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.

Combination of Intense Pulse Light and Topical Eflornithine Therapy versus Intense Pulse Light Therapy alone in the Treatment of Idiopathic Facial Hirsutism: A Randomized Controlled Trial.

OBJECTIVE: To compare the efficacy of combination of Intense Pulse Light and topical eflornithine therapy versus Intense Pulse Light therapy alone in the treatment of idiopathic facial hirsutism. METHODOLOGY: A total of 78 patients were included in the study, and were divided into two groups, having 39 patients each. Patients in group A were subjected to combined treatment i.e., topical eflornithine to be applied twice a day and IPL session to be received by patients once a month. Patients in group B were subjected to receive IPL monthly sessions alone. Treatment was continued for 6 months in both groups. After completion of treatment, average number of terminal hair and percentage hair reduction were calculated to see the efficacy. RESULTS: Out of 78 patients, 39 patients were included in group A, and similar number of patients were included in group B. The age of patients ranged from 22-42 years with mean age of 29.59±5.29. Maximum number of patients were in their third decade of life. Mean age in group A was 29.23±5.44, while in group B it was 29.95±5.19. Efficacy in group A was 39(100%) with mean percentage hair reduction of 90.44%, while efficacy in group B was 19 (48.7%) with mean percentage hair reduction of 59.23%, with statistically significant p-value of 0.00. CONCLUSIONS: The combination of intense pulse light and topical eflornithine therapy is more efficacious than intense pulse light therapy alone in the treatment of idiopathic facial hirsutism.

Effectiveness of Oral Methotrexate Therapy versus Systemic Corticosteroid Therapy in Treatment of Generalised Lichen Planus.

OBJECTIVE: To compare the effectiveness of oral methotrexate versus systemic corticosteroids in treatment of lichen planus. STUDY DESIGN: Randomised controlled trial. PLACE AND DURATION OF STUDY: Department of Dermatology, Lady Reading Hospital, Peshawar from September 2013 to February 2014. METHODOLOGY: Patients with generalised lichen planus involving at least 20% of total body area diagnosed clinically and were randomly allocated into two equal groups by lottery method. Patients in group A were subjected to oral methotrexate 10 mg once weekly for eight weeks with standard monitoring of full blood count and liver and renal function tests. Patients in group B were subjected to oral corticosteroids 40 mg for eight weeks taken daily than tapered according to the protocol. The results were assessed at baseline and at the eighth week after starting the treatment. The responses were analysed by Visual Analogue Scale (VAS) and sorted into four categories: 0-3 = poor response, 4-5 = moderate, 6-7 = good, and >7 excellent response. Chi-square test was applied to compare the efficacy in two groups with significance of less than or equal to 0.05. RESULTS: Group A (methotrexate) had 47 (60%) male patients and 32 (40%) female patients. Group B (oral corticosteroids) had 51 (64%) male patients and 28 (36%) females. Group A 55 (70%) patients had lichen planus in <50% of the body; whereas in group B 53 (67%) patients had lichen planus in <50% of the body. Methotrexate was effective in 63 (80%) patients; whereas, oral corticosteroid was effective in 57 (72%) patients. No remarkable side effects were observed with either agent. CONCLUSION: Methotrexate is more efficacious than systemic corticosteroids, but the effect is not statistically significant.

Efficacy of Intense Pulse Light Therapy and Tripple Combination Cream Versus Intense Pulse Light Therapy and Tripple Combination Cream Alone in Epidermal Melasma Treatment.

OBJECTIVE: To compare the efficacy of intense pulse light therapy (IPL) and triple combination cream (TCC) versus intense pulse light therapy and triple combination cream alone in epidermal melasma treatment, downgrading MASI score to more than 10. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Dermatology Department, Lady Reading Hospital, Peshawar, from August 2014 to January 2015. METHODOLOGY: Patients of 18-45 years were included in the study with Fitzpatrick skin type II-V. Sample of 96 patients was divided in to three groups of 32 each, through consecutive (non-probability) sampling method. Detailed history was taken, Woods Lamp Examination done, and melasma area and severity index (MASI) score was calculated. TCC had to be applied daily at night for two months by group A patients while group B was consigned for IPL therapy fortnightly, and those in group C were given both for two months. Efficacy was compared by recalculating MASI score at treatment end as well as at follow-up after 4 weeks, using Chi-square test with significance at p < 0.05. RESULTS: Male and female patients were 10 (31.2%) and 22 (68.8%) in group A, 7 (21.9%) and 25 (78.1%) in group B, while in group C were 12 (37.5%) and 20 (62.5%). The average age was 28.70 +8.70 years. MASI score reduction was achieved in 22 (68.8%) patients in group A; whereas, in 20 (62.5%) and 30(93.8%) patients in group B and C, respectively. Efficacy-wise distribution was significant (p=0.009). CONCLUSION: Intense pulse light therapy and triple combination cream are more efficacious in epidermal melasma treatment than intense pulse light therapy and triple combination cream alone.

Efficacy of Trichloro-Acetic Acid Peel Alone Versus Combined Topical Magnesium Ascorbyl Phosphate for Epidermal Melasma.

OBJECTIVE: To compare the efficacy in terms of reduction in melasma area and severity index (MASI) score by more than 10 of a combination of 20% trichloro-acetic acid peel plus 5% topical magnesium ascorbyl phosphate versus 20% trichloroacetic acid peel alone in the treatment of epidermal melasma. STUDY DESIGN: Randomized controlled trial. PLACE AND DURATION OF STUDY: Department of Dermatology, Lady Reading Hospital (LRH), Peshawar, from May 2012 to May 2013. METHODOLOGY: Patients aged 18 - 65 years, with Fitzpatrick skin type III-V were divided into two equal groups having 74 patients each. Detailed history was taken and Wood's lamp examination done to rule out mixed and dermal melasma. Melasma area and severity index (MASI) score was calculated for every patient. Priming was done for all patients with tretinoin cream applied once daily at night for 2 weeks, and to use a broad spectrum sun block cream before sun exposure. Patients in group Awere subjected to combined treatment, i.e. trichloro-acetic acid peel 20% (weekly) plus magnesium ascorbyl phosphate cream (applied once daily), while patients in group B were subjected to trichloro-acetic acid peel 20% (weekly) alone. Treatment was continued for 6 weeks. After completion of treatment, MASI score was recalculated. Proportion of patients with significant MASI score reduction was compared using chi-square test with significance at p < 0.05. RESULTS: Male and female patients were 11 (14.9%) and 63 (85.1%), respectively in group A, whereas 13 (17.6%) and 61 (82.4%) in group B. The mean age in group Awas 30.28 ±8.08 years, and 29.36 ±6.84 years in group B. Significant MASI score reduction in group Awas seen in 60 (81.1%) patients and in group B 49 (66.2%, p= 0.040). CONCLUSION: Combination of trichloro-acetic acid peel and topical magnesium ascorbyl phosphate cream was significantly more effective than trichloro-acetic acid peel alone in treatment of melasma.

Feasibility, relevance and effectiveness of teaching and assessment of ethical status and communication skills as attributes of professionalism.

OBJECTIVE: To examine the feasibility and effectiveness of teaching and assessing professionalism in a developing country. METHODS: The pre-intervention and post-intervention study was conducted from January to August 2012 and comprised 7 workshops of three days each that were held at four teaching hospitals of Khyber Pakhtunkhwa province in Pakistan. Overall, there were 10 Objective Structured Clinical Examination stations and 10 written scenarios. After the pre-test, workshop was held on various aspects of professionalism which was considered 'intervention', and it was followed by a post-test similar to the pre-test at the end of day 3. Stata 12 was used for all statistical analyses. RESULTS: There were 136 postgraduate residents in the study. The correlation between Objective Structured Clinical Examination stations and written exam for pre-test was 0.42 (p<0.001), while for post-test the correlation was 0.17(p=0.046). Correlation between pre-test written and post-test Objective Structured Clinical Examination stations was 0.23 (p=0.001), but the correlation between pre-test Objective Structured Clinical Examination stations and post-test written was not significant (p>0.05).The standardised effect size for the adjusted regression was 0.37 for both comparisons (p<0.001).Mean pre-test scores were 38.13+/-13.13% vs. 76.50+/-14.4%for the post-test score (p<0.001). CONCLUSIONS: Although post-test scores increased significantly both for the Objective Structured Clinical Examination stations and the written scenarios, the former has shown a higher reliability compared to the written test. Furthermore, teaching and assessment of professionalism was found relevant, effective and feasible in resource-constrained countries. Teaching and assessment of professionalism has become globally relevant and is recommended to be included in the curricula of medical institutions.

Survey on perceptions and skills amongst postgraduate residents regarding breaking bad news at teaching hospitals in Peshawar, Pakistan.

OBJECTIVE: To assess the perception, skills and comfort level of postgraduate residents with respect to breaking bad news. METHODS: Five workshops were conducted on communication skills, including the task of breaking bad news, at three teaching hospitals of Peshawar, Pakistan. Teaching methods included interactive lectures, video presentations, role play and small group discussions. Pre- and post-workshop data was collected from all the 97 participants to assess their previous training, comfort level and perceptions regarding the subject and any improvement after attending the workshop. RESULTS: Of the total participants, 92 (95%) residents had not received any training in communication skills at the undergraduate level. Only 64 (66%) residents had witnessed bad news being broken by a consultant. Before the workshop, 83 (85%) residents felt either not comfortable or somewhat comfortable while breaking bad news compared to 36% post-workshop (p < 0.0000). Besides, 64 (66%) residents reported breaking bad news to be extremely stressful or very stressful before the workshop versus 25% post-workshop (p < 0.0000). Before the workshop, 18 (19%) residents said they would withhold the information from the patient on family's insistence despite the patient's wish to be informed, compared to 6% post-workshop (p < 0.007). Regarding the utility of the workshop, 91 (94%) residents said it had changed their perceptions to a major extent, while 92 (95%) residents rated the workshop as extremely useful or very useful. CONCLUSION: Formal structured training in breaking bad news is lacking both at undergraduate and postgraduate levels in Pakistan. Structured training programmes for residents can do the task effectively.