Fixed drug eruption and intradermal provocation tests.

OBJECTIVE: 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. RESULTS: 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. CONCLUSION: 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.

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.

Prevalence of hepatitis B surface antigen carrier state in patients with lichen planus--report of 200 cases from Lahore, Pakistan.

BACKGROUND: To determine the prevalence of hepatitis B surface antigen carrier state in patients with lichen planus. METHODS: 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. RESULTS: 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. CONCLUSION: No association between HBsAg carrier state and LP was found in our study.

Fixed drug eruption: topical provocation and subsequent phenomena.

OBJECTIVE: To determine the usefulness of topical provocation in detecting the incriminated drug causing fixed eruption. DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: Department of Dermatology, Shaikh Zayed FPGMI, Lahore, from November 2002 to December 2005. PATIENTS AND METHODS: Three hundred and five, clinically diagnosed cases of Fixed Drug Eruption (FDE) of either gender and of any age were subjected to topical provocation with different drugs by using concentration of 1% (n=203), 2% (n=210) and 5% (n=235) in white soft paraffin. Drug ointment of one strength was applied one at a time on normal skin of flexor surface of right or left forearm. The effects of tests on involved and uninvolved skin were observed for 48 hours. The changes in lesions like erythema, hyperpigmentation, itching, burning or appearance of new lesion were considered a positive response. In case of no change, the patients (n=5) were subjected to oral provocation test, by giving half to full therapeutic dose of the suspected drug depending upon the severity of the initial attack. A patient who exhibited see-sawing phenomenon with 5% metamizole TPT was given oral challenge with same drug. Control topical tests were repeated in equal number of normal persons with various drug ointments and in patients of FDE with white soft paraffin on normal and affected skin. RESULTS: One hundred and thirty-seven patients were males and one hundred and sixty-eight patients were females. Maximum number of patients belonged to third decade. With 1% drug preparations 12 out of 316, with 2% drug preparations 28 out of 422 and with 5% drug preparations, 312 out of 523 TPTs were positive. The comparison revealed a highly significant association (Chi-square 448.1 and p < 0.000) among various strengths of preparations and positive response. Sulphamethoxazole was found to be the most commonly incriminated cause of FDE applied in 5% concentration yielded sensitivity rate of 91% compared to 4% with lower concentrations. Positive patch test was also observed with oxytetracycline. Five patients who were given oral provocation with different drugs were found to be positive to tinidazole, dapsone, propylphenazone, belladonna and phenobarbitone. Interesting phenomena like earlier reactivation of lesion situated distal to site of application of preparation, marching, see-sawing (with oral metamizole) and lightening observed, are not yet reported in literature. CONCLUSION: Topical provocation test with 5% drug concentration applied on normal skin of patient with FDE is a possible first line investigation in finding the incriminated drug.

Common allergens in shoe dermatitis: our experience in Lahore, Pakistan.

BACKGROUND: Shoe dermatitis is a form of contact dermatitis resulting from exposure to shoes. Different chemicals, in conjunction with a hot and humid environment within the shoe, give rise to allergic or irritant dermatitis. Allergic shoe dermatitis is commonly caused by constituents of rubber, leather, adhesives, and rarely by linings and dyes. AIM: To determine the frequency of various allergens in shoe dermatitis in our patients. METHODS: One hundred and nine patients suspected of having contact dermatitis due to shoe allergens were included. All patients were patch tested with the Shoe series and European Standard series. Patches were applied on the upper back and removed after 48 h. Results were read at 48, 72, and 120 h and interpreted according to International Contact Dermatitis Research Group (ICDRG) criteria. RESULTS: Of the 119 patients, 87 (73%) reacted positively to various allergens, 48% of whom showed polysensitivity. Glues (33.6%), particularly para-tert-butylphenol formaldehyde resin (PTBP-FR) (26.9%), were the leading cause of shoe dermatitis. Other allergens were leather chemicals (26.4%), potassium dichromate (16.18%), rubber allergens (7.6%), and dyes (7.6%). Shoe scrapings tested positive in 26.3% of patients. Other common allergens were nickel sulfate (22.7%), neomycin sulfate (10.1%), and cobalt chloride (8.4%). CONCLUSIONS: Considering the diversity of allergens, all patients presenting with shoe dermatitis should be patch tested with the Shoe series and a standard series to determine the etiologic allergens.

Frequency of anti-HCV antibodies in patients with lichen planus.

OBJECTIVE: 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 METHODS: 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 hepatitis C virus antibodies (anti-HCV Ab). Polymerase chain reaction for hepatitis 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. RESULTS: 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 percent patients had history of dental treatment and 63% had received multiple injections for various ailments. Forty percent 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 alpha-interferon and ribazole therapy for liver disease, showed marked improvement in their skin disease. CONCLUSION: A high prevalence of HCV infection was detected in patients with lichen planus. Patients with lichen planus should be screened for HCV carrier state.

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

OBJECTIVE: 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 METHODS: 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 up to six months for fingernail onychomycosis and nine months for toenail onychomycosis. RESULTS: 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. CONCLUSION: Itraconazole was found to be effective, well-tolerated and safe therapy for disto-lateral subungual onychomycosis.