The Association of HLA Alleles and Haplotypes with Age of Disease Onset in Pakistani Psoriatic Patients.

INTRODUCTION: The human leukocyte antigen (HLA) region on chromosome 6p21 is well known to carry the most important genetic factors in susceptibility to psoriasis. Different HLA alleles and haplotypes have been reported to be associated with psoriasis in different populations. Psoriasis has a variable age of onset and, based on this, it can be classified into two types; type I with age of onset before 40 years of age and type II with age of onset after 40 years of age. The objective of this study was to determine the association of HLA class I and class II alleles and haplotypes with disease and stratification using age of onset in Pakistani psoriatic patients. METHODS: A group of 603 individuals (326 cases and 277 controls) were analyzed for HLA class I and II alleles and haplotype association by sequence specific PCR. The association was further analyzed according to the age of onset of the patients. RESULTS: We found that HLA alleles B*57 and Cw*06:02, DQB1*03:03:02 are strongly associated with early onset psoriasis, while alleles B*15, DRB1*13:02 and DQB1*03:03:02 are associated with late-onset psoriasis. Cw*06:02 allele was not associated with late-onset psoriasis patients. Allele DQB1*03:03:02 had the highest odds ratio in all patients. We found a novel association specifically with late-onset psoriasis samples with the haplotype HLA-A*11; B*15; Cw*04; DRB1*15; DQB1*05 (Pc = 3.60 × 10-7). We also found strong association with previously reported extended haplotype EH-57.1: HLA-B*57; Cw*06:02; DRB1*07:01; DQB1*03:03:02 in all our patients (Pc = 8.34 × 10-07). CONCLUSION: Our results show that different HLA class I and II alleles and haplotypes are associated with psoriasis at different age of onset. In this study, we have reported novel alleles and haplotype association with late-onset psoriasis. Our data confirm the previous strong associations with HLA alleles and haplotypes and also reports novel alleles and haplotype association in Pakistani psoriasis patients.

Identification and association of recurrent ALOXE3 mutation with non-bullous congenital ichthyosiform erythroderma in two ethnically distinct Pakistani families.

Non-bullous congenital ichthyosiform erythroderma (NCIE) is characterized by skin scaling with erythema. In this study, two Pakistani families with NCIE are genetically characterized through Whole Exome and Sanger sequencing to identify molecular basis of the disease. We identified a nonsense homozygous c.2026C>T mutation of ALOXE3, causing premature termination of the eLOX3 protein (p.Q676X). In silico studies predicted impaired enzymatic activity of the premature truncated eLOX3, leading to abnormal synthesis of specific hepoxilin derivatives, essential for epidermal barrier formation. It is the first ever study reporting homozygotes of p.Q676X mutation in ethnically distinct two Pakistani families; otherwise, heterozygotes of the said mutation have been reported in South Asian population only. Hence, mutation seems to be region-specific and may be useful for molecular diagnosis of NCIE. Moreover, our findings should help in genetic counseling and career screening.

Identification of recurrent c.742G>T nonsense mutation in ECM1 in Pakistani families suffering from lipoid proteinosis.

Lipoid proteinosis (LP) is one of the rare, recessive autosomal disorders clinically characterized by widespread deposition of hyaline-like material in the skin, mucosa and viscera. Classical features include beaded eyelid papules, laryngeal infiltration and hoarseness of voice caused by pathogenic mutations in the ECM1 gene located on 1q21.2. In present study ethnically different, three consanguineous Pakistani families with typical cutaneous features of LP were analysed to investigate the underlying molecular basis. PCR based linkage analysis using microsatellite markers localized the families to locus 1q21.2, harboring ECM1 gene. To identify the mutation in the candidate gene (ECM1), Sanger sequencing was carried out. All the families were found to carry c.742 G>T nonsense mutation in exon 7 of the ECM1 gene that resulted in a truncated ECM1 protein containing 247 amino acids instead of 540 (p.E248X). To further investigate the impact and importance of mutation in LP pathogenesis we applied different bioinformatics tools. In silico studies has predicted lack of functional domains and 65 % shorter ECM1 mutant protein. It is the first report of recurrence mutation from Pakistan as c.742G>T nonsense mutation was found in three ethnically different Pakistani families with LP. Study strengthens the conclusion that c.742G>T mutation is the pathological cause of LP. Furthermore, data also support the fact that exon 7 is one of the most common hot spots of pathological mutations in ECM1. The absence of functional domains and truncated sequence most likely contribute to the lack of ECM1 function and thereby influence several aspects of dermal homeostasis that leads to LP pathogenesis.

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.

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.

Colloid milium: a rare cutaneous deposition disease.

Colloid milium is a rare degenerative skin disorder known by the development of small translucent, yellowish brown pappular nodules or plaques, generally located in sun exposed areas. Clinically they are of two types, adult and juvenile type. We present a case of adult type Colloid milium in a 60 years old female patient with clinical and histological findings unmistakable of the condition. She was treated with IPL. (Intense Pulsed Light) laser following unsatisfactory response with dermabrasion.

Many faces of cutaneous leishmaniasis.

BACKGROUND: Cutaneous leishmaniasis (CL) is known for its clinical diversity and increasing numbers of new and rare variants of the disease are being reported these days. AIM: The aim of this descriptive study was to look for and report the atypical presentations of this common disease occurring in Pakistan. METHODS: The study was carried out in three hospitals (MH, Rawalpindi; PAF Hospital, Sargodha; and CMH, Muzaffarabad) from 2002 to 2006. Military and civilian patients of all ages, both males and females, belonging to central and north Punjab province and Kashmir were included in the study. Clinical as well as parasitological features of cutaneous leishmaniasis were studied. The unusual lesions were photographed and categorized accordingly using simple descriptive statistics. RESULTS: Out of 718 patients of cutaneous leishmaniasis, 41 (5.7%) had unusual presentations. The commonest among unusual morphologies was lupoid leishmaniasis 14 (34.1%), followed by sporotrichoid 5 (12.1%), paronychial 3 (7.3%), lid leishmaniasis 2 (4.9%), psoriasiform 2 (4.9%), mycetoma-like 2 (4.9%), erysipeloid 2 (4.9%), chancriform 2 (4.9%), whitlow 1 (2.4%), scar leishmaniasis 1 (2.4%), DLE-like 1 (2.4%), 'squamous cell carcinoma'-like 1 (2.4%), zosteriform 1 (2.4%), eczematous 1 (2.4%), verrucous 1 (2.4%), palmar/plantar 1 (2.4%) and mucocutaneous 1 (2.4%). CONCLUSION: In Pakistan, an endemic country for CL, the possibility of CL should be kept in mind while diagnosing common dermatological diseases like erysipelas, chronic eczema, herpes zoster, paronychia; and uncommon disorders like lupus vulgaris, squamous cell carcinoma, sporotrichosis, mycetoma and other deep mycoses.

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.

Miltefosine in cutaneous leishmaniasis.

OBJECTIVE: To determine the efficacy of oral Miltefosine in patients with cutaneous leishmaniasis and its comparison with the most effective standard treatment, pentavalent antimony compound. DESIGN: A non-randomized, open label comparative clinical trial. PLACE AND DURATION OF STUDY: Dermatology Department, Military Hospital, Rawalpindi, Pakistan from March to October 2005. PATIENTS AND METHODS: Thirty patients, 12 years of age or older clinically and histopathologically diagnosed as cutaneous leishmaniasis were selected. Fifteen patients received orally administered Miltefosine 2.5mg/kg/day for 28 days and remaining 15 received injectable pentavalent antimony 20mg/kg/day for 28 days. Pre-treatment complete physical examination was done along with necessary laboratory investigations in all cases. These were repeated again after 2 weeks and at the end of treatment to note any deviation from the normal limits. Groups were almost matched in terms of age, weight, parasitological score. The efficacy was evaluated by ulcer size, before therapy, at 2 weeks and 4 weeks. Patients were followed-up at 3 and 6 months. Efficacy of two groups was statistically compared by calculating p-value by z-test. RESULTS: All patients completed the study without any serious complication. Lesions improved significantly and only scarring and post-inflammatory pigmentation was left. At 3 months, cure rate was 93% in group A and it was 73.33% in group B while at the end of 6 months, it was 86% and 66.6% respectively. This difference between efficacies of two groups was not found to be statistically significant (p-value>0.5). CONCLUSION: Miltefosine appears to be a safe and effective alternative to currently used therapies. The striking advantage of Miltefosine is its oral administration and it may also be helpful in regions where parasites are resistant to current agents.

Acquired smooth muscle hamartoma.

Smooth muscle hamartoma is an uncommon, usually congenital, cutaneous hyperplasia of the arrectores pilorum muscles. When it is acquired, it may be confused with Becker's nevus. We report a case of this rare tumor in a 19-year-old man. The disease started several years ago as multiple small skin-colored papules that subsequently coalesced to form a large soft plaque on the back of the left shoulder. The diagnosis of acquired smooth muscle hamartoma was confirmed on histopathology. The patient was reassured about the benign nature of the lesion and was not advised any treatment.

Clinicopathological spectrum of mycosis fungoides type cutaneous T-cell lymphoma.

OBJECTIVE: To determine the clinical, histological, and immunophenotypic characteristics of mycosis fungoides type cutaneous T-cell lymphoma. DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: This study was conducted from January 2000 to December 2004 at the Department of Dermatology, Military Hospital and the Department of Dermatopathology, Armed Forces Institute of Pathology, Rawalpindi. MATERIALS AND METHODS: The medical case records of patients with mycosis fungoides diagnosed during the period of study were surveyed. Data was collected pertaining to patient s characteristics, clinical descriptions, histopathological features, immunophenotypic analysis and stage of disease at the time of diagnosis. RESULTS: A total of 33 cases of mycosis fungoides were diagnosed between the years 2000 and 2004. There were 24 male and 9 female patients with male to female ratio of 2.6:1 The age ranged from 24 to 68 years and the duration of disease prior to diagnosis varied between 2 to 36 months. The number of skin biopsies performed for definite diagnosis ranged from 01 to 5. The various clinical presentations recorded in these patients were hypopigmented patches in 7 (21.3%), infiltrated papules and plaques in 6 (18.2%), erythroderma in 5 (15.2%), psoriasiform lesions in 3 (9%), and nodular lesions in 3 (9%) patients. There were 2 (6%) cases respectively of noduloulcerative, ichthyosiform and poikilodermatous lesions, and 1(3%) case each of follicular, morphoea-like and purpuric skin lesions. The predominant histological features were lymphocytic infiltrate in the upper dermis, epidermotropism, haloed lymphocytes in epidermis, Pautrier s microabscesses, and interface dermatitis. The immunohistochemical studies (n=12) showed predominantly T helper cell immunophenotype (CD3+, CD45RO+) in 11(92%) cases and T suppressor cell immunophenotype (CD3+, CD8+) in 1(8%) patient. CONCLUSION: The mycosis fungoides type cutaneous T-cell lymphoma has a wide clinicopathological spectrum. In a clinically non-specific dermatosis, a high index of suspicion and a regular follow-up may eventually lead to the definite diagnosis.

Paederus dermatitis in Sierra Leone.

Paederus dermatitis, a type of irritant contact dermatitis attributed to a Staphylinid beetle, is prevalent in most parts of the world. We studied 50 cases of Paederus dermatitis at the United Nations Hospital at Koidu Sierra Leone (West Africa), over a period of 6 months from Oct 2003 to Mar 2004. The objectives of the study were to determine clinical patterns of dermatitis and its response to topical steroids, with and without antibiotics. Patients with a definite history of contact with the insect were included in the study. Amongst these, 14 of the more severe cases were treated with oral prednisolone or intralesional triamcinolone acetonide. The remainder of the 36 patients were divided in two equal groups A and B. Patients in Group A were treated with topical diflucortolone valerate 0.001 percent and oral cetirizine hydrochloride; patients in group B were given oral ciprofloxacin in addition. In 50 patients studied, 43 (86%) were males and 7 (14%) were females. The neck was the most common site involved followed by face. Healing time ranged from 14 to 28 days and lesions in all the patients healed with residual dyschromia. Healing time was shorter in Group B patients in comparison with those in Group A. Paederus dermatitis in Sierra Leone is a relatively severe form of this dermatitis. The better response to a combination of topical steroids and oral antibiotics may indicate concurrent bacterial infection.

Comparative cellular immune host response in acute vs healed lesions of cutaneous leishmaniasis.

BACKGROUND: Cutaneous leishmaniasis (CL) has become a major public health problem in Pakistan and research is now focused to characterize the host's immune response, its clinical correlation and subsequent implications in management in this disease. This study was done to evaluate cellular immune host response in patients with active and healed CL and its possible implications in prevention of disease in susceptibles. METHODS: This cross sectional and comparative study was conducted in Armed Forces Institute of Pathology (AFIP) and Military Hospital (MH) Rawalpindi (1998-2000). 30 biopsies of active skin lesions and 15 biopsies from healed lesions, after processing, were studied for various immunophenotype cells by using monoclonal antibodies. Total and differential T cell counts were recorded in these skin tissues. Non parametric Kruskal-Wallis Test for one way ANOVA was used to compare the median cell counts between active, healed and normal skin and p-value < 0.05 was considered significant. RESULTS: The total cell counts, CD3+ cells and CD57+ (NK) cells were found statistically different (p = < 0.001) when active forms of the disease were compared with healed lesions and normal skin tissue. The difference was not significant (p = > 0.05) on comparing healed lesions with normal skin tissue biopsies except in case of CD3+ cell counts (p = < 0.05). However, CD4+, CD8+ and CD19+ (Plasma cells) counts were never seen significant (p = > 0.05) on comparison. CONCLUSION: NK cells and gamma delta cells seem to be responsible for limitation of the disease and elimination of the parasite from the lesion in cases of acute cutaneous leishmaniasis.

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.

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.

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.

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.

Zosteriform Lichen planus.

Ordinarily, Lichen planus (LP) is as easily recognizable as an old friend of a dermatologist. But some times it comes in disguise. It has been reported to occur in the scars of previous herpes zoster lesions. Zosteriform pattern in LP, without evidence of herpes zoster, is an extremely rare occurrence and such presentation of the disease over head and neck region, to the best of our knowledge, was not reported in literature before. We present a patient who had grouped lichenoid lesions on one side of the neck with no previous or concomitant history of herpes zoster on the involved site or elsewhere on the body.