Comparison of efficacy and safety of tofacitinib and azathioprine in patients with alopecia areata and variants: a double-blind, randomized controlled trial.

BACKGROUND: Alopecia areata (AA) is an autoimmune pathology manifested by loss of hair. OBJECTIVE: To evaluate and compare the efficacy and safety of tofacitinib and azathioprine in patients with AA and variants. METHODS: In this double-blind randomized controlled trail (RCT) carried out at the Department of Dermatology, Medical Teaching Institute-Lady Reading Hospital (MTI-LRH), Peshawar, Pakistan, patients aged ≥ 12 years diagnosed with AA, alopecia totalis (AT) or alopecia universalis (AU) with minimum 50% scalp hair loss for a period ≥ 06 years were included. Patients were randomly assigned to receive oral tofacitinib 5 mg twice daily (Group I) or oral azathioprine 2 mg/kg body weight once daily (Group II). The primary endpoint was Severity of Alopecia Tool (SALT) score, evaluated at baseline and 06 months follow-up. Safety was consistently assessed during the study. RESULTS: A total of 104 patients underwent random allocation into either the tofacitinib group (n = 52) or the azathioprine group (n = 52). The mean (SD) age of patients was 20.23 (7.14) years and 22.26 (8.07) years, while the mean (SD) disease duration was 6.59 (4.01) years and 7.98 (4.40) years in in Group I and II, respectively. Overall, 40 (38.5%) patients were adolescents while 70 (67.3%) were male. 52 (50%) had AA, 37 (35.5%) had AT and 15 (14.5%) had AU. Mean baseline SALT score in tofacitinib group was 91.02 ± 10.21 and azathioprine group was 91.02 ± 10.63, which at 06 months follow-up improved to 14.1 ± 24.6 and 63.9 ± 33.9, respectively (difference, 11.5 points; 95% confidence interval, 38.3-61.3, p < 0.0001). Overall, no major adverse effects and no difference among the minor adverse effects in the two groups (04 adverse events for tofacitinib group and 08 for azathioprine group: p = 0.23) was observed. CONCLUSIONS: Efficacy of tofacitinib was significantly higher than azathioprine, whilst both drugs were well-tolerated in patients with AA and variants.

Pre-Infusion Checklist For Rituximab In Pemphigus Vulgaris Patients: Clinical Audit.

OBJECTIVE: To evaluate whether or not the pre-infusion checklist for rituximab was followed in patients of pemphigus vulgaris. Method: The audit, intervention and re-audit was conducted at the Dermatology Department, Medical Teaching Institution-Lady Reading Hospital, Peshawar, Pakistan, and comprised in-patients of pemphigus vulgaris, confirmed by skin biopsy and immunofluorescence, who received rituximab between January 1 to March 31, 2022. The randomly picked cases were reviewed to check if the standard guidelines for rituximab prior to infusion had been followed. After completion of the first audit cycle, the medical team was give awareness about the latest pre infusion rituximab guidelines, and they were also provided with a checklist and consent form to implement the change. Re-audit was performed from May to July, 2022, using the same method to see if improvements had been made. Data was analysed using SPSS 23. RESULTS: Of the 20 cases evaluated against 16 parameters, the first audit showed 7(43.5%) parameters to have been met across all cases. Re-audit comprised another set of 20 cases, and showed that 15(93.75%) parameters had been applied across the board Pneumococcal and influenza vaccine was the only element 1(6.25%) not touching universal application. CONCLUSIONS: Re-audit showed major improvement in compliance with the standard guidelines.

Juvenile Dermatomyositis With Rare Cutaneous Manifestation: Generalised Hypertrichosis.

Juvenile dermatomyositis (JDM) is a rare autoimmune disease characterised by inflammation of muscles and skin with extra muscular involvement of joints, heart, intestine, and liver. Pathogenesis of JDM is believed to be due to vasculopathy. Along with classic cutaneous features of JDM, rare findings include hypertrichosis, lipoatrophy, photosensitivity, bullous lesions, and hyperhidrosis. We present, here, a case of JDM with hypertrichosis as very few cases have been reported previously.

A clinic-epidemiological study of 148 patients of pemphigus at Lady Reading Hospital, Peshawar: a case series.

A seven-year retrospective study was held at the Department of Dermatology, Lady Reading Hospital, Peshawar, between 2013 to 2020 to determine the demography and clinical features of pemphigus. Among 148 patients included in this study 88 (58%) were females and 60 (40%) were males with a female to male ratio of 1.46:1. Average age at onset of the disease was 38±12 years (range 14-75 years). On the basis of Autoimmune Bullous Skin Disorder Score (ABSIS), 14 (9.3%) patients had mild disease, 58 (38.7%) had moderate disease, and 76 (50.7%) patients had severe disease. In total, 144 (96%) patients had pemphigus vulgaris, 3 (2%) patients had pemphigus foliaceous and 1 (0.7%) patient had paraneoplastic pemphigus. Severe pemphigus was more frequently associated with multiple relapses (p=0.00). This study shows poor prognostic factors like severe pemphigus vulgaris associated with multiple relapses. Five years of follow-up shows that complete remission on minimal therapy was achieved more in patients who received Rituximab.

Comparison Of Efficacy Of Miltefosine Versus Meglumine Antimonate In The Treatment Of Cutaneous Leishmaniasis.

BACKGROUND: Cutaneous Leishmaniasis is a morbid condition that generates stigmatization and disfiguring scars. Pakistan is among the ninety-eight countries where cutaneous Leishmaniasis is endemic. Purpose of study was to compare the efficacy of miltefosine and meglumine antimoniate in the treatment of cutaneous Leishmaniasis. METHODS: All patients with cutaneous Leishmaniasis (CL) who met the inclusion criteria were divided into two groups using the envelop method. Capsule Miltefosine 50 mg (2.5 mg/ kg) was given to group A, while intralesional Glucantime injection was given to group B. The treatment's efficacy was evaluated after four weeks and again after eight weeks. RESULTS: Out of 74 patients, 37 patients were included in each group. In group A (miltefosine group), 56.75% were males, and 43.25% were females. In group B (meglumine antimoniate group), 62% were males, while 38% were females (p=0.63). The mean age was 32.81 years±12.09 SD, the mean duration of the disease was 5.4 months±2.3 SD and the mean number of lesions was 2.56±1.33 SD. The efficacy of Miltefosine and meglumine antimoniate (I/L) was 91.9% and 56.75%, respectively (p<0.001). CONCLUSIONS: Miltefosine was more effective than intralesional meglumine antimoniate in the treatment of cutaneous Leishmaniasis (p<0.001).

Efficacy Of Methotrexate Versus Azathioprine In The Treatment Of Chronic Actinic Dermatitis: A Randomized Control Trial.

Background: Azathioprine is first line immunosuppressive agent in treatment of chronic actinic dermatitis. The role of methotrexate has been effective in different dermatosis and it seems reasonable to use it in the treatment of chronic actinic dermatitis. Aims: We sought to compare the efficacy of methotrexate versus azathioprine in treatment of chronic actinic dermatitis. Methods: Patients with chronic actinic dermatitis were randomized to receive methotrexate in group A and azathioprine in group B. The response to treatment in terms of percentage PASI reduction and side effects of medications were assessed 12 weeks follow-up. Results: In group A, the percentage PASI reduction was <25% in 2 (1.19%) patients, 25-49% in 47 (27.9%) patients, 50-74% was achieved by 35 (20.8%) patients while in group B, the percentage PASI reduction of 25% was achieved by 2 (1.19%) patients, 25-49% in 45 (26.7%) patients, 50-74% in 37 (22.0%) patients. More than or equal to 75 percentage PASI reduction was not achieved by any patient in the study. Both drugs were found efficacious in treatment of CAD. A total of 23 (27.38%) patients in group A and 22 (26.19%) patients in group B showed derangement in laboratory investigations during 12 weeks treatment. The limitation of study was inability to do photo-patch test, so patients were diagnosed clinically and biopsy was done in clinically challenging cases. Conclusion: : This study shows that methotrexate is equally effective as azathioprine in the treatment of chronic actinic dermatitis with its added benefits of being cost effective and better safety profile.