Response of vitiligo to PUVA therapy in Saudi patients.

BACKGROUND: Vitiligo is not uncommon in southern Saudi Arabia. The response of Saudi patients to PUVA therapy has not been previously assessed. The aim of this study was to evaluate this response. METHODS: This is a retrospective study for the period of 1990-2001 in which 32 patients were included: Data were collected from the patients' records, including: age, sex, age at onset of disease, type of vitiligo, cumulative dose, maintenance dose, total number of sessions, number of sessions to induce pigmentation, treatment duration, and response rate. RESULTS: The overall response rate was 59.4%. The most sensitive sites were the face, trunk, arms, and legs, while the most resistant sites were the hands, feet, and perioroficial areas (perioral and periorbital). Acute complications occurred in 59.4%, while chronic complications occurred in 78.1%. Analysis of the factors that affect the response rate showed that age, sex, the disease duration, and the treatment duration did not affect the response rate, while the surface area and the number of sessions to induce pigmentation showed a positive relation. CONCLUSIONS: PUVA is still considered as the most appropriate and effective treatment for vitiligo. Saudi patients showed good response to treatment in general. Some sites such as the face, trunk, arms, and legs showed sensitivity to therapy, while hands, feet, and periorificial areas showed resistance to therapy. Generalized type was the best type to respond, followed by the periorificial type. Acral and segmental types were very resistant to therapy.

Isotretinoin therapy: any need for laboratory assessment?

BACKGROUND: Recently studies showed the no need for laboratory follow up of patients on isotretinoin therapy. The aim of this study is to assess this issue. PATIENTS AND METHODS: A retrospective study on-400 patients was performed to analyze the laboratory data before and after isotretinoin therapy of acne vulgaris patients. All patients received isotretinoin at a dose of 1mg/kg for 20 weeks. RESULTS: AST was elevated in 25/400(6.25 %), ALT was elevated in 10/400(2.5 %). Cholesterol was elevated in 55/400(13.75%). Triglycerides were elevated in 20/400(5 %). CONCLUSION: This study supports the previous evidence for the no need for performing laboratory investigations for patients on isotretinoin therapy.

The incidence of pemphigus in the southern region of Saudi Arabia.

BACKGROUND: This is the first epidemiologic study of pemphigus in the southern region of Saudi Arabia. METHODS: Data were collected from patient records in the outpatient and inpatient departments of Asir Central Hospital during the period 1990-99. The diagnosis of pemphigus was based on the clinical, histopathologic, and direct immunofluorescence patterns which were consistent with pemphigus. RESULTS: The results showed that the mean incidence of the disease in the general population was 0.16/100 000; the mean incidence of the disease in the population above 20 years of age was 0.27/100 000. The prevalence of the disease at the end of the study period was 1.56/100 000 for the total population, and 2.7/100 000 for the population above 20 years of age. The male to female ratio was 2.2 : 1. The age of onset of the disease ranged from 23 to 67 years, except for one case at an age of 9 years, giving an average of 43.1 +/- 13.4 years and a median of 40 years. Pemphigus vulgaris was the most commonly encountered type, followed by pemphigus erythematosus (94.7% and 5.3%, respectively). Mucosal involvement occurred in 84.2% of cases. No association with neoplasia was found in the current study. CONCLUSIONS: Pemphigus in the southern region of Saudi Arabia is as common as in other parts of the world, but with higher mucosal involvement.

Richner-Hanhart's syndrome: new ultrastructural observations on skin lesions of two cases.

New ultrastructural observations are described in skin lesions of two brothers with Richner-Hanhart's syndrome (RHS). Physical examination of the two patients showed painful skin lesions of palms and soles combined with denderitic corneal ulceration and mental retardation. The diagnosis of RHS was confirmed biochemically with high tyrosine levels in both blood and urine. Examination by transmission electron microscopy revealed several abnormal ultrastructural changes in the epidermal cells. The horny cells contained heterogeneously, electron-dense cytoplasm with many lipid droplets. The granular cell cytoplasm contained abundant tonofibrils and keratohyaline granules. The spinous cell cytoplasm was vacuolated due to the presence of minute tyrosine crystals, which are known to have a lytic effect. The surrounding keratinocytes contained multilobed nuclei. The basal epidermal cells appeared normal except for Merkel cells, which were severely damaged by vacuolatio, also due to the presence of tyrosine crystals. This study showed that high tyrosine levels can induce several ultrastructural pathological changes in the epidermal cells, including the skin chemoreceptor Merkel cells.

Terbinafine in the treatment of cutaneous leishmaniasis: a pilot study.

Twenty-seven patients were randomly picked for an open pilot study using terbinafine with a dose range of 250-500 mg/day for 4 weeks. The inclusion criteria were as follows: (1) the patient had to be aged 5 years or older; (2) the patient could be of either sex; (3) any number or location of the lesions was allowed; (4) parasitologic confirmation was required; (5) the patient was allowed no previous treatment; (6) pregnant or lactating patients were excluded; (7) informed consent from the patient or his/her parents was required. The parasitologic diagnosis was carried out by a slit smear technique followed by a Giemsa stain for parasite identification. Terbinafine was given in two different doses to two groups sorted according to age. The groups were as follows: Group 1, 5-15 years, 125 mg orally twice daily for 4 weeks: Group 2, > 15 years, 250 mg orally twice daily for 4 weeks. Laboratory blood investigations including complete blood count, creatinine, urea, and liver function tests were carried out initially and at 2 weeks and 4 weeks. Clinical response was evaluated by assessing the per cent of improvement of erythema, induration, and ulceration at 2 weeks and at 4 weeks after admission. The final assessment was reported at 4 weeks: complete cure, 100% improvement with no relapse; partial cure, > or = 60% improvement; failure, < 60% improvement. Overall clinical response included patients with both complete and partial cure. Follow-up for patients with complete cure was carried out monthly for 6 months to assess the relapse rate. Patients with partial cure or failure were switched to sodium stibogluconate intralesionally.

Darier-White disease in a Saudi patient associated with systemic involvement.

A 22 year-old Saudi patient is reported who had Darier-White disease (Keratosis follicularis), presenting with the classical cutaneous manifestation of this disease in addition to systemic symptoms, including chronic renal failure, mental retardation, epilepsy, cataract and corneal opacities.

Richner-Hanhart syndrome: importance of early diagnosis and early intervention.

Fewer than 100 cases of Richner-Hanhart syndrome have been reported. We describe two additional patients who have the classic clinical, biochemical, and microscopic features of this syndrome.

Human cutaneous leishmaniasis: ultrastructural interactions between the inflammatory cells and Leishman bodies in the skin lesions.

The ultrastructural interactions between the inflammatory infiltrate and Leishman bodies (LBs) were described in skin lesions from 16 patients with acute cutaneous leishmaniasis. In early stages of the inflammation, the cellular infiltrate consisted of both undifferentiated and differentiated (activated) monocytes (M), macrophages (Mc), multinucleated giant cells (MNGC), plasma cells (PC), lymphocytes (Ly), and fibroblasts (F). In late stages, the infiltrate was in the form of tuberculous granulomas consisted mainly of type I secretory, and type II vesicular epithelioid cells (ECs), in addition to remnant of some inflammatory cells seen in the early stages. The two types of ECs were found only in six patients. The activated M, Mc and MNGC were often parasitized by LBs. The parasites were enclosed within the host cell digestive vacuoles (DVs), or phagolysosomes, together with skin melanosomes which are known to have lysosomal effect. In the DVs, LBs either survived or were killed and expelled from the host cell cytoplasm. This study showed, for the first time, that the melanosomes were apparently involved in killing of the LBs possibly by increasing the fatal effects of the DVs hydrolytic enzymes. Plasma cells were packed with large "Russell's bodies" indicating a high cellular immunoglobulin activity. The large, granular lymphocytes were in close contact to the activated M, possibly to promote delivery of activation signals. The type I secretory ECs contained mucin-like granules with electrondense cores. In late stages of inflammation, the type II vesicular ECs contained lysosomal granules, and were found together with the type I ECs in broken-down tuberculous granulomas. The type I secretory ECs were previously thought to produce a mediator, or "granuloma factor" which recruits undifferentiated mononuclear cells to perpetuate the granulomatous process; while the type II vesicular ECs were thought to appear where the granulomatous process in brought to an end, preceeding the healing by fibrosis.

Value of touch preparations (imprints) for diagnosis of cutaneous leishmaniasis.

BACKGROUND: The clinical diagnosis of cutaneous leishmaniasis is confirmed by demonstrating the organism on a superficial smear or on a biopsy of the lesion. Misdiagnosis in a biopsy specimen may be due to scanty Leishmania organisms that may not be identified in histologic sections. METHODS: Punch biopsies of skin lesions, suspected clinically to be cutaneous leishmaniasis, from 29 patients were taken. Touch smears on slides were air-dried, fixed with methyl alcohol, and stained with Giemsa stain. Results of routine histologic examination were then compared with those of touch preparation. RESULTS: Twenty-one cases were positive for leishmaniasis. In 18 cases, the organisms were seen both in the biopsy and in the touch preparation. In three cases, the organisms were only identified on touch preparation. CONCLUSIONS: A touch preparation improves the sensitivity of the diagnosis of cutaneous leishmaniasis without incurring additional cost to the laboratory.

Cutaneous leishmaniasis: schedules for intralesional treatment with sodium stibogluconate.

BACKGROUND: Various therapeutic modalities have been used for treating cutaneous leishmaniasis. Intralesional pentavalent antimonial injection is one of the effective therapeutic modalities. In this study, the efficacy of three different intralesional schedules with sodium stibogluconate have been investigated. METHODS: Ninety-six patients with 129 lesions were entered into the study, all with confirmed diagnosis of cutaneous leishmaniasis. The lesions were treated with three different schedules, including daily, alternate day, and weekly interlesional injections of sodium stibogluconate. The clinical response was then compared to arrive at the most effective schedule. RESULTS: The clinical responses (complete and partial cure) were 67%, 97%, and 91% for the daily, alternate-day, and weekly schedules, respectively. Lesions with either partial cure or failure of treatment were injected weekly with the same medication until complete cure had been achieved. The final overall success rate of complete cure was 99.2%. CONCLUSIONS: Alternate day or weekly intralesional treatment of cutaneous leishmaniasis with sodium stibogluconate are more effective than daily treatments.

Skin diseases among adolescent boys in Abha, Saudi Arabia.

BACKGROUND: Adolescence is characterized by a sensitivity to issues of attractiveness. With dermatologic conditions, this may adversely affect early detection and compliance. METHODS: A cross-sectional study was carried out on a multistage stratified random sample of 647 adolescent schoolboys in Abha, Saudi Arabia, to determine the prevalence of skin diseases. The age of the boys ranged from 11 to 19 years with an average of 15.3 +/- 1.9 years. RESULTS: It was found that 19.8% of the children were affected by one form or another of transmissible skin diseases (TSD). The most common types were: pediculosis capitis (9.6%), verruca vulgaris (3.9%), and tinea pedis (1.9%). The prevalence of TSD increased significantly as the age decreased and as the crowding index increased. As for non-transmissible skin diseases, acne vulgaris was the most prevalent disease (56.3%). The prevalence and severity of acne increased significantly as the age increased. CONCLUSIONS: The findings indicate the need to develop regional intervention programs at the school level. Appropriate continuing medical education programs for school health workers in the region are mandatory to achieve this goal.

Visceral and cutaneous leishmaniasis comparative ultrastructure of host-parasite interactions.

The comparative ultrastructure of host-parasite interactions is described for the first time in patients with visceral (VL) and cutaneous (CL) leishmaniasis. In patients with VL, the parasite invades the bone marrow (BM) macrophages (Mcs) and neutrophils, while in patients with CL, the parasite invades the dermal fibroblasts in addition to Mcs. The skin Mcs seem to have more lethal effects on the parasite than the BM Mcs; this is possibly due to the presence of numerous melanosomes with acid phosphatase activity in the Mcs digestive vacuole. In patients with high level of VL parasitaemia, the parasite may induce the BM reticulocytes to phagocytose both the parasite and mature erythrocytes, i.e. lost recognition. In patients with low level of VLparasitaemia, the parasite may induce the BM Mcs to be haemophagocytic, i.e. temporarily mimick malignant histiocytosis until the course of treatment. In early stages of CL infection, the cellular infiltrate consists of the monocyte-macrophage system, plasma cells, lymphocytes and fibroblasts; while in the late stages, two types of epithelioid cells (ECs) are added to the infiltrate and are involved in the formation of tuberculous granulomas. Type I ECs thought to produce a granuloma factor, while type II ECs possibly precedes healing by fibrosis. However, the severity of host-parasite interactions seems to depend mainly on species of the parasite, the degree of parasitaemia, the type of infected tissue(s), and the variation of host tissue reaction against the parasite from one patient to another.

The pattern of skin diseases in Asir region, Saudi Arabia: A 12-month prospective study in a referral hospital.

The literature on the pattern of skin diseases in Saudi Arabia is scanty. We have attempted to analyze the pattern of skin diseases seen in the dermatology unit of Asir Central Hospital, Abha, Southern Saudi Arabia, during a 12-month period from March 1992 to March 1993. All new patients who were seen for dematological complaints in the skin clinics, emergency room or in the wards were studied prospectively. A total of 1285 dermatoses were diagnosed in 1223 patients during the 12-month study period. Out of the top 12 groups diseases, eczema/dermatitis (25.68%) came first, followed by viral infections. Among the eczema group, atopic eczema accounted for 53.64% and was most frequently observed in children (110/177 or 62.14%) compared to adults. The main causes of superficial mycoses were dermatophytosis and candidiasis. Psoriasis was the most common papulosquamous disorder. Scabies was seen in expatriate Egyptians and Asiatics only. Primary pyogenic infections of the skin were uncommon. The pattern of skin diseases in Saudi Arabia shows a predominance of eczema. Viral infections and dermatophytosis are the most common infective dermatoses, while pyogenic infections are relatively uncommon.