Topical Tacrolimus Ointment Alone versus in Combination with Microneedling for Refractory Stable Vitiligo.

OBJECTIVE: To assess the efficacy of microneedling in combination with topical tacrolimus ointment 0.1% versus topical tacrolimus ointment 0.1% for treatment of refractory stable vitiligo. STUDY DESIGN: Comparative cross-sectional study. Place and Duration of the Study: Department of Dermatology, PNS Shifa, Karachi, Pakistan, from December 2022 to May 2023. METHODOLOGY: The study included 30 clinically diagnosed individuals of either gender who had refractory symptoms and aged between 20 and 60 years. For every patient, two comparable lesions on two comparable limb regions were selected. Group A (right side) received treatment with both topical tacrolimus ointment 0.1% twice daily in addition to microneedling every two weeks, whereas, Group B (left side) was treated with topical tacrolimus ointment 0.1% only. Every lesion was investigated as a separate entity. Both groups were subsequently observed for a further six months. RESULTS: When topical tacrolimus ointment 0.1% was combined with microneedling, the total re-pigmentation rate was substantially higher than the usage of tacrolimus ointment 0.1% alone. Fifty-three percent of lesions treated with topical tacrolimus ointment 0.1% alone and 76.7% of lesions treated with microneedling in conjunction with it showed a good-to-excellent response. No adverse negative effects were noted. During the follow-up period, no problems or recurrences were noted. CONCLUSION: Tacrolimus ointment combined with microneedling is a successful treatment for refractory stable vitiligo. KEY WORDS: Dermapen, Depigmentation, Microneedling, Tacrolimus ointment, Vitiligo.

Efficacy of Platelet-Rich Plasma versus 5% Topical Monixidil for the Treatment of Androgenetic Alopecia.

OBJECTIVE: To compare the efficacy of platelet-rich plasma (PRP) versus 5% topical minoxidil for the treatment of androgenetic alopecia (AGA). STUDY DESIGN: Randomised-controlled trial. Place and Duration of the Study: Department of Dermatology, PNS Shifa Hospital, Karachi, Pakistan, from 1st November 2021 to 31st July 2022. METHODOLOGY: Seventy AGA patients aged between 18-60 years of either gender were randomly divided into two groups. Group A was given 5% topical minoxidil and Group B was given PRP. Both groups were followed up over a period of 6 months, and the final analysis was done with the help of global photography, hair pull test, and patient satisfaction score. RESULTS: At the end of 6th month, 27 patients (77%) in Group A had a negative hair pull test as compared to only 14 (40%) in Group B (p = 0.001). In Group A, 32 patients (91.4%) reported improvement in hair scalp from baseline. Whereas, in Group B, 26 patients (74.3%) reported improvement from baseline (p = 1.00). PRP was effective in 26 patients (74.5%) and 5% topical minoxidil in 15 patients (43.7%) (p = 0.007). CONCLUSION: PRP therapy can be a useful alternative to topical minoxidil in the treatment of AGA. KEY WORDS: Androgenetic alopecia, Global photography, Platelet-rich plasma, 5% Topical minoxidil, Treatment.

A Rare Case of Angiolymphoid Hyperplasia With Eosinophilia With a New Effective Treatment.

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign locally proliferating lesion of unknown etiology, composed of vascular channels lined by endothelial cells, surrounded by lymphocytes and eosinophils. It presents clinically as a cluster of skin to violaceous-colored nodules on the head and neck, particularly in and around the ear. We present the case of a 50-year-old, Pakistani woman with unilateral multiple nodular lesions for eight years in the left ear concha and postauricular area causing complete obliteration of the external auditory meatus with conductive hearing loss of the left ear for seven years. Biopsy showed lymphoid follicles and dilated blood vessels with mixed infiltrate predominantly eosinophils corresponding to the diagnosis of angiolymphoid hyperplasia with eosinophilia. Surgical excision was not feasible, and there was no response to topical steroids. The patient was started on beta blockers. After three months, postauricular lesions completely resolved, and the size of the rest of the nodules decreased markedly; then hearing loss also recovered. Our objective in this study is to emphasize the importance of considering beta blockers for the treatment of ALHE.

Basaloid follicular hamartoma syndrome: acquired sporadic variant with hypothyroidism, hypohidrosis and alopecia, a rare case.

Basaloid follicular hamartoma is a rare benign malformation of hair follicles, characterised clinically as generalised or localised multiple brown papules mostly on face, scalp and trunk. It may be congenital or acquired with or without any associated disease. Histologically it is composed of epithelial proliferation of basaloid cells with radial disposition enclosed in a fibrous stroma. It is of important consideration because it can be mistaken for basal cell carcinoma both clinically and histologically. Here we report the case of a 51-year-old female with acquired, generalised basaloid follicular hamartomas associated with alopecia, hypothyroidism and hypohidrosis which is an extremely rare disease.

Linezolid and Ciprofloxacin-Induced SJS/TEN (Stevens-Johnson Syndrome/Toxic Epidermolysis Necrosis) Overlap in a Patient With Borderline Personality Disorder During a Single Hospital Stay: A Difficult Case to Manage.

SJS/TEN (Stevens-Johnson syndrome/toxic epidermolysis necrosis) is a T-cell mediated hypersensitivity syndrome in which cytotoxic CD8+ cells react against keratinocytes, resulting in widespread apoptosis and cell necrosis. About 90% of these cases are attributed to drug reactions, while 10% are idiopathic. The disease is classified according to body surface area (BSA) involvement and the thickness of epidermal loss. We report a case of a female with borderline personality disorder on antipsychotic medication, who developed SJS/TEN overlap after taking ciprofloxacin for her urinary tract infection (UTI). Her condition improved with meticulous management, but after switching her antibiotic from intravenous clarithromycin to oral linezolid, she developed SJS/TEN again, this time with more severe involvement. She received active management involving a multidisciplinary approach. Her condition improved slowly and, after one month, her lesions began to heal, and she was discharged with advice not to use both antimicrobial drugs in the future.

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.

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.

A Rare Case Report of Periorbital Pseudolymphoma.

Pseudolymphoma (PSL) of the orbit is a benign lymphoid hyperplasia (LH). It is a rare disease with an extensive range of known causative agents. LH is further classified into "reactive" (RLH) and "atypical" (ALH) types. It clinically presents as a single or a few plaques and/or nodular lesions, particularly on the head, neck, and upper trunk. It must be differentiated from orbital malignant lymphoma. In this report, we present a case of a 58-year-old Pakistani female with an asymptomatic recurrent right periorbital swelling for three years. It was clinically diagnosed as an angiotensin-converting enzyme (ACE) inhibitor-induced angioedema as it responded to stopping the ACE inhibitor; however, after four months, the patient again started to develop right periorbital swelling. An incisional biopsy revealed perivascular and periadnexal infiltration of lymphocytes, plasma cells, and a few neutrophils along with pigmentary incontinence. The formation of multiple lymphoid follicles and infiltration by monomorphic lymphoid cells in deeper skeletal muscle fibers were also observed. Immunohistochemistry (IHC) showed polyclonality and low Ki-67 labeling (20%), corresponding to periorbital RLH. Our objective in this study is to highlight the importance of considering PSL as a differential diagnosis in periorbital swelling. We also suggest that recurrent angioedema may lead to PSL.

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).

Rare case of adult Xanthogranuloma: A case report.

Xanthogranulomas are the most common form of non-Langerhans cell histiocytosis. They are benign, asymptomatic, and self-healing, affecting mostly infants, children, and very rarely adults. They present clinically as erythematous to yellow-brown papules. In children they can be single to multiple but in adults they are solitary. We present the case of a 23-year-old Pakistani man with an erythematous to yellow-brown papule on his neck that persisted for 1.5 years. The results of an excision biopsy showed histopathological features of histiocytes, tuoton giant cells and necrobiosis corresponding to xanthogranuloma. We emphasize the importance of considering xanthogranuloma in skin coloured nodules.

Effectiveness of Autoinoculation in Patients with Multiple Warts Presenting at a Tertiary Care Hospital.

OBJECTIVE: To determine the effectiveness of autoinoculation in patients with multiple skin warts. STUDY DESIGN: A Quasi-experimental study. PLACE AND DURATION OF STUDY: Dermatology department of PNS Shifa Hospital, from April to October 2021. METHODOLOGY: Ninety-six patients with multiple warts were enrolled in this study after informed consent. Under strict aseptic measures and local anaesthesia, wart tissue was removed and crushed on a glass slide with the scalpel. Autoinoculation was done on flexor aspects of bilateral forearms after making a subcutaneous pocket which was then stitched. Patients were assessed at monthly intervals for 03 months and after 01 month of the last autoinoculation to see sustained response. Effectiveness was recorded according to ordinal scale; worsening of lesions/no response at <50% resolution/partial response at >50%- <100% resolution and complete response at 100% resolution. RESULTS: Complete response was observed in 88 (91.66%) of the cases, no response was observed in 2 (2.1%) cases where as 6 (6.3%) showed worsening. All patients were compliant with the follow-up. No new eruptions were observed. CONCLUSION: Autoinoculation is a minimally invasive and cost-effective procedure with excellent response to wart. It also decreases recurrence by generating viral-specific immunity. KEY WORDS: Viral warts, Autoinoculation, Multiple, Immunotherapy, Verrucous, Treatment, HPV, Resistant.

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 Topical 0.1% Adapalene Gel Versus Cryotherapy In Patients With Plantar Warts.

BACKGROUND: Plantar wart is a common viral infection of the plantar surface of the foot. Multiple treatment modalities are available but there is no definitive management option. The aim of this study is to compare topical adapalene gel 0.1% with cryotherapy in patients presenting with plantar warts in terms of time taken for complete clearance of the lesions. METHODS: The study was conducted at the Department of Dermatology, PNS Shifa Hospital, Karachi from 28th April to 28th October 2020. Eighty-four patients with plantar warts who fulfilled the inclusion and exclusion criteria were included in the study. Approval from the institutional ethical review committee was sought and written informed consent was taken from all the patients. Patients were divided into two groups, A (Adapalene 0.1% gel) and B (Cryotherapy) of 42 patients each. Adapalene gel was applied twice daily under occlusion at home and cryotherapy was done at the clinic after every two weeks. Patients were followed weekly from the onset of treatment and days taken for complete clearance of plantar warts were noted. Both the groups were compared for the outcome, i.e., time taken for complete clearance of lesions. RESULTS: The mean time for complete clearance of plantar warts in group A was 35.619±3.154 days and in group B, it was 50.404±3.178 days. CONCLUSIONS: Adapalene gel 0.1% used for the treatment of plantar warts helped in complete clearance of lesions faster than cryotherapy.

Onychopathy Induced by Nivolumab: A Targeted Immunotherapy.

Nivolumab is a human immunoglobulin G4 (IgG4) monoclonal antibody that binds to the PD-1 receptor on T-cells and blocks its interaction with PD-L1 and PD-L2, releasing the PD-1 pathway-mediated inhibition of the immune response, including the anti-tumor immune response, resulting in decreased tumor growth. Here, we present a case of a 56-year-old lady with a diagnosis of squamous cell carcinoma (SCC) of the lip who presented with dystrophy of 20 nails, distal onycholysis, yellow-black discoloration of nail plates, painful paronychia with superimposed bacterial infection of big toes of both feet for three months. Few warty growths were also appreciated on big toes of both feet. She had undergone for her SCC 33 sessions of radiotherapy and 43 cycles of nivolumab 140mg for 60 minutes every two weeks. Following discontinuing this drug, the peri-ungual and nail bed inflammation improved, however nail plate dystrophy persisted. To our knowledge, the occurrence of nail dystrophy with nivolumab has never been reported before but it has been described with other targeted therapies.

Comparison of the Efficacy of Tap Water Iontophoresis Versus Aluminum Chloride Hexahydrate in the Treatment of Palmoplantar Hyperhidrosis.

OBJECTIVE: To compare the efficacy of tap water iontophoresis (TWI) versus aluminum chloride (AC) hexahydrate in the treatment of palmoplantar hyperhidrosis. METHODS: The study was a randomized control trial performed at the dermatology department of Pakistan Navy Station (PNS) Shifa Hospital, Karachi from March 2022 to September 2022. A total of 70 palmoplantar hyperhidrosis patients were included in the study after getting approval from the ethical committee. Patients were divided into two groups. Group A patients were treated with TWI three times a week for four weeks. Group B patients were treated with a 20% AC topical solution applied at night to the affected areas for four weeks. The Hyperhidrosis Disease Severity Scale (HDSS) score for both groups was calculated at baseline, one, two, three, and four weeks. The final response was labeled at four weeks by comparing mean HDSS reduction in both groups. SPSS version 28 (IBM Corp., Armonk, NY) was used for data analysis. RESULTS: Mean HDSS was compared for both groups at the end of the study, which showed a significant reduction in the mean score from 3.40 ± 0.65 to 1.48 ± 0.78 in group A, as compared to a decline in scores in group B from 3.28 ± 0.67 to 2.14 ± 0.94 (p = 0.002). In group A, zero, one, two, and three points HDSS improvement was 2.9%, 25.7%, 48.6%, and 22.9%, respectively. Whereas in group B, it was 34.3%, 22.9%, 34.3%, and 8.6%, respectively (p = 0.001). CONCLUSION: As compared to AC topical solution, TWI is an effective, safe, and inexpensive management option for palmoplantar hyperhidrosis. It causes more improvement in HDSS scores and has lesser side effects.

Effect of oral eplerenone in anatomical and functional improvement in patients with chronic central serous chorioretinopathy.

OBJECTIVE: To determine the efficacy of oral eplerenone in anatomical and functional improvement in patients with chronic central serous chorioretinopathy (CSCR). METHODS: This quasi experimental study was performed at PNS Shifa Hospital Karachi from September 2018 to February 2019. Study included 23 patients. Patients were included using consecutive sampling technique and informed consent was taken from all patients before staring treatment. 50 mg of oral eplerenone per day was given for three months. Subretinal fluid (SRF) height and visual acuity (VA) were noted at baseline, one month and three month follow-up. Structured Study performa was used for data collection. Data was analysed and assessed with SPSS version 23. P value of <0.05 was considered statistically significant. RESULTS: Mean age of patients was 40.7±7 years and mean duration of disease before treatment was 3.7±0.76 months. Mean baseline BCVA and SRF height was 0.39±0.02 logMAR and 123±12.5 µm respectively. Sixty-five percent patients responded at one month and 80% at three months with reduction in SRF height. Improvement in visual acuity was also statistically significant at 3 months (p<0.05). CONCLUSION: Use of eplerenone in chronic CSCR resulted in significant improvement in vision and decrease in mean SRF height.

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.