Quality of Life Index in Patients with Vitiligo.

OBJECTIVE: To ascertain the quality of life (QoL) impairment among the Pakistani population with vitiligo and to determine the relationship between sociodemographic and clinical characteristics. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: Dermatology Outpatients at the Aga Khan University in collaboration with outpatients of seven tertiary care hospitals of Sindh, Punjab, KPK, Balochistan, and AJK to collect data from March 2015 to April 2019. METHODOLOGY: All clinically diagnosed patients of vitiligo, who signed consent and assent forms, were included in the study. A validated 25-item, QoL scale for vitiligo was used. Socio-economic status of the patients, clinical assessment of the disease and patients' engagement in social and domestic lives was noted. RESULTS: Five hundred and seventy-three patients were enrolled in the study, having mean age 29.8 ± 16.2 years. In 306 (53.4%) males and 267 (46.65%) females; 21.8% were below 18 years. Mean vitiligo QoL index was 38.4 ± 11.8. Patients of vitiligo with disease duration 5-10 years, those affected on exposed parts, more than five body sites, rapidly progressing disease and of female gender had a higher impairment of quality of life. These scores were found significantly higher as compared to other levels of these parameters (p<0.05). CONCLUSION: Patients with vitiligo experience low self-esteem. The disease adversely affects their quality of life. The authors recommend the use of disease-specific instruments to assess the quality of life which enables the treating physician to devise best possible management plan individually. KEY WORDS: Vitiligo, Quality of life, Pakistan, Vitiligo life quality index.

Efficacy of Autoinoculation in Treatment of Multiple Viral Warts - A Single Arm Study.

OBJECTIVE: To test the effectiveness of autoinoculation of a wart in patients with multiple viral warts. STUDY DESIGN: An experimental study. PLACE AND DURATION OF STUDY: Department of Dermatology, Pak Emirates Military Hospital (PEMH), Rawalpindi, from February 2021 to February 2022. METHODOLOGY: Patients above 12 years of age, having more than 5 warts were included. Those getting any other treatment for warts were excluded. The procedure was performed on a total of 70 patients with warts on 3 sites i.e. face/neck, palmoplantar and multiple sites. The outcome was categorised into cleared (no wart), partially cleared (reduced number of warts than baseline), and no response (same or increased number of warts than baseline). RESULTS: Out of 70 patients, 54 (77.1%) patients showed complete response, 6 (8.6%) showed partial response and 10 (14.3%) showed no response at all. Out of 54 patients who showed complete response, 36 (66.6%) were cleared after only one inoculation, fifteen (27.7%) were cleared after two inoculations, and 3 (5.5%) were cleared after three inoculations. The results were statistically significant with p-value <0.05. CONCLUSION: Autoinoculation is a simple and minimally invasive procedure which proved to be very effective against all types of warts, with very promising results against palmoplantar warts. KEY WORDS: Viral warts, Multiple viral warts, Autoinoculation, Delayed hypersensitivity, Human papilloma virus (HPV), Palmoplantar warts, Immunity.

Comparison Of Oral Dapsone With Intramuscular Meglumine Antimoniate In Cutaneous Leishmaniasis.

BACKGROUND: Many drugs are effective are used as second line treatment for cutaneous leishmaniasis. Dapsone therapy is tolerated well and cost effective. The aim of present study is to determine the efficacy of oral dapsone in comparison with intramuscular meglumine antimoniate in patients with cutaneous leishmaniasis and thus find out an effective second line treatment agent. METHODS: This randomized controlled trial was carried out at dermatology department, of tertiary care centre Rawalpindi, Pakistan from November 2017 to June 2018. Hundred biopsy proven patients of cutaneous leishmaniasis completed the study with 50 patients in two group. Group A received intramuscular meglumine antimoniate (15 mg/kg/day). Group B received oral dapsone2.5 mg /kg/body weight /day (200 mg per day). Efficacy of therapeutic response was noted at the end of treatment. Data was analyzed with statistical analysis program (IBM-SPSS V22). Chi-square test was applied to compare efficacy, p value of ≤0.05 was significant. Stratification of data with respect to age, gender, duration of disease, number of lesions and weight was done to see their effect on treatment efficacy. Post stratification chi-square test for both groups was applied (p≤0.05 considered significant). RESULTS: A total of 100 participants took part in the study. Duration of treatment (p-value <0.001) and the efficacy of the drugs (p-value=0.020) were significant. Meglumine antimoniate therapy group displayed a comparatively fast-paced recovery in (21- 40 days) whereas Dapsone group showed better recovery in (41-60 days) in their lesions. CONCLUSIONS: Dapsone is an effective treatment for cutaneous Leishmaniasis.

Comparison of Efficacy of Platelet-Rich Plasma (PRP) With PRP Microneedling in Androgenetic Alopecia.

Background Limited data are available on the efficacy of platelet-rich plasma (PRP) and microneedling versus PRP alone. In this study, we aimed to compare the efficacy of PRP and microneedling with PRP alone in androgenetic alopecia (AGA). Methodology This prospective, randomized, interventional study was conducted in Pak-Emirates Military Hospital, Rawalpindi, from September 2020 to December 2020. In total, 60 individuals suffering from AGA of up to Hamilton-Norwood grade 4 were randomly assigned to two groups, namely, PRP+microneedling versus PRP alone. A total of three sessions, each one month apart, were offered. Pre and post-intervention photographs, hair count (/cm2), hair-pull test, and physician's and patient's perception of hair loss were recorded. The data were statistically analyzed. Results A greater proportion of patients in the microneedling group achieved a negative hair-pull test and improved perception of hair loss compared to the PRP-alone group (82.1% vs. 51.9% and 88.0% vs. 73.9%, respectively). The percentage increase in mean hair count in the microneedling group (24.53 ± 9.49%) was significantly higher than the increase in the PRP-alone group (17.88 ± 10.15%) (p = 0.011). For grades 2 and 3 hair loss, microneedling+PRP caused a much greater increase in hair count than PRP alone. This difference was less pronounced for Norwood grade 4. No notable side effects were noted in any patient. Conclusions Combined PRP and microneedling is more efficacious than PRP alone in patients with AGA up to Hamilton-Norwood grade 4.

The Psychological Impact of Coronavirus Disease 2019 on Patients Attending a Tertiary Healthcare Facility in Pakistan: A Cross-Sectional Study.

The COVID-19 pandemic has had a damaging impact on global health. Post-infection, patients may experience mental health difficulties and therefore require suitable psychological treatment and support. The objective of this study was to identify the psychological impact of COVID-19 on patients who were recovering from the physical effects of the disease, and to examine socio-demographic correlates within one month of treatment at a tertiary healthcare facility in Pakistan. A cross-sectional study was employed that utilized the Depression Anxiety Stress Scale-21 and Post-Traumatic Stress Disorder (PTSD) Checklist for DSM-5. A questionnaire was administered to 250 patients, with data collected over three months. Mild to extremely severe scores of depression, anxiety and stress were reported by approximately 43%, 52% and 42% of participants, respectively, and 8% developed PTSD. The incidence of depression, anxiety, stress or PTSD was not significantly associated with gender, age or previous interaction with COVID-19 patients. Depression was significantly associated with levels of education, severity of COVID-19 disease and a patient's current condition. Anxiety was associated with healthcare worker status. The severity of disease and a patient's current condition were also linked to the levels of anxiety, stress and the presence of PTSD. Collectively, these results indicate that a high percentage of patients recovering from COVID-19 experience psychological distress.

Split-Face Comparative Analysis Of Micro-Needling With Tranexamic Acid Vs Vitamin C Serum In Melasma.

BACKGROUND: Melasma is a very common skin problem that is much more prevalent in women. In our society, it results in many psycho-social implications and eventually leads to an impaired quality of life. Many treatment modalities have been developed for it. However, in recent years resistant forms of melasma have emerged that are unresponsive to the usual first line treatment options. Thus, this study is being conducted to explore new treatment modalities for this disease by using micro-needling with vitamin C and tranexamic acid. METHODS: Thirty patients participated in this non-randomized clinical trial including 11 males and 19 females. All patients received Tranexamic acid via micro-needling on right side of the face and Vitamin C on the left side. A total of three biweekly sessions were performed. Patients' response was evaluated at week 2, 4 and 6 on the basis of Physician Global Assessment, Patient Global Assessment, modified Melasma Area Severity Index and clinical assessment. Paired sample t-tests were used to calculate the difference in the means of two groups at 2, 4 and 6 weeks and p-value of <0.05 was considered significant. RESULTS: After first session, there was more improvement observed with tranexamic acid. At the end of 6 weeks, modified Melasma Area Severity Index, Physician Global Assessment and Patient Global Assessment showed significant improvement with both tranexamic acid and vitamin C. However, the difference between them was not statistically significant (p>0.05). CONCLUSIONS: Both Tranexamic acid and Vitamin C are potent therapies for melasma as an adjuvant to micro-needling.

Dermatological Manifestations of COVID-19 in Patients Reporting to a Tertiary Care Hospital in Rawalpindi, Pakistan.

Introduction The clinicopathological description of dermatological manifestations of COVID-19 leaves much to be desired. There is a need to determine their association with disease severity, outcome, and other clinical variables. Objectives The objectives of this study are to record and histopathologically examine the cutaneous manifestations of COVID-19 and correlate these to age, disease severity, and mortality. Methods All confirmed COVID-19 patients admitted to a single tertiary healthcare hospital in Rawalpindi, Pakistan, were included. Their diseases were classified as mild, moderate, severe, and critical. The recent onset skin eruptions in these patients were recorded via photographs along with relevant clinical data. The photographs were independently reviewed by a group of three dermatologists without knowledge of the clinical information. The skin manifestations were divided into disease-specific and nonspecific categories using an already defined algorithm. Histopathological examination of skin manifestations was conducted. Results A total of 23% (n=47) had "new" skin manifestations. Specific skin findings were seen in 21.6% (n=44), which consisted of ecchymosis/purpura in 50% (n=22), maculopapular exanthem in 18% (n=8), livedo reticularis in 16.2% (n=7), ischemia/gangrene in 16.2% (n=7), perniosis in 15.9 % (n=7), vesiculo-bullous rash in 9% (n=4) and urticaria in 4% (n=1). Non-specific findings were seen in 6% (n=13) and included bedsores, dermatitis passivata, dryness, herpes labialis, oral ulcerations, and nasogastric tube-induced ulcerations. There was a significant association (p=0.03) between disease severity and specific skin lesions. Ischemia/gangrene was significantly associated with COVID-19 disease severity and mortality. Vesiculobullous lesions were associated with higher mortality, though not with disease severity. Livedo reticularis had a higher-than-expected count in critical disease, albeit statistically insignificant. The association of maculopapular exanthem and ecchymosis/purpura with severe/critical disease was statistically insignificant. Urticaria was significantly associated with low disease severity. Mean age with specific manifestations was 56.86 ± 15.81 and with nonspecific/without any manifestations was 42.58 ± 16.96, a highly significant difference, with p-value < 0.001. Old age (>60 years) was significantly associated with ecchymosis (p=0.038), maculopapular exanthem (p=0.021), and vesiculo-bullous rash (p=0.029). Histopathology varied according to the type of skin lesion. Conclusions Dermatological manifestations coexist in many patients and tend to appear more in severe cases of COVID-19 among the older age group and only minimally in mild/moderate cases. Their presence could help set prognostic criteria of COVID-19 disease in the future.

Frequency Of Metabolic Syndrome In Patients With Psoriasis.

BACKGROUND: Psoriasis is a non-communicable, long-lasting disorder of the skin comprising various immunological inflammatory changes. Increasing evidence suggests that psoriasis is closely related to multiple organ systems, potentially arising due to underlying co-morbid conditions such as diabetes, hypertension, dyslipidaemia and obesity. Aim of this study was to know the frequency of metabolic syndrome in psoriasis patients. METHODS: This cross-sectional study was conducted from May to November 2020 in a Tertiary-care hospital. Eighty patients diagnosed with psoriasis were selected using non-probability consecutive sampling. Informed written consent was obtained from each patient and a questionnaire was filled. Blood pressure, waist circumference, body surface area covered by psoriasis, Psoriasis Area Severity Index were recorded on initial visit. Fasting blood sugar, serum triglyceride and HDL cholesterol levels were advised. Patients were diagnosed to have metabolic syndrome if ≥3 out of 5 criteria for the modified version of National Cholesterol Education Program Adult Panel III were met. RESULTS: There were 62 male and 18 female patients. A total of 39 patients (48.8%) met the criteria for metabolic syndrome. Amongst these, 26/62 (41.9%) males vs 13/18 (72.2%) females fulfilled the criteria. The mean BMI of males was 26.0 while those of females was 28.3, comparison of which demonstrated a noteworthy difference (p=0.04). A statistically significant (p=0.038) positive correlation (r) of 0.233 was observed between body surface area and BMI. CONCLUSIONS: Metabolic syndrome is seen frequently in patients of Psoriasis. Female patients have a significant frequency of metabolic syndrome and tend to have a higher BMI than males.

Malignant Acanthosis Nigricans: An Indicator of Internal Malignancy.

Acanthosis nigricans is a skin disease characterised by symmetric velvety hyperpigmented, verrucous plaques of the intertriginous surfaces of the axilla, neck, inframammary, and mucocutaneous regions. Malignant acanthosis nigricans is a paraneoplastic phenomenon most commonly associated with gastric adenocarcinoma. Tripe palms, florid cutaneous papillomatosis and oral involvement along with generalised acanthosis nigricans are the features which are highly suggestive of internal malignancy. This case report describes a rare case of a patient who presented with combination of malignant acanthosis nigricans, tripe palms, florid cutaneous papillomatosis and oral involvement associated with undifferentiated malignant neoplasm of hepatic bile ducts.

HLA- DR Alleles in Pakistani Patients of Pemphigus Vulgaris.

OBJECTIVE: To determine frequency of HLA-DR alleles in Pakistani patients of pemphigus vulgaris in comparison with local healthy controls. STUDY DESIGN: Cross-sectional, comparative study. PLACE AND DURATION OF STUDY: Department of Immunology, Armed Forces Institute of Pathology (AFIP), Rawalpindi, from January 2011 to January 2014. METHODOLOGY: Twenty eight patients with biopsy proven diagnosis of pemphigus vulgaris referred from Department of Dermatology, Military Hospital, Rawalpindi were included. Patients were compared with a group of 150 unrelated local healthy subjects. DNA was extracted from peripheral blood collected in Tri-potassium EDTA. HLA-DRB1 typing was carried out on allele level (DRB1*01--DRB1*16) using SSP (sequence specific primers). HLA type was determined by agarose gel electrophoresis and results recorded. Phenotype frequency of various alleles among patient group and control group was calculated by direct counting and significance of their association was determined by Fisher's exact test/ Chi square test. RESULTS: A total of 12 male and 16 female patients, with age ranging from 21 to 34 (mean 23.4 years) were genotyped for HLA-DRB1 loci. A statistically significant association of the disease with HLA-DRB1*04 was observed (50% versus 20.7% in controls, p < 0.05). CONCLUSION: There is a strong association of HLA-DRB1*04 with pemphigus vulgaris in Pakistani population.

Efficacy of clarithromycin in pityriasis rosea.

OBJECTIVE: To determine the efficacy of clarithromycin in the treatment of Pityriasis Rosea (PR). STUDY DESIGN: Double blind randomized controlled trial. PLACE AND DURATION OF STUDY: Dermatology OPD, Military Hospital, Rawalpindi, from July 2008 to July 2009. METHODOLOGY: Patients aged above 10 years, diagnosed with PR, were randomly assigned to two groups of 30 each to receive either clarithromycin or similar-looking placebo for one week. Neither the patient nor the treating physician knew to which group the patient belonged. Patients were assessed at 1, 2, 4 and 6 weeks after presentation and compared for complete, partial or no response. RESULTS: Among the 60 patients, no significant difference was found between the two groups at 2 weeks after presentation (p = 0.598). In the placebo group, complete response was seen in 20 (66.7%), partial response in 3 (10.0%) while no response was seen in 7 (23.3%). In clarithromycin group, there was complete response in 23 (76.7%), partial response in 3 (10.0%) and no response in 4 (13.3%) patients. CONCLUSION: Clarithromycin is not effective in treatment of pityriasis rosea.

Adams-Oliver syndrome.

A new-born male baby with typical features of Adams-Oliver syndrome (AOS) is described. Adams-Oliver syndrome is the association of aplasia cutis congenita with terminal transverse limb reduction defects with or without cutis marmorata telangiectatica congenita. The patient presented with brachydactyly involving all the digits of his hands and shortening of both big toes along with aplasia cutis on the scalp. There was no systemic involvement. The patient was placed on regular follow-up.

Scleroderma renal crisis in a newly diagnosed mixed connective tissue disease resulting in dialysis-dependent chronic kidney disease despite angiotensin-converting enzyme inhibition.

Mixed connective tissue disease (MCTD) is a rheumatic disease with a combination of multiple connective tissue disorders, which includes dermatomyositis or polymyositis, systemic sclerosis, systemic lupus erythematosus, rheumatoid arthritis and Sjögren's syndrome. It affects various organs of the body, which includes the lungs, heart, kidneys, joints, muscles and the haematological system. Here, we report a case of MCTD consisting of scleroderma, Sjögren's syndrome and polymyositis complicated by scleroderma renal crisis (SRC) but with negative anti-nuclear antibody (ANA), anti-Scl 70 and anti-centromere antibodies. The patient was started on captopril for the treatment of SRC but developed chronic kidney disease despite adequate blood pressure control with angiotensin-converting enzyme inhibitor (ACEi).

Pseudoainhum in acute psoriasis.

The term Pseudoainhum is used in medical literature to elaborate the presence of constricting bands around the digits of hands and feet due to variety of etiologies. This phenomenon can lead to irreversible damage to the supplying neurovasculature and sequential autoamputation of the affected digits. The report herein, describes the rare presentation of pseudoainhum occurring concomitantly in acute psoriasis. Timely recognition of such rare disease entities by physicians is imperative to avoid unnecessary complications.

Patterns of psoriatic arthritis.

OBJECTIVE: To describe the clinical patterns of arthritis in psoriasis. STUDY DESIGN: Cross-sectional, observational study. PLACE AND DURATION OF STUDY: Combined Military Hospital, Kharian Cantonment, Pakistan, from January to December 2007. METHODOLOGY: One hundred consecutive patients with psoriasis reporting to dermatology outpatient department were included. Pregnant ladies (due to X-ray hazard) and rheumatoid factor positive patients were excluded. The demographic profile of patients was recorded. Psoriatic arthritis was diagnosed on the basis of Moll and Wright criteria. Standardized examination of axial and peripheral joints was made. The severity of psoriasis was assessed by PASI score. The presence of a clinical type of psoriatic arthritis, enthesitis, dactylitis, and nail changes were noted. X-ray films of involved joints were taken. A statistical analysis using chi-square test and student's t-test were done where applicable. RESULTS: The mean age of patients was 39.8+15.8 years. Seventy one percent were males and 29% were females. Forty six percent of the patients gave a history of joint involvement and fulfilled the Moll and Wright criteria. The mean PASI score in non-arthritic patients was 26.8+34.8 and in psoriatic arthritis patients it was 28.4+41.2, p=0.08. Thirteen patients (28.2%) had predominantly axial disease, while the rest had predominantly peripheral disease. Single joint involvement (monoarthritis) was the commonest clinical presentation. Nail involvement was seen in 29% of the patients without arthritis while in patients having arthritis, nail involvement was 74% (p=0.001). CONCLUSION: Joint involvement is common in psoriatic patients. However, the criteria of diagnosis lack consensus.

Presentation of early onset psoriasis in comparison with late onset psoriasis: a clinical study from Pakistan.

BACKGROUND: Early onset psoriasis and late onset psoriasis are known to have different clinical patterns in Caucasian population. However, there is paucity of data among Asian patients. AIMS: To compare the clinical presentation of early onset psoriasis with late onset psoriasis in Pakistani population. METHODS: During the study period, participating dermatologists filled a pre-tested questionnaire for each patient with psoriasis on first encounter. The questionnaire incorporated information regarding clinical and demographic features of psoriasis including age of onset, clinical type of psoriasis, nail or joint involvement, and PASI score. Patients were then divided into early onset (age of onset < 30 years, group I) and late onset (age of onset > or =30 years, group II) psoriasis. RESULTS: Five hundred and fifteen questionnaires were filled and returned for evaluation. There was no statistically significant difference in both groups with regards to gender, family history (P = 0.09), nail (P = 0.69) and joint (P = 0.74) involvement, disease severity (P = 0.68), and clinical type of psoriasis (P = 0.06). No significant difference between disease severities measured by PASI score was observed in the two groups (P = 0.68). Presence of nail involvement was associated with joint disease in both groups (odds ratio 2.8, confidence interval 1.9-4.1). CONCLUSION: Patients with early and late onset psoriasis in Pakistani population do not show different clinical and demographic features contrary to the Western patients.

Aplasia cutis congenita associated with azathioprine.

Aplasia cutis congenita is a rare skin condition characterized by the absence of localized or widespread areas of skin at birth. We are reporting a variant aplasia cutis congenita, which involved over 90% of the body surface area, which occurred in a baby born to a mother with pemphigus vulgaris who was on oral prednisolone and azathioprine. A case of extensive aplasia cutis congenita was seen and oral intake of azathioprine by the mother during pregnancy was suspected as an etiologic factor. The parents of the patient did not consent for biopsy or autopsy so the histopathological picture was not available and hence involvement of other systems could not be ascertained. Due, to financial constraints some of the investigations which might have helped in assigning the patient to a particular category of aplasia cutis such as karyotyping and CT scan brain could not be carried out.

Vitiligo appearing in striae distensae as a Koebner phenomenon.

Koebner phenomenon, the appearance of preexisting skin lesions following trauma to previously uninvolved skin, has been seen frequently with vitiligo. The type of trauma leading to Koebner phenomenon can vary from scratching, surgical scars, radiotherapy, burns, irritation from drug use and laser therapy. Striae distensae are a form of injury to the skin and in this particular case resulted from rapid increase in body size at puberty and possibly the use of systemic steroids for the treatment of vitiligo. The appearance of vitiligo in striae distensae as a form of Koebner phenomenon has been reported rarely. We describe a 14-year-old boy with vitiligo for the past 2 years, which Koebnerized in the striae distensae.

Comparison of 30% salicylic acid with Jessner's solution for superficial chemical peeling in epidermal melasma.

OBJECTIVE: To compare the efficacy and safety of Jessner's solution with 30% salicylic acid as superficial chemical peeling agents in treating epidermal melasma in Asian skin. STUDY DESIGN: Double blind, randomized, interventional comparative study. PLACE AND DURATION OF STUDY: Department of Dermatology, Combined Military Hospital, Malir Cantt, Karachi, from January to December 2004. PATIENTS AND METHODS: Sixty consenting patients with epidermal melasma were randomly divided into two groups. Group A was treated with Jessner's solution and Group B with 30% salicylic acid. Baseline Melasma Area Severity Index (MASI) score was noted and peeling started at 2-weekly intervals. Sunscreen in morning and moisturizer at night were prescribed in all patients. MASI score and adverse effects were recorded biweekly. Treatment was stopped at 12 weeks and patients were followed-up at 4 weekly intervals for further 12 weeks. Final MASI score and adverse effects were noted at the end of follow-up period. Mean MASI scores were compared using paired sample t-test and one-way ANOVA. RESULTS: Difference in baseline, treatment end and follow-up end MASI scores was not statistically significant between the two groups (p 0.54, 0.26, and 0.55 respectively). On the other hand, within group analysis of difference between pre and posttreatment MASI score was highly significant in both groups (p<0.0001). Adverse effects were mild and comparable in both groups. CONCLUSION: Jessner's solution and 30% salicylic acid are equally effective and safe peeling agents for use in epidermal melasma in Asian skin.