A hidden dilemma; post COVID-19 first detection of Varicella zoster M4 genotype from Pakistan.

OBJECTIVES: During the COVID-19 pandemic, the risk of childhood infectious diseases was increased. Post-COVID-19 escalation of chickenpox cases, becoming an emerging public health concern. Thus, the study was designed to compare chickenpox prevalence and Varicella zoster virus (VZV) genotypes circulating before, during, and post-COVID-19 in Pakistan. METHODS: A total of 267 lesion specimens collected from tertiary care hospitals, and chickenpox outbreaks from Pakistan were analysed by a two-amplicon approach with phylogenetic analysis. RESULTS: Among suspected cases, overall 178/267 were VZV positive. Majority (84.2 %; 150/178) cases were of post-COVID-19 pandemic time. Small outbreaks occurred soon after COVID-19 in Rawalpindi and Islamabad (Pakistan), 40 positive cases out of 178 cases were outbreak cases. There was first time detection of the M4 genotype, which was significantly associated with disease severity (p = 0.0006) and post-COVID-19 chickenpox outbreaks in 2021 (77.9 %; 46/59; p < 0.00001). However, in pre-COVID-19 only M2 genotype was detected. The M2 prevalence varied from 2019 (100 %; 19/19) to 2022 (3.2 %; 3/91). However, the most prevalent strain of 2022 belonged to the M1 genotype (64.8 %; 59/91). CONCLUSION: A significant rise in chickenpox cases detected soon after COVID-19 in Pakistan, and oscillation of different VZV genotypes with first time detection of M4 genotype is an alarming situation. This demands further detailed genotypic studies on transmission dynamics of a rare M4 with other genotypes to protect the local population and restrict spread in other regions.

Assessment of the Efficacy of Tranexamic Acid Solution 5% in the Treatment of Melasma in Patients of South Asian Descent.

Melasma is a common dermatologic condition affecting all skin types. Increasing rates of melasma warrant identification of a reliable topical treatment. In recent years, off-label tranexamic acid (TA) has emerged as a potential treatment of melasma. Although the mechanism of action remains unclear, it is thought that TA inhibits melanin synthesis by blocking the interaction between melanocytes and keratinocytes while reversing the abnormal dermal changes associated with melasma. Our study assessed the efficacy of TA solution 5% for the treatment of melasma in patients with darker skin types.

Comparing the Efficacy for Pulse Versus Continuous Dose Terbinafine Therapy in Patients With Onychomycosis.

Recently, treatment outcomes in patients with toenail onychomycosis have improved considerably due to more effective oral antifungal medications such as terbinafine and itraconazole. These medications can either be used continuously for several weeks at a lower dose or intermittently (pulsed) at a higher dose. Previous literature comparing pulse and continuous therapy has generated mixed results.  Our study aims to compare the efficacy, in terms of clinical cure rate, of continuous vs pulse dose terbinafine regimens for toenail onychomycosis. Sixty patients with onychomycosis of Fitzpatrick skin types IV to VI, between 15 and 65 years of age, were divided into a continuous treatment group receiving 250 mg terbinafine once daily for 12 weeks and a pulse treatment group receiving 250 mg twice daily terbinafine for 1 week repeated every 4 weeks for 12 weeks. Each patient was followed up at weeks 4, 8, and 12.  Efficacy of the continuous treatment group was significantly greater at 76.67% compared with 26.67% in the pulse treatment group. Thus, we conclude that the clinical cure rate of a continuous dose regimen of terbinafine is a superior treatment option for toenail onychomycosis. However, we also suggest further studies including combinations of multiple agents and hybrid regimen models for the optimal onychomycosis treatment.   J Drugs Dermatol. 2023;22(10):     doi:10.36849/JDD.7323R1.

A Randomized Control Trial Comparing the Efficacy of Platelet-Rich Plasma and 5% Topical Minoxidil for the Treatment of Androgenetic Alopecia.

Androgenetic alopecia (AGA) is the most common cause of hair loss in men and has limited treatment options. Minoxidil is a common therapeutic option for AGA patients because of its availability. Platelet-rich plasma (PRP) therapy is a newer option in AGA management with promising results that may be suitable for some patients. Despite a great prevalence of AGA outside the United States and Europe, there remains limited studies on the efficacy of PRP for AGA treatment. Our study's objective was to compare the efficacy of PRP and minoxidil therapy for the treatment of AGA in a Pakistani population. 72 patients were included in this randomized control trial and were either treated with PRP or topical minoxidil. After 12 weeks of treatment, the hair pull test was performed and extracted hair was counted. We report a 91.7% negative hair pull rate in the PRP treatment group which was significantly greater than the 69.4% negative hair pull rate in the minoxidil-treated group. Our study suggests that PRP therapy demonstrates a higher efficacy compared to minoxidil for treating AGA, especially in our patient demographic. These results have the opportunity to improve patient compliance and overall satisfaction while offering an improved option in patients unsatisfied with topical minoxidil.  Citation: Shah R, Asim M, Ouellette S, et al. A randomized control trial comparing the efficacy of platelet-rich plasma and 5% topical minoxidil for the treatment of androgenetic alopecia. J Drugs Dermatol. 2023;22(9):905-909. doi:10.36849/JDD.7031.

Efficacy of Intralesional Vitamin D3 for Treatment of Verruca Vulgaris: A Randomized Control Study.

Cutaneous warts are benign epithelial lesions caused by human papillomavirus and are common entities, affecting nearly 10 percent of the United States population. While most warts spontaneously resolve, the immunocompromised are susceptible to recalcitrant warts which often require medical treatment. Most current therapies use either physical or chemical destruction for wart removal, but these treatments are associated with adverse effects. Intralesional vitamin D3 has the potential to demonstrate a stronger treatment response due to its ability to stimulate the immune system at the injection site via cell-mediated immunity. We sought to test the efficacy of intralesional vitamin D3 for wart treatment in a sample size of 70 patients over a three-month period. Efficacy was determined as "excellent" if there was greater than a 90-percent reduction in both size and number of lesions, "good" if there was a 60 to 89-percent reduction, and "fair" if there was less than a 60-percent reduction. Treatment efficacy was excellent in 20 (28.6%) patients, good in 29 (41.4%) patients, fair in 18 (25.7%) patients, and poor in three (4.3%) patients. Patients in the younger age group had a higher treatment efficacy compared to other treatment groups. Thus, intralesional vitamin D3 has promising qualities as a treatment for cutaneous warts and should be considered at the clinician's disposal. Vitamin D is an innovative approach for treating warts without the various side effects posed by other commonly used agents. The unique features of this treatment modality including its simplicity, safety, and efficiency make it a promising option for a very common cutaneous condition.

Topical Application of 0.5% Timolol Maleate Hydrogel for the Treatment of Superficial Infantile Hemangiomas.

BACKGROUND: Oral propranolol is considered the first line therapy in the treatment of infantile hemangiomas (IHs). However, there are considerable side effects due to its ability to penetrate the blood brain barrier. Alternatively, topical timolol, a non-selective beta blocker, has resulted in fewer side effects and is 4–10 times more potent in comparison to oral propranolol. This study evaluates the efficacy of 0.5% timolol maleate hydrogel for the treatment of IH. METHODS: This study was conducted via a quasi-experimental design from October 30, 2020 – April 29, 2021, at the Department of Dermatology Benazir Bhutto Hospital, Rawalpindi. 145 infants between 1–12 months in age diagnosed with superficial cutaneous hemangiomas were included in the study with a male to female ratio of 2.4:1. A thin layer of timolol maleate 0.5% hydrogel was applied to the entire surface of the patient’s IH three times daily. Digital photographs and measurements of the hemangiomas were taken at one-month intervals for a maximum of 6 months. RESULTS: The age range in this study was from 1–12 months with a mean age of 6.10 ± 2.52 months. The majority of the patients 89 (61.4%) were between 1–6 months of age. Of the 145 patients, 89 (61.4%) showed an excellent response, 44 (30.3%) showed a good response, and 12 (8.3%) showed no response to the topical 0.5% timolol maleate hydrogel treatment. CONCLUSION: The use of topical 0.5% timolol maleate hydrogel is a promising therapeutic option for the treatment of superficial IHs. Anwar F, Mahmood E, Sharif S, et al. Topical application of 0.5% timolol maleate hydrogel for the treatment of superficial infantile hemangiomas. J Drugs Dermatol. 2023;22(6):594-598. doi:10.36849/JDD.7054.

Histopathological Spectrum And Role Of Clinicopathological Correlation In The Diagnosis Of Vesiculobullous Lesions.

Background: Histopathology is an important diagnostic modality for vesiculobullous lesions, however the diagnosis may at times require use of Immunofluorescence techniques which are expensive and not widely available. The aim of this study was to determine the histopathological spectrum of vesiculobullous diseases and to determine the role of clinic-pathological correlation in diagnosing bullous lesions. Methods: This was cross sectional validation study conducted in a tertiary care hospital, over a period of 18 months. All the clinically diagnosed cases of bullous diseases were included and examined as histological sections by three histopathologists. Results: Out of 58 total cases, the most frequently diagnosed lesions included Pemphigus vulgaris (27%), Bullous pemphigoid (13.8%) and Pemphigus foliaceous (12.1%). Females comprised 55% of cases, age distribution was wide but most patient were in age bracket of 20-39 years. Conclusion: There was 89.6% correlation between clinical and histopathological diagnosis. Only 2 cases were sent for Immunofluorescence studies, as histopathology was inconclusive in those cases. Therefore, we conclude that histopathological examination along with clinical correlation is a very useful way of diagnosing vesiculobullous disorders.

A Comparison of Microneedling versus Glycolic Acid Chemical Peel for the Treatment of Acne Scarring.

Background: Acne vulgaris is a common skin disease that frequently results in scarring. Scars secondary to acne can lead to physical disfigurements and a profound psychological impact. Early and effective treatment is the best means to minimize and prevent acne scarring. In patients with darker skin tones, current acne scar treatments pose complications, including dyspigmentation, further scarring, and overall unsatisfactory clinical outcomes. Objective: We sought to compare the efficacy of microneedling versus 35% glycolic acid chemical peels for the treatment of acne scars. Methods: Sixty patients with Fitzpatrick Skin Phototype IV to VI with atrophic acne scars were randomized into two groups: Group A underwent microneedling every two weeks for a total of 12 weeks and Group B received chemical peels every two weeks for a total of 12 weeks. Acne scar treatment efficacy was represented by an improvement greater than one grade from baseline according to the Goodman and Baron Scarring Grading System, measured two weeks after the completion of the last treatment session. Results: Group A demonstrated more improved outcomes in acne scar treatment compared to Group B; 73.33% (n=22) of patients in Group A achieved treatment efficacy while 33.33% (n=10) in Group B did the same. Additionally, 26.67% (n=8) in Group A showed no efficacy after treatment compared to 66.67% (n=20) in Group B. Conclusion: Microneedling provided better treatment outcomes compared to 35% glycolic acid peels for acne scar treatment in our patient population with Fitzpatrick Skin Phototypes IV to VI.

A Randomized Trial of Oral Tranexamic Acid With Fluocinolone-Based Triple Cream Versus Fluocinolone Based Triple Cream Alone for the Treatment of Melasma.

Oral tranexamic acid (TXA) is a relatively new treatment option for melasma. It is thought to reduce hyperpigmentation through inhibition of the plasminogen/plasmin pathway with resulting decreases in epidermal melanocyte tyrosinase activity, inflammatory mediators, dermal neovascularization, and mast cell numbers.

Platelet Count, Mean Platelet Volume, and Red Cell Distribution Width as Markers for Psoriasis Severity.

BACKGROUND: Psoriasis is a chronic, inflammatory skin condition that is growing in prevalence globally. Routinely available options to assess psoriasis severity and progression are limited. More options are needed to monitor disease progression as therapeutic management is based on disease severity. OBJECTIVES: This study evaluates the usage of complete blood count components (CBC) including platelet count, mean platelet volume (MPV), and red cell distribution width (RDW) as hematological markers for assessing psoriasis severity. MATERIALS AND METHODS: In this cross-sectional study of 120 patients with psoriasis, disease severity was assessed using the PASI score followed by a blood draw to determine whether correlations existed between each marker and PASI score. RESULTS: A significant, positive correlation was found between total platelet count and PASI while no such correlation was found in MPV and RDW. When stratifying for age, duration of disease, sex, and body parts involved, we found intriguing relationships and offer potential explanations for their occurrence. CONCLUSION: Our findings suggest that hematological parameters MPV, platelet count, and RDW found in the CBC are useful in identifying psoriasis severity to some extent. We foresee the use of RDW, MPV, and platelet count biomarkers as a complement to the PASI score in assessing severity for psoriasis patients, while also as a gauge for likelihood of developing comorbidities such as cardiovascular disease. J Drugs Dermatol. 2022;21(2):156-161. doi:10.36849/JDD.6127.

Prevalence and Associated Risk Factor of COVID-19 and Impacts of Meteorological and Social Variables on Its Propagation in Punjab, Pakistan.

The current study identifies the spatial distribution of COVID-19 cases and its association with meteorological and social variables in Punjab (densely populated province of Pakistan). To identify the COVID-19 propagation, the weekly growth, recovery, and deaths rate have also been calculated. The geographic information system (GIS) has used to determine COVID-19 impacts on gender (male/female), age groups, and causalities over an affected population (km-2) for the period of 11th March to 12th August, 2020 in each district of province. Our results show that 43 peak days (where daily positive cases were above 900) have been observed in Punjab during 27th May to 8th July, 2020. The high population density districts, i.e., Lahore and Islamabad, have been affected (five persons per square kilometers) due to COVID-19, whereas the maximum death tolls (> 50 persons per millions) have also been observed in these urban districts. The meteorological variables (temperature, humidity, heat index, and ultraviolet index) show negative significant relationship to basic reproduction number (R0), whereas daily COVID-19 cases are positively correlated to aerosols concentration at 95% confidence level. The government intervention (stringency index) shows a positive impact to reduce the COVID-19 cases over the province. Keeping in view the COVID-19 behavior and climatology of the region, it has been identified that the COVID-19 cases may likely to increase during the dry period (high concentration of aerosols) i.e., October-December, 2020 and post-spring season (April to June), 2021 in urban areas of Pakistan. This study provides an overview on districts vulnerability that would help the policy makers, health agencies to plan their activities to reduce the COVID-19 impacts.

COVID-19 in a Dermatologist's Clinic: A Case From Pakistan.

SARS-CoV-2 is a novel virus that is the causative agent of COVID-19. It can affect a variety of human organ systems, including the skin. Five clinical patterns of this infection have been described. These patterns not only help in diagnosing the disease but are also helpful in predicting the severity of infection. The percentage of dermatological manifestations of COVID-19 is highly variable in different regions of the world, with some western countries reporting the percentage as high as 20%. However, the data from Asia, especially Pakistan, in this regard is sparse. We report a case of COVID-19 infection (PCR proven) with maculopapular eruption. To our knowledge, this is the first case report of its kind being reported from Pakistan. We would encourage our fellow physicians to report more such cases so that the dermatological pattern of COVID-19 in Pakistan can be appropriately categorized in the literature.

Comparison Of Efficacy Of Two Different Doses Of Famciclovir In The Prevention And Treatment Of Postherpetic Neuralgia.

BACKGROUND: Herpes Zoster is a common dermatological ailment. Various treatment modalities are in use for prevention of Post Herpetic Neuralgia (PHN) which is the most common complication of herpes zoster. Our study aimed to compare the efficacy of famciclovir 250 mg versus 500 mg in this regard. METHODS: The study was conducted at a tertiary care hospital recruiting subjects by using simple random sampling, group A patients received famciclovir 250 mg thrice daily for 1 week while group B patients were administered 500 mg. Follow ups were arranged at 2, 4 & 12 weeks. Efficacy was assessed by pain evaluation as per numeric rating scale and counting number of skin lesions. PHN was taken as persistent pain at 4 weeks follow up. All the statistical analysis was done using SPSS. RESULTS: A total of 30 patients were included in the study with each group (A & B) containing 15 patients each. Both dosing groups were statistically consistent with each other in reducing pain at 2, 4 and 12 weeks follow up. Skin lesions were not observed after 2 weeks in either group. The median of difference of pain scores at 2 weeks was similar as at 4 weeks. CONCLUSION: Famciclovir 250 mg thrice daily for one week is equally effective as 500 mg in treating active herpes zoster and prevention of PHN. However, long term follow-up is required for assessing the true incidence of PHN.