mind in the differential diagnosis of such lesions.

Chilblains at Abbottabad, a moderately cold weather station.

BACKGROUND: Chilblains are quite often seen in various parts, in particular cold weather areas of Pakistan. Unfortunately, no studies have so far been carried out in Pakistan, to determine epidemiological aspects of chilblains. The objective of this study was to see the epidemiological patterns of chilblains at a moderately cold weather station. METHODS: The study was conducted at Dermatology out patient department of Combined Military Hospital, Abbottabad from 1 Dec 2004 to 31 Mar 2005. All the patients fulfilling clinical criteria for the diagnosis of chilblains were registered. Every patient was interviewed in detail followed by thorough physical examination. Complete Blood Count, Urine Routine Examination and Anti Nuclear Factor were carried out in only those patients, having the disease of more than 3 years duration. A pre-designed proforma was filled separately for each patient. RESULTS: Out of 111 patients, 67 (60.4%) males and 44 (39.6%) females were registered with the diagnosis of chilblains. Fifty nine (53.2%) patients were locals and 52 (46.8%) were non locals. Out door workers were 75 (67.6%). Onset in majority of the patients (42.3%) was in the age group 11-20 years. Family history of chilblains was present in 25 (22.5%) patients and 8 patients (7.2%) were smokers. The disease of longer duration was more common in females and locals. CONCLUSION: At moderately cold weather areas, out door workers and young adolescents are more likely to develop Chilblains. The disease of longer duration is more common among females and local residents. On the other hand, first episode or the disease of shorter duration is more common among non locals at moderately cold weather stations because of poor acclimatization and inadequate protection.

Rickets in xeroderma pigmentosum.

Xeroderma pigmentosum patients are advised to strictly avoid sun exposure to prevent ultraviolet-induced DNA damage. We describe a 2 1/2 years old boy having xeroderma pigmentosum, who also developed rickets. He was given one injection of vitamin D along with dietary vitamin D supplements to which he responded. He is being followed- up regularly in outdoor clinic with the advice to the parents to continue dietary vitamin D supplements and to avoid sun exposure.