Dermoscopic Nail Disorders in School-Going Children.

Introduction The majority of nail diseases in children are comparable to those in adults, while there are some physiological changes that start to happen around this age and go away over a few years. These conditions could be symptoms of infections and systemic illnesses. Pediatric nail disorders are typically easy to diagnose clinically, although there are occasionally conditions that masquerade as juvenile nail problems. Dermoscopy has grown in favour as a rapid, easy, non-invasive clinical procedure for examining nail diseases. This study aims to assess dermoscopic findings of child nail diseases. Methods A prospective analysis was conducted for seven months between January and July, 2022, at PNS Shifa Hospital, Karachi, Pakistan. A total of 180 patients who presented in the outpatient department with any dermatological complaint underwent thorough history and examination. Special emphasis was given to clinical and dermoscopic examinations of nails. Data analysis enclosed descriptive and inferential statistics. The quantitative data was presented with help of mean and standard deviation, while the qualitative data was presented with help of frequency and percentage tables. Chi-square test was applied to compare nail findings diagnosed on clinical examination and dermoscopic examination. Results The mean age of study subjects was 9.4±3.2 years and ranged between five years and 18 years. The most common nail changes were hand eczema (n=41, 23%) followed by nail changes due to nutritional disorders (n=38, 21%), anaemia (n=34, 19%) and habit tic deformity (n=31, 17.2%). Conclusions Clinical evaluation is crucial for nail disease diagnosis. Dermoscopy of nails can help with the final diagnosis of nail disease and confirm clinical diagnoses. Also, it aids in the management of nail illnesses by providing a clearer picture of pathology and nail structure.

Comparing Dermatoscopic Features With Slit Skin Smear and Histopathology in Diagnosis of Cutaneous Leishmaniasis.

OBJECTIVE: To evaluate dermatoscopic features of cutaneous leishmaniasis and to compare its diagnostic accuracy against slit skin smear and skin histopathology. METHODS:  This cross-sectional study was conducted at the Department of Dermatology, Pakistan Navy Station (PNS) Shifa Hospital, Karachi, Pakistan, from August 2021 to August 2022. A total of 200 lesions from 70 patients of cutaneous leishmaniasis diagnosed with slit skin smear for Leishmania-Donovan (LD) bodies and skin biopsy were included via non-probability consecutive sampling technique. Dermatoscopic evaluation was performed via a handheld dermatoscope (DELTA 20T; HEINE, Gilching, Germany) on 10x magnification. All dermatoscopic images were analyzed by two different observers who had command of dermatoscopy. Data analysis was done using Statistical Package for the Social Sciences SPSS version 27 (IBM Corp., Armonk, NY, USA). RESULTS: Common dermatoscopic findings were erythema 200 (100%), hyperkeratosis 140 (70%), crusting 50 (25%), ulceration 42 (21%), milia-like structure 58 (29%), tear drop-like structure 46 (23%), yellow tears 70 (35%), and white starburst pattern 68 (34%). Less common findings were yellow hue 28 (14%), orange areas 26 (13%) and scar seven (3.5%). Vascular structures frequently observed were linear vessels 109 (54.5%), dotted vessels 80 (40%), and hairpin vessels 61 (30.5%); less common findings were comma-shaped vessels 52 (26%), arborizing vessels 20 (10%), crown vessels nine (4.5%). Comparison of dermatoscopic features was done with slit skin smear for LD bodies (p value = 0.003 ) and histopathology (p value = 0.001). CONCLUSIONS: Dermatoscopy is a non-invasive technique that is helpful in diagnosing cutaneous leishmaniasis, saving time in making rapid diagnosis and saving the need to undergo extensive invasive investigation. Yield of dermatoscopy was comparable to slit smear for LD bodies and histopathology and was found to be effective in making rapid diagnosis with significant accuracy (p value <0.05).

Clinical spectrum of cutaneous leishmaniasis: an overview from Pakistan.

The clinical spectrum of leishmaniasis encompasses subclinical (inapparent), localized (skin lesions), and disseminated infection (cutaneous, mucosal, or visceral). The clinico-pathological picture of cutaneous leishmaniasis is variable and depends not only on the leishmania species but also on endemic region, host factors, and immuno-inflammatory responses. Symptomatic disease is subacute or chronic and diverse in presentation and outcome. Pakistan is one of the countries in which cutaneous leishmaniasis is becoming an epidemic disease and because of its morbidity and disfiguring scars, it is considered a serious public health problem. This is an attempt to review the clinical spectrum of old world cutaneous leishmaniasis, classical and unusual clinical presentations, occurring in Pakistan.

Dermatology Residency Training in COVID-19 Pandemic: Transition from Traditional to Online Teaching.

The novel coronavirus (COVID-19) pandemic has placed unprecedented demands on the health profession; and unique challenges are emerging in almost all fields of medicine, including dermatology. This ongoing health crisis has also significantly disrupted medical education globally. As the pandemic continues to develop, traditional medical education of in-person lectures, seminars and bedside teaching is being rapidly replaced by various modalities of online education. This transition was already taking place for last many years in the developed world, but developing countries were experiencing barriers even for its partial implementation. Current challenge of COVID-19 has created an opportunity for these countries to adopt online teaching as a major tool of education. We describe our preliminary experience of this rapid transition, its advantages, challenges faced and future perspectives in a resource-constrained environment and ongoing enormous health crisis of COVID-19. Key Words:  Novel coronavirus, Medical education, Developing countries, Postgraduate training, Online teaching, E-learning, WhatsApp, Pandemic pedagogy.

Harlequin Fetus in a Twin Pregnancy: An Extremely Rare Presentation.

Harlequin ichthyosis (HI) is a rare fatal type of congenital ichthyosis with autosomal recessive inheritance pattern. We report an uncommon presentation of a case of HI in a neonate, who was the second outcome of the dizygotic twin pregnancy of a Pakistani female. Whilst the first twin remained alive and healthy, HI baby was not able to survive beyond the third day of her life. Although very few cases of HI from Pakistan have been reported in the past; but this case being one of the outcomes of twin pregnancy is unique in its presentation; and to the best of authors' knowledge, has not been reported earlier. Key Words: Harlequin ichthyosis, Autosomal recessive, Congenital ichthyosis, Twin pregnancy.

Clinical spectrum of nasal leishmaniasis in Muzaffarabad.

OBJECTIVE: To determine the frequency of nasal leishmaniasis and the presentation of disease involving nose as well as nasal mucosa in patients reporting from the Muzaffarabad district of Azad Jammu and Kashmir (AJK). STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Combined Military Hospital, Muzaffarabad, from January 2006 to May 2008. METHODOLOGY: All patients belonging to Muzaffarabad district of AJK, clinically suggestive of Cutaneous Leishmaniasis (CL) and supported by laboratory diagnosis were registered. Diagnosis was made on the basis of clinical characteristics of the lesions, laboratory demonstration of leishmania trophozoite bodies on skin smears or skin biopsies and therapeutic trials. Those having lesions primarily on nose, irrespective of age and gender were included in the study. All those cases with primary lesion elsewhere over face and secondarily involving nose (by extension of primary lesion) were excluded. Various demographical features of the patients and clinical patterns of the lesions were recorded in all cases and subsequently categorized accordingly. RESULTS: Seventy three out of 252 (29%) cases of nasal leishmaniasis were encountered. Male to female ratio was 43:30. Fifty five had solitary lesions which were restricted only to nose in 51 patients. Morphological patterns included psoriasiform (30), furunculoid (8), nodular (13), lupoid (8), mucocutaneous (4), rhinophymous (3), erysipeloid (1), basal cell carcinoma-like (1), discoid lupus erythematosis-like (1), mutilating (2), verruciform (1) and keloidal (1). CONCLUSION: Nose was a common site of involvement in CL, where the disease can present in various forms. In endemic areas, CL should be included in the differential diagnosis of all nasal lesions.

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.

Familial dysbetalipoproteinemia: a potentially fatal disorder.

Familial dysbetalipoproteinemia is an inherited disorder in which both cholesterol and triglycerides are elevated in the plasma of the blood, which pre-disposes people to coronary artery disease and peripheral vascular disease. We report two young boys with multiple cutaneous xanthomas and grossly abnormal serum cholesterol and triglycerides. Two of the family members had died of cardiovascular accidents in young age and rest of the family members had deranged lipid profile. Patients were managed with lipid lowering drugs and fat restriction diet. All family members were counseled and advised regular exercise and follow-up.

Clinical spectrum of onchodermatitis.

OBJECTIVE: To describe the frequency and to see various dermatological presentations of onchocerciasis in black Africans of Sierra Leone. DESIGN: An observational study. PLACE AND DURATION OF STUDY: Eastern province (Kenema) of Sierra Leone from November 2004 to October, 2005. PATIENTS AND METHODS: Local black patients of all age groups, attending dermatology outpatient department of Pak Field Hospital (established as a part of UN peacekeeping mission in Sierra Leone) with clinical diagnosis of onchodermatitis, based on symptomatology and morphological features of the disease, were included. UN troops were excluded. Laboratory investigations including blood complete picture and skin snips were carried out in all patients. Skin biopsy and nodule biopsy was performed in selected cases. Skin manifestations were recorded and categorized into various clinical patterns, i.e. acute, chronic, lichenified, onchocercoma, etc. Data was analyzed by using descriptive statistics in "Instat." RESULTS: A total of 3011 patients, belonging to different local tribes, having a variety of skin disorders, were seen during the study period. One hundred and eighty-seven (6.2%) patients were found to have onchodermatitis. Patients were of all ages and both sexes, their ages ranging from 1 month to 73 years. Gender ratio was almost equal. A whole clinical spectrum of onchodermatitis was observed, chronic papular onchodermatitis being the most common pattern. CONCLUSION: Onchodermatitis with a large spectrum of clinical manifestations was seen in black Africans of the eastern part of Sierra Leone.

Hydroa vacciniforme in an adolescent girl.

Hydroa vacciniforme (HV) is a rare photosensitivity disorder with onset in childhood. Recurrent vesicles, bullae and crusting occur on sun-exposed skin that heals with vacciniform scarring. This rare disorder is hereby reported in an adolescent girl who developed a severe episode of hydroa vacciniforme on a hot sunny day during harvesting season. She had repeated episodes afterwards in succession until she was appropriately sun-screened. Her lesions healed without scarring because of early reporting, short-lived episodes, early diagnosis and response to appropriate therapy.

Superficial chemical peeling with salicylic Acid in facial dermatoses.

OBJECTIVE: To determine the effectiveness of salicylic acid chemical peeling in common dermatological conditions affecting face in people with predominant Fitzpatrick skin type IV and V. DESIGN: An interventional, quasi-experimental study. PLACE AND DURATION OF STUDY: Military Hospital, Rawalpindi and PAF Hospital, Sargodha, from July 2002 to June 2003. PATIENTS AND METHODS: A total of 167 patients of either gender, aged between 13 to 60 years, having some facial dermatoses (melasma, acne vulgaris, postinflammatory hyperpigmentations, freckles, fine lines and wrinkles, post-inflammatory scars, actinic keratoses, and plane facial warts) were included. A series of eight weekly hospital based peeling sessions was conducted in all patients under standardized conditions with 30% salicylic acid. Clinical improvement in different disorders was evaluated by change in MASI score, decrease in the size of affected area and % reduction in lesions count. McNemar test was applied for data analysis. RESULTS: Majority of the patients showed moderate to excellent response. There was 35% to 63% improvement (p<0.05) in all dermatoses. Significant side effects, as feared in Asian skins were not observed. CONCLUSION: Chemical peeling with salicylic acid is an effective and safe treatment modality in many superficial facial dermatoses.

Juvenile onset classical pityriasis rubra pilaris: every patient may not require systemic therapy.

Juvenile onset classical Pityriasis Rubra Pilaris (PRP), although rare, is the most common presentation of PRP in children. It has good prognosis and resolution over a few months. Use of potentially hazardous systemic drugs in a disease, that is likely to resolve spontaneously, needs to be assessed carefully. We report a 09 years old boy suffering from this rare disorder, whose disease is well under control with emollients and a combination of diluted topical steroids and keratolytics, for over 06 months.

Pseudoxanthoma elasticum and nephrolithiasis: a rare association.

Pseudoxanthoma elasticum (PXE) is a multi-systemic, genetic disorder of connective tissue characterized by progressive calcification and fragmentation of elastic fibers in skin, retina and cardiovascular system. A young patient reported to urologist in emergency with azotemia secondary to acute bilateral obstructive uropathy. Upon successful management, he was found to have full-blown skin and eye manifestations and was evaluated thoroughly regarding extent and potential systemic complications of Pseudoxanthoma elasticum.

Sensitivity of leishmanin skin test in patients of acute cutaneous leishmaniasis.

BACKGROUND: The leishmanin skin test (LST) is frequently used for clinical diagnosis of cutaneous leishmaniasis (CL). Although, LST is highly sensitive for CL, no definitive data exists as to how early in the disease does the test becomes positive. OBJECTIVE: The study was aimed to evaluate the sensitivity of LST in early cases of CL. PATIENTS AND METHODS: One hundred male patients with CL of not more than 2-weeks duration and having parasitologically proven diagnosis were enrolled in this study, carried out in a military hospital in Balochistan, Pakistan. LST was done by intradermal injection of 0.1 ml leishmanin on the volar surface of the forearm. The skin test reaction was read after 48 hours and then at 72 hours if the first reading was negative or marginal. If the initial test was negative, the LST was repeated after every 7 days until a positive reaction was produced. The total time from the onset of skin lesions until a positive LST was obtained was recorded for every patient. RESULTS: A positive LST was demonstrated in 78/100 patients with skin lesions of

Cutaneous Leishmaniasis in Khyber Pakhtunkhwa Province of Pakistan: Clinical Diversity and Species-Level Diagnosis.

This study primarily aimed to identify the causative species of cutaneous leishmaniasis (CL) in the Khyber Pakhtunkhwa Province of Pakistan and to distinguish any species-specific variation in clinical manifestation of CL. Diagnostic performance of different techniques for identifying CL was assessed. Isolates of Leishmania spp. were detected by in vitro culture, polymerase chain reaction (PCR) on DNA extracted from dried filter papers and microscopic examination of direct lesion smears from patients visiting three major primary care hospitals in Peshawar. A total of 125 CL patients were evaluated. Many acquired the disease from Peshawar and the neighboring tribal area of Khyber Agency. Military personnel acquired CL while deployed in north and south Waziristan. Leishmania tropica was identified as the predominant infecting organism in this study (89.2%) followed by Leishmania major (6.8%) and, unexpectedly, Leishmania infantum (4.1%). These were the first reported cases of CL caused by L. infantum in Pakistan. PCR diagnosis targeting kinetoplast DNA was the most sensitive diagnostic method, identifying 86.5% of all samples found positive by any other method. Other methods were as follows: ribosomal DNA PCR (78.4%), internal transcribed spacer 2 region PCR (70.3%), culture (67.1%), and microscopy (60.5%). Clinical examination reported 14 atypical forms of CL. Atypical lesions were not significantly associated with the infecting Leishmania species, nor with "dry" or "wet" appearance of lesions. Findings from this study provide a platform for species typing of CL patients in Pakistan, utilizing a combination of in vitro culture and molecular diagnostics. Moreover, the clinical diversity described herein can benefit clinicians in devising differential diagnosis of the disease.

Mucormycosis: a devastating fungal infection in diabetics.

Mucormycosis is a highly invasive, devastating and usually fatal fungal infection of the sinuses, brain, or lungs that occurs primarily in people with immune disorders. Despite advances in diagnosis and treatment, a high mortality still exists. We present a middle aged diabetic male with this serious fungal infection involving nose, paranasal area and adjacent periorbital regions with a high risk of progressing further towards the dura mater. He was promptly diagnosed and managed with serial surgical debridements with systemic antifungals and was later fitted with a nasal prosthesis.

Tolerance and safety of superficial chemical peeling with salicylic acid in various facial dermatoses.

BACKGROUND: Chemical peeling is a skin-wounding procedure that may have some potentially undesirable side-effects. AIMS: The present study is directed towards safety concerns associated with superficial chemical peeling with salicylic acid in various facial dermatoses. METHODS: The study was a non-comparative and a prospective one. Two hundred and sixty-eight patients of either sex, aged between 10 to 60 years, undergoing superficial chemical peeling for various facial dermatoses (melasma, acne vulgaris, freckles, post-inflammatory scars/pigmentation, actinic keratoses, plane facial warts, etc.) were included in the study. Eight weekly peeling sessions were carried out in each patient. Tolerance to the procedure and any undesirable effects noted during these sessions were recorded. RESULTS: Almost all the patients tolerated the procedure well. Mild discomfort, burning, irritation and erythema were quite common but the incidence of major side-effects was very low and these too, were easily manageable. There was no significant difference in the incidence of side-effects between facial dermatoses (melasma, acne and other pigmentary disorders). CONCLUSION: Chemical peeling with salicylic acid is a well tolerated and safe treatment modality in many superficial facial dermatoses.

A Therapeutic update on Cutaneous leishmaniasis.

Leishmaniasis, in its visceral (VL), cutaneous (CL) and mucocutaneous (MCL) forms, directly affects hundreds of thousands people per annum, with millions of individuals at risk worldwide. Cutaneous leishmaniasis (CL) is an infective skin disease that manifests as ulcerated nodules, upto several centimeters in size, which are quite resistant to treatment. A wide variety of therapeutic modalities have been employed for cutaneous leishmaniasis. However, none has been demonstrated to be good enough as the first-line therapeutic agent to treat patients in all the epidemiological scenarios. Although pentavalent antimonials are widely used in the treatment of all forms of leishmaniasis, the response is far from satisfactory. These must be administered parenterally with occurrence of therapeutic failures. Secondary treatments incorporate amphotericin B, which is highly active but its use is limited by extensive toxicity complications and high cost. Several oral drugs, such as pentamidine, ketoconazole and itraconazole, have also been tested. Results obtained are not entirely satisfactory. The majority of topical agents have been tested in non-controlled studies, with only few subjects. The interpretation of results is usually difficult due to the lack of a standard and well-accepted cure definition. There remains a pressing need for new anti-leishmanials. This review is focused upon the current status of chemotherapy, the various avenues being investigated by researchers and their potential application in the future.

Multiple familial trichoepithelioma: a rare cutaneous tumour.

Multiple familial trichoepithelioma (MFT) is a rare autosomal dominant skin disease that present as many small tumours predominantly on the face. We report a case of multiple familial trichoepithelioma occurring in three members of a family. They were diagnosed simultaneously. Only one was treated with medium depth chemical peeling with partial response.

Laboratory profile in patients of cutaneous leishmaniasis from various regions of Pakistan.

OBJECTIVE: To delineate the different laboratory findings in patients of cutaneous leishmaniasis and to see the efficacy of some recent immunodiagnostic tools in the diagnosis of disease. DESIGN: Descriptive case-control study. PLACE AND DURATION OF STUDY: The study was conducted over a period of two years in Military Hospital (MH) and Armed Forces Institute of Pathology (AFIP), Rawalpindi, Pakistan. PATIENTS AND METHODS: Fifty patients with clinical diagnosis of cutaneous leishmaniasis(CL), were included in the study from western, south-western and northern regions of the country (Quetta, Multan, Chakwal, Kohat, Northern areas and Islamabad). Complete blood picture, blood groups, skin slit smears, impression smears and skin biopsies and serological tests including Enzyme-linked immunosorbent assay (ELISA), indirect fluorescent antibody test (IFAT), and indirect hemagglutination assay (IHA) were done in all cases. Immunohistochemistry with IFAT was performed in 20 patients and kDNA (kinetoplast DNA) probes in 16 patients. These tests were then evaluated to see their efficacy in diagnosis of CL. RESULTS: Blood CP was normal except for low hemoglobin levels. Most prevalent blood group was B-positive. Skin slit smear and impression smears were positive in 30% and 36% cases respectively. On histopathology four distinct histological patterns emerged. Results with H&E, Giemsa and Leishman stains were similar (36%) and PAS failed to stain parasite. On tissue section IFAT yielded 36%, peroxidase-antiperoxidase (PAP) 45% and kDNA probes 25% positive results. Serology was positive in 56% with ELISA, in 50% each with IFAT and IHA tests. CONCLUSION: Routine blood tests have no role in diagnosis of CL. Skin slit smear and touch impression smears are rapid means of diagnosis. Modern immunodiagnostic methods can produce better results but these are costly and availability is limited. In our setup slit skin smear/impression smear and light microscopy with routine H and E staining are probably the most co-effective accurate diagnostic methods.