Follicular Becker's Nevus: A New Clinical Variant

Becker's nevus, also known as pigmented hairy epidermal nevus, is characteristically described as a unilateral, hairy, light to dark brown macule with sharply outlined but irregular border. The etiopathogenesis of Becker's nevus is still not clearly understood. Perifollicular pigmentation has been described earlier by some authors. But, Becker's nevus presenting exclusively with follicular lesions has not been described. We are reporting a series of patients of Becker's nevus with follicular lesions. The diagnosis in all the patients was made after clinicopathological correlation. Follicular epithelium may hold a significant role in the etiopathogenesis of Becker's nevus.

Prevalence of HPV Genotypes in Adult Male Patients with Cutaneous Warts: A Cross-Sectional Study

AIM

This study was aimed at determining the distribution of type-specific human papillomavirus (HPV) in men with cutaneous warts and correlating this with the clinical and morphological presentation of warts.

METHODS

Cutaneous wart samples were obtained from 167 adult men presenting to a dermatology clinic. The tissues were fixed and screened for HPV DNA using real-time PCR. The HPV genotype was determined by PCR-based sequencing.

RESULTS

Nine different HPV genotypes were detected, comprising 6 from the α genus (HPV2, 6, 27b, 57b, 57c, and 94), 2 from the γ genus (HPV4 and 65), and HPV1a from the mu genus. Single HPV infection was encountered in 93.4% of the patients, whereas multiple infections were encountered in only 6.6%. The prevalence of HPV27b was highest among four body sites, followed by HPV57c, 1a, and 2. HPV1a was the most common genotype encountered in multiple infections, followed by HPV27b. Patient age, the number of warts, the duration of the presence of warts, and contact with people who have warts were not predictors of wart location. However, a high number of patients with palmar or common body warts had wart sizes of <1 cm.

CONCLUSIONS

This study shows that genus α HPV types are detected in about 82% of patients with cutaneous warts.

Association of HPV genotypes with external anogenital warts: a cross sectional study

BACKGROUND

This study was undertaken to determine the distribution of type-specific human papillomavirus (HPV) in external anogenital warts, and the correlation with clinical presentation of warts and demographic data of patients.

METHODS

Genital warts specimens were obtained from 129 men and 27 women attending a dermatology clinic, who had been advised surgical excision. The tissues were fixed and screened for HPV DNA by using real-time PCR. HPV genotype was determined by PCR-based sequencing.

RESULTS

Sixteen different HPV genotypes were detected, comprising 4 oncogenic HPV genotypes (16, 18, 33, 38), 2 low-risk HPV types (LR) (6, 81), HPV 9, and other types associated with common warts (1a, 2, 4, 7, 27b, 27, 57b, 57c, 65). Oncogenic HPV types were found in 34.62% of patients, LR HPV types in 14.4%, HPV 9 in 0.64%, and common warts type in 50.6%. The prevalence of HPV infection with a single type was 88.4, 9.0% for two types, and 2.6% for three types. Multiple logistic regression model showed that age, gender, nationality, number of warts, size of each wart, and positive history of wart in sexual partner, were not predictors of HPV type. However, patients with anogenital warts of one to six months duration were three times more likely to have oncogenic HPV infection compared to those with less than one month.

CONCLUSIONS

This study shows that oncogenic HPV types are detected in around 35% of patients with genital warts, and are prevalent in warts of one to six months duration.

The effect of tumor necrosis factor inhibitor therapy on the incidence of myocardial infarction in patients with psoriasis: a retrospective study

BACKGROUND

Psoriasis has been shown to be associated with increased incidence of myocardial infarction (MI). The data on the effect of tumor necrosis factor (TNF) inhibitors on MI in psoriasis are scarce.

OBJECTIVE

To evaluate the effect of TNF inhibitors on the risk of MI in psoriasis patients compared with methotrexate (MTX) and topical agents.

METHODS

Data were obtained from the Electronic Health Records database of Farwaniya Hospital from psoriasis patients seen from January 2008 to December 2014. Patients were categorized into TNF inhibitor, MTX and topical cohorts.

RESULTS

The study included 4762 psoriasis patients. Both TNF inhibitor and MTX cohorts showed a statistically lower rate of MI compared with topical cohort. However, there was no statistically significant difference in MI rate between TNF inhibitor and MTX cohorts (P = .32). The probability of MI was lower in TNF inhibitor responders compared with non-responders (p = .001).

CONCLUSIONS

The use of TNF inhibitors in psoriasis showed a significant reduction in the risk of MI compared with topical agents and a non-significant reduction compared with MTX. Responders to TNF inhibitor therapy showed a reduction in MI rate compared with non-responders.

De-regulation of diabetic regulatory genes in psoriasis: Deciphering the unsolved riddle

The purpose of our study was to identify the currently lacking molecular mechanism that accounts for the co-occurrence of two seemingly disparate diseases: psoriasis and type II diabetes. We aimed to investigate a panel of 84 genes related to the diabetic regulatory network in psoriasis (Ps), psoriasis type II diabetes (Ps-T2D), type II diabetes (T2D) and healthy control (HC). We hypothesize that such attempts would provide novel diagnostic markers and/or insights into pathogenesis of the disease. A quantitative Real Time-PCR Human Diabetes RT(2) Profiler PCR Array was chosen to explore the expression profile 84 diabetic genes in study subjects. Statistical analysis was carried out using appropriate software. The analysis revealed three candidate genes GSK3B, PTPN1, STX4 that are differentially expressed in study subjects. GSK3B was highly significant in Ps-T2D (P=0.00018, FR=-26.6), followed by Ps (P=0.0028, FR=-14.5) and T2D groups (P=0.032, FR=-5.9). PTPN1 showed significant association only with PS-T2D (P=0.00027, FR=-8.5). STX4 showed significant association with both Ps (P=0.0002, FR=-20) and Ps-T2D (P=0.0016, FR=-11.2). ACE represents an additional marker that showed suggestive association with Ps (P=0.0079, FR=-9.37). Our study highlights the complex genetics of Ps-T2D and present biomarkers for the development of T2D in Ps cases.

Psoriasis Patients Treated With Biologics and Methotrexate Have a Reduced Rate of Myocardial Infarction

Psoriasis is a chronic inflammatory skin condition characterised by the formation of red scaly plaques on the skin. It is an autoimmune disease cause by the dysregulation of cytokines controlling the inflammatory pathways, a mechanism likely contributing to various comorbidities observed in patients with psoriasis. Cardiovascular disease is one comorbidity observed more frequently in the psoriasis patient population. Biologic treatments specifically target the dysregulation of cytokines in the inflammation pathway and have shown to be an effective treatment for moderate to severe psoriasis where other systemic treatments have failed. More recently, biologics have been shown to reduce the incidence of myocardial infarction in patients with psoriasis compared to patients treated with topical agents. In the present study, 4 international psoriasis patient cohorts are combined and analyzed to examine the effect that biologic or methotrexate treatment has on reducing the incidence of myocardial infarction. Both methotrexate and biologic treatments were found to lower the incidence of myocardial infarction in moderate to severe psoriasis patient populations.

Bilateral Extensive Periorbital Milia en Plaque Treated with Electrodesiccation

Background:

Milia en plaque (MEP) is a rare form of milia. Only 25 cases of this rare condition have been reported to date ( MEDLINE search). Only one previous case of MEP has been treated with electrodesiccation.

Objective:

To report a new case of this rare condition and present the outcome with electrodesiccation.

Conclusion:

The case is being reported here to highlight the features of this rare but now well-recognized dermatologic condition, which has been reported increasingly in the recent past, to discuss the various treatments tried, and to share our experience of treating patients with the simple, inexpensive, easily available, and nonsophisticated office procedure of electrodesiccation.

Effects of tumor necrosis factor α inhibitors extend beyond psoriasis: insulin sensitivity in psoriasis patients with type 2 diabetes mellitus

Psoriasis is a chronic inflammatory disease that has been associated with an increased incidence of insulin resistance and diabetes mellitus (DM). Tumor necrosis factor (TNF) α inhibitors and IL-6 blockers, which are routinely used for the treatment of psoriasis, have been positively associated with insulin sensitivity. The aim of this study was to assess the effects of treatment with TNF-α inhibitors on insulin sensitivity in psoriatic patients with type 2 DM. This study confirms a beneficial effect of anti-TNF-α agents on insulin resistance and insulin sensitivity in psoriasis patients with type 2 DM.

Spatial assessment of monitoring network in coastal waters: a case study of Kuwait Bay

Spatial analyses of water-quality-monitoring networks in coastal waters are important because pollution sources vary temporally and spatially. This study was conducted to evaluate the spatial distribution of the water-quality-monitoring network of Kuwait Bay using both geostatistical and multivariate techniques. Three years of monthly data collected from six existing monitoring stations covering Kuwait Bay between 2009 and 2011 were employed in conjunction with data collected from 20 field sampling sites. Field sampling locations were selected based on a stratified random sampling scheme oriented by an existing classification map of Kuwait Bay. Two water quality datasets obtained from different networks were compared by cluster analysis applied to the Water Quality Index (WQI) and other water quality parameters, after which the Kriging method was used to generate distribution maps of water quality for spatial assessment. Cluster analysis showed that the current monitoring network does not represent water quality patterns in Kuwait Bay. Specifically, the distribution maps revealed that the existing monitoring network is inadequate for heavily polluted areas such as Sulaibikhat Bay and the northern portion of Kuwait Bay. Accordingly, the monitoring system in Kuwait Bay must be revised or redesigned. The geostatistical approach and cluster analysis employed in this study will be useful for evaluating future proposed modifications to the monitoring stations network in Kuwait Bay.

Hypertrophic Lupus Erythematosus Treated Successfully with Acitretin as Monotherapy

Hypertrophic lupus erythematosus (HLE) is a distinct and rare subset of chronic cutaneous lupus erythematosus characterized by verrucous lesions which are chronic in course and resistant to treatment (1). We describe the successful use of acitretin in a patient with HLE who had multiple hyperkeratotic verrucous plaques over the dorsa of his hands, feet, and legs and who failed to respond to local steroids and antimalarials.

Spatial and temporal characterizations of water quality in Kuwait Bay

The spatial and temporal patterns of water quality in Kuwait Bay have been investigated using data from six stations between 2009 and 2011. The results showed that most of water quality parameters such as phosphorus (PO4), nitrate (NO3), dissolved oxygen (DO), and Total Suspended Solids (TSS) fluctuated over time and space. Based on Water Quality Index (WQI) data, six stations were significantly clustered into two main classes using cluster analysis, one group located in western side of the Bay, and other in eastern side. Three principal components are responsible for water quality variations in the Bay. The first component included DO and pH. The second included PO4, TSS and NO3, and the last component contained seawater temperature and turbidity. The spatial and temporal patterns of water quality in Kuwait Bay are mainly controlled by seasonal variations and discharges from point sources of pollution along Kuwait Bay's coast as well as from Shatt Al-Arab River.

Effect of narrowband ultraviolet B therapy on serum vitamin D and cathelicidin (LL-37) in patients with chronic plaque psoriasis

BACKGROUND

Narrowband ultraviolet B (NB-UVB) has been widely used in the treatment of psoriasis. It has been shown that vitamin D is a major regulator of the expression of human antimicrobial peptide cathelicidin LL-37, which has a critical role in inflammatory cascade in psoriasis.

OBJECTIVE

To evaluate the effect of NB-UVB therapy on serum levels of cathelicidin LL-37 and 25-hydroxyvitamin D [25(OH)D] in psoriasis patients.

METHODS

Ninety-three psoriasis patients and 50 controls were included in the study. For psoriasis patients, serum levels of 25(OH)D and cathelicidin LL-37 were estimated before and after NB-UVB therapy.

RESULTS

Before treatment, serum 25(OH)D levels were significantly lower in psoriasis patients (31.5 ± 14.41 nmol/L) compared to controls (53.5 ± 19.6 nmol/L), p  =  .015. In contrast, serum LL-37 was significantly higher in psoriasis patients (13.24 ± 3.2 ng/mL) than in controls (7.92 ± 5.33 ng/mL), p < .001. After NB-UVB treatment, there was a highly significant elevation of serum 25(OH)D to reach 56.85 ± 5.2 nmol/L (p < .001) and further elevation of serum LL-37 to reach 29.4 ± 4.2 (p  =  .02).

CONCLUSIONS

The elevation of serum 25(OH)D and cathelicidin LL-37 could be an additional possible mechanism of action of NB-UVB therapy in the treatment of psoriasis.

The effect of weight reduction on treatment outcomes in obese patients with psoriasis on biologic therapy: a randomized controlled prospective trial

BACKGROUND

Obesity has long been associated with psoriasis and it is considered to be an independent risk factor for chronic heart diseases in these patients. Recently, some of the biologic drugs used for psoriasis have been reported to cause increase in body weight. It is currently not clear if this increased body weight seen in psoriasis patients on biologics leads to decrease in there efficacy or vice versa. We carried out this study to see if reduction in body weight leads to increased efficacy of biologics in obese psoriasis patients.

OBJECTIVE

To evaluate the effect of weight reduction by dietary control on treatment efficacy of biologics in obese patients as indicated by the Psoriasis Area and Severity Index (PASI) score.

METHODS

Obese patients with psoriasis receiving biologic therapy, satisfying the inclusion criterion, were randomized in a 1:1 ratio to receive low-calorie diet versus normal diet (control group). We included 262 patients with moderate to severe, stable plaque psoriasis with a PASI score 20:50 on anti TNF-α biologic therapy (infliximab, etanercept, ustekinumab and adalimumab). The patients in the dietary intervention group were given a low calorie diet (≤ 1000 kcal per day) for 8 weeks to induce weight loss. The treatment outcome was assessed using PASI. The PASI scores were assessed at baseline and every 4 weeks up to week 24.

RESULTS

There were no significant differences in age, sex distribution, body weight, body mass index, waist circumference, psoriasis duration, or PASI score between the two studied groups at base line. At week 24, the mean (±SD) weight loss was 12.9 ± 1.2 kg in the diet intervention group, and -1.5 ± 0.5 kg in the control group. The average improvement in mean PASI score was 84% for the diet group, and 69% for the control group. PASI 75 was achieved by 85.9% in the diet group, and 59.3% in the control group (p < 0.001). The mean (±SD) body surface area values at week 24 were 3.3 ± 4.4% and 8.1 ± 6.9% in the diet group and control group.

CONCLUSIONS

Body weight reduction in obese patients on biologics may increase the efficacy of the drug.

Measurement of vitamin D and cathelicidin (LL-37) levels in patients of psoriasis with co-morbidities

BACKGROUND

During the last decade, a lot of co-morbidities (diabetes, obesity, heart disease, etc.) have been described to be associated with psoriasis, but the exact link at the molecular level is not well-known. Researchers have shown molecular level changes in vitamin D pathway and its relationship to cathelicidin.

AIMS

To estimate the levels of cathelicidin (LL-37), and vitamin D in psoriasis patients with co-morbidities, and compare them with matched healthy controls.

METHODS

One hundred consecutive patients with stable plaque psoriasis (psoriasis area and severity index ≥10) with no systemic treatment in the past 3 months were investigated for the serum levels of vitamin D and LL-37, and compared with equal number of matched healthy volunteers.

RESULTS

The serum vitamin D levels were significantly lower in patients. Furthermore, the levels of serum LL-37 were significantly high.

CONCLUSION

Our study showed that the low serum levels of vitamin D, and higher blood levels of cathelicidin could form a molecular level clue in the pathogenesis of psoriasis patients, who are more likely to develop co-morbidities.

Resistant palmoplantar lesions in patients of psoriasis: evaluation of the causes and comparison of the frequency of delayed-type hypersensitivity in patients without palm and sole lesions

OBJECTIVE

To examine the reasons for resistance to treatment in cases of palmoplantar psoriasis, and also to compare the frequency of delayed-type hypersensitivity to common sensitizers with those cases of psoriasis without palmoplantar involvement.

SUBJECTS AND METHODS

One hundred and three patients with resistant palmoplantar psoriasis were examined for a possible drug reaction, fungal infection or contact allergy. Patch testing was done for another 100 patients with psoriasis vulgaris without palm and sole involvement. χ(2), Fischer's exact test, Mann-Whitney U test and logistical regression analysis were done using SPSS 15.0.

RESULTS

Of the 103 patients with resistant palmoplantar lesions, 26 (25.24%) had a positive patch test to at least one of the tested allergens, 6 (5.8%) had psoriasiform spongiotic dermatitis on biopsy, 5 (4.8%) reported exacerbation after starting biologic therapy and 3 (2.9%) were potassium hydroxide positive in the sole lesions. In comparison, of the 100 patients with no palm or sole lesions, 11 (11%) had a positive patch test to at least one of the allergens. There was a direct relationship between the increase in the prevalence of dermatitis and the duration of psoriasis. There was no correlation between the clinical type of psoriasis and patch-test positivity.

CONCLUSION

Secondary fungal infection, allergic contact dermatitis to topical agents or common allergens, or at times an unusual reaction to the antipsoriatic therapeutic agents sometimes led to treatment failure in patients with psoriasis vulgaris with palmoplantar lesions. Also, psoriasis patients with palm and sole lesions tended to have higher rates of contact hypersensitivity than patients without lesions on their palms and soles.

Onychomycosis in patients of nail psoriasis on biologic therapy: a randomized, prospective open label study comparing Etanercept, Infliximab and Adalimumab

INTRODUCTION AND OBJECTIVE

The association between patients of psoriasis on anti TNF therapy and onychomycosis has not been explored. The aim of this study was to determine the rate of onychomycosis in patients of psoriasis with nail involvement on anti TNF therapy.

MATERIALS AND METHODS

All patients of psoriasis with nail involvement seen between February 2007 - July 2012 were examined. All the patients with negative nail scrapings for fungus were enrolled. Patients found fit for biologics after investigations were randomly divided into 3 groups (Group A: Infliximab, Group B: Etanercept and Group C: Adalimumab). The patients were followed up every 4 weeks for 24 weeks. Repeat nail scrapings were done at week 24. The results were compared with controls.

RESULT

In total, 315 (178 males and 137 females) patients were enrolled. The mean age was 37.5 ± 11.4 years. The results for scraping for fungus at the end of 24 weeks were as follows: 33% (33/100) in patients on Infliximab followed by 15.45% (17/110), 13.33% (14/105) in patients on treatment with Etanercept and Adalimumab respectively as compared to 13.89% (25/180) among controls. Onychomycosis in association with nail psoriasis was more common in males.

CONCLUSION

This study revealed statistically significant association between fungal infections of the nail in patients of psoriasis on treatment with Infliximab.

Mucocutaneous warts in children: clinical presentations, risk factors, and response to treatment

INTRODUCTION

Human papillomaviruses (HPV) cause cutaneous and mucosal infections in both adults and children. Warts are very common in children.

METHODS

All patients younger than 13 presenting with cutaneous warts in a 1-year period at Farwaniya Hospital in Kuwait were included in the study. In addition, their parents completed a questionnaire about possible environmental risk factors for warts. The treatment modalities used and their outcomes were recorded.

RESULTS

This study included 2,916 children with warts. Common warts affected male patients more frequently. Warts were mostly located on the hands, in 1,172 patients (40.19%), followed by the feet in 1,096 patients (37.59%). Frequently associated environmental factors were walking barefoot, using a swimming pool, or having a family member with warts. The first-line treatment used was cryotherapy, followed by topical salicylic acid preparations. A total of 2,128 (72.98%) patients were cleared of their warts, and 232 (10.90%) patients had a recurrence. The cure rate in patients with hand warts was slightly higher than with warts on the feet (78.67% versus 70.52%). Treatment side effects were a complaint of 1,796 (61.59%) patients.

CONCLUSIONS

The prevalence of warts is lowest among children less than 6 years old. No particular therapy has been confirmed to be effective at achieving complete remission in every patient.

Eosinophilic annular erythema is a peculiar subtype in the spectrum of Wells syndrome: a multicentre long-term follow-up study

BACKGROUND/OBJECTIVE

Eosinophilic annular erythema (EAE) was proposed to describe annular skin lesions associated with tissue eosinophilia, however, its relation to Well's syndrome (WS) remains a source of controversy. We studied a series of patients to increase awareness of this entity and to clarify its relation to WS.

METHODS

A multicentre study in which the clinical records, histological findings, laboratory results, therapeutic responses and follow-up of 10 patients were demonstrated.

RESULTS

The study included seven women and three men with age ranging from 31 to 54 years. The duration of the disease ranged from 3 to 28 months. All patients showed involvement of trunk and extremities. Early lesions were manifested as erythematous plaques, which progressed to well-developed figurate lesions and ended as large annular lesions with pigmented centre and elevated border. Flame figures were only observed in well-developed and long-standing lesions. Blood eosinophilia was found in all patients with different grades. Associated disorders included chronic gastritis, diabetes mellitus, chronic hepatitis-C virus infection and chronic kidney disease. The disease showed chronic course with high relapse rate and resistance to various therapeutic modalities including systemic steroid alone and in combination with hydroxychloroquine and cyclosporine.

CONCLUSION

We believe that EAE is a peculiar clinical variant in the spectrum of WS, which is characterized by a chronic course, resistance to treatment and high relapse rate. The diagnosis and evaluation of this condition need a close monitoring with repeated clinical, histological and laboratory assessment.

Associated cutaneous diseases in obese adult patients: a prospective study from a skin referral care center

OBJECTIVE

The aim of the present study was to determine the spectrum of skin diseases seen among adult obese patients referred to Farwaniya Hospital.

MATERIALS AND METHODS

A total of 437 overweight/obese subjects (200 men and 237 women) aged 18-74 years were enrolled in the study, which was conducted from October 2008 to November 2009. Demographic details such as age, sex, occupation, personal and family history of diabetes mellitus, hypertension, and obesity were recorded. A thorough examination was performed by an experienced dermatologist (N.A.M.). Blood investigations such as complete blood count, fasting and postprandial blood sugar levels, liver function tests, kidney function tests, lipid profile, and thyroid function tests were done for all patients in addition to hormonal assay and abdominal sonar to exclude polycystic ovary disease for indicated patients.

RESULTS

Common skin diseases found among these patients were plantar hyperkeratosis: n = 197; acanthosis nigricans: n = 144; skin tags: n = 131; striae cutis distensae: n = 102; intertrigo: n = 97; acne vulgaris: n = 94. Diabetes mellitus was diagnosed in 87 patients, polycystic ovary syndrome/hyperandrogenism in 74 female patients, and hyperlipidemia in 209 patients.

CONCLUSION

This study shows that certain dermatoses such as plantar hyperkeratosis, acanthosis nigricans, skin tags, striae cutis distensae, and intertrigo are more common among obese persons. Some, such as plantar hyperkeratosis, could serve as markers of obesity and its severity, while the presence of acanthosis nigricans and skin tags may point to underlying internal disease such as diabetes and polycystic ovary syndrome.

Comparative study on the efficacy, safety, and acceptability of imiquimod 5% cream versus cryotherapy for molluscum contagiosum in children

To compare the efficacy, safety and acceptability of imiquimod (IMQ) 5% cream with cryotherapy for the treatment of molluscum contagiosum (MC) in children. Prospective, randomized, comparative, observer blinded study. A total of 74 children, with MC were divided randomly to receive treatment with either IMQ 5% cream (group A) 5 days a week or cryotherapy (group B) once a week until clinical cure or up to a maximum of 16 weeks. All the patients were followed up weekly during active treatment. The patients were followed-up for 6 months after clinical cure to look for recurrence. In the IMQ group (group A), the overall complete cure rate was 91.8% (34 of 37), 22 of the 37 patients cleared by the end of 6 weeks and 12 more patients cleared by the end of 12 weeks, while the remaining three patients (8.1%) did not clear even after 16 weeks. Whereas, in the cryotherapy group, all 37 patients achieved complete cure, 26 of 37 (70.27%) patients cleared after 3 weeks, and the remaining 11 (29.72%) cleared by the end of 6 weeks. No statistically significant difference was found between the overall complete cure rate in both groups at the end of maximum treatment period (16 weeks). Pain, bullae formation, pigmentary changes, and superficial scarring were more significantly common in the cryotherapy group compared with the IMQ group. Imiqimod 5% cream seems to be slow acting but an effective agent for the treatment of MC in children. IMQ appears to be practically painless and more cosmetically accepted treatment when compared with cryotherapy, and may be the preferred treatment of MC in children especially with numerous small lesions. Cryotherapy has the advantage of being rapidly effective, and is less expensive than IMQ and may be the preferred treatment for large solitary or few lesions.

Comorbidities associated with psoriasis: an experience from the Middle East

Recent studies suggest that psoriasis patients have higher rates of comorbidities. We sought to determine the prevalence of comorbidities and co-medications in our psoriasis patients. We conducted case-control study in 1835 patients with psoriasis vulgaris and age- and gender-matched cohort without psoriasis. Patients were examined for clinical characteristics of psoriasis, PASI scores, and data of age, sex, body mass index (BMI), smoking status, comorbidities, and co-medications were analysed for both patients and controls. We identified 1661 (92.8%) patients with mild to moderate psoriasis (PASI < 10) and 129 patient's (7.03%) with severe psoriasis (PASI > 10). Patients with psoriasis were more likely to be current smokers (51.34% vs 32.51% controls). Respective prevalence rates of risk factors in those with mild-moderate psoriasis, severe psoriasis, and controls were as follows: inflammatory arthritis (20%, 31% and 10.68%); coronary heart disease (4.1%, 8.35% and 1.42%); obesity (BM1) (32.5%, 41% and 17%); diabetes mellitus type II (37.4%, 41% and 16%); hypertension (32%, 40.3% and 11.55%); dyslipidemia (14.1%, 22.48% and 4.96%); metabolic syndrome (16%, 26.35% and 6.76%); chronic obstructive pulmonary disease (COPD) (5.36%, 6.98% and 4.03%); cancer (0.3%, 1.55% and 0.16%). They had a higher odds of inflammatory arthritis, coronary heart disease, obesity, diabetes mellitus II, hypertension, dyslipidemia, and metabolic syndrome. They were receiving significantly wider varieties of drugs. Which most commonly included antidiabetic drugs, antihypertensives, and hypolipidemic drugs.

Clinical and mycologic characteristics of onychomycosis in diabetic patients

The aim of the study was to examine the relative prevalence of dermatophytic, yeast and non-dermatophytic mould onychomycosis among diabetic patients, and to compare it with nondiabetic patients. The study included 460 consecutive diabetic patients and the same number of nondiabetic age-matched subjects attending dermatology clinics at Farwaniya Hospital, Kuwait, over a period of 4 years. All patients were examined clinically and mycologically for any evidence of onychomycosis. All cases of clinically suspected and/or mycologically proven onychomycosis were prescribed terbinafine tablets 250 mg orally per day continuously for 6-12 weeks. The prevalence of clinical onychomycosis in the diabetic and control group was 18.7% (86 cases) and 5.7% (26 cases), respectively. Elderly diabetic patients were at an increased risk of developing onychomycosis. Toenails were affected in 54 (62.8%), fingernails in 20 (23.3%), and both fingernails and toenails in 12 (14%) cases in diabetic group. Distal subungual onychomycosis was the most common clinical presentation, recorded in 67.4% of patients, followed by total dystrophic onychomycosis in 11.6% of patients. Culture positivity alone was seen in 16 (18.6%), both culture and KOH positivity in 52 (60.5%), and positive KOH alone in 10 (11.6%) cases; 8 cases had negative KOH examination and culture, but were PAS positive. Dermatophytes were the most common isolate. Seven percent cases treated for onychomycosis from the diabetic group were evaluated as unsuccessful (relapsed) at the end of the study. This study confirmed that diabetic patients are at a high risk of having or contracting onychomycosis. Onychomycosis was found to correlate significantly with increasing age and male gender. These findings reinforce the importance of attending to infections in diabetics to reduce the associated morbidity. Managing onychomycosis in diabetics may require systemic antifungal treatment, physical measures and patient education.

Tropical medicine rounds: Treatment of Old World cutaneous leishmaniasis with dapsone, itraconazole, cryotherapy, and imiquimod, alone and in combination

BACKGROUND

Cutaneous leishmaniasis (CL) is a major public health problem. The currently available therapies are expensive, not freely available, toxic, and not always curative. A simple, effective, noninvasive therapeutic approach is required for the treatment of CL.

AIMS

To determine the clinical patterns of CL and to report our experience in the management of CL.

METHODS

One hundred and ten patients with CL seen between January 2005 and December 2007 were included in this study. The diagnosis was based on clinical features, parasitologic diagnosis, histopathology, and culture. Each patient was treated according to disease severity with either topical (cryotherapy or imiquimod) or systemic (itraconazole or dapsone) monotherapy, or a combination of these modalities.

RESULTS

CL was more common in adult expatriate men, with the upper limbs as the most commonly affected site. Noduloulcerative CL was the most common presentation (84.6%). Atypical CL was found in 18 patients. Skin biopsy was the most common diagnostic technique (66.6%). Monotherapy showed an overall success rate of 56.41%, whereas combination therapy was successful in 69.56% of cases. Cryotherapy alone was successful in 68.18% of cases. Imiquimod alone was ineffective.

CONCLUSION

A stepwise approach represents a rational and practical way of confirming CL. A combination of itraconazole/dapsone and topically applied imiquimod is safe, simple, and effective for the treatment of CL. More studies are needed to establish the role of such an approach. Cryotherapy is also safe, simple and effective for the treatment of CL.

Clinicopathological characteristics of lichen planus pigmentosus and its response to tacrolimus ointment: an open label, non-randomized, prospective study

BACKGROUND

Lichen planus pigmentosus (LPP) is an uncommon variant of lichen planus, for which no effective treatment is available. Objectives The aim of this study was to determine the clinical, epidemiological and histopathological characteristics of LPP patients in Kuwait.

METHODS

Thirty-three LPP patients who attended the Dermatology outpatient clinics at Farwaniya Hospital, Kuwait from the year 2002 to 2008 were studied for clinical, epidemiological and histopathological findings. Thirteen of these patients were treated with topical tacrolimus 0.03%. Ointment applied topically twice daily for the duration varying from 6 to 12 weeks.

RESULTS

Of the 33 patients, 21 were men and 12 were women. The duration of eruption ranged from 6 weeks to 3 years. The face and neck were the commonest sites, affecting 18 (54.5%) patients. The pattern of pigmentation was diffuse in 18 (54.54%) patients, reticular in seven (21.2%), blotchy in five (15.2%), linear in two (6.1%) and perifollicular in one (3%). Twenty patients had positive serology for hepatitis C virus (HCV), with significantly higher serum liver enzymes (ALT and AST). Of the 13 patients, who were treated with tacrolimus Ointment, seven (53.8%) showed appreciable lightening of the pigmentation after an average of 12 weeks.

CONCLUSIONS

We conclude that HCV may be one of the factors associated with LPP, in those who have a tendency to develop LPP. However, this possible association should be interpreted carefully. In addition, tacrolimus ointment could have a beneficial role in the treatment of LPP.

308-nm excimer laser for the treatment of alopecia areata in children

Alopecia areata (AA) is a common skin disease which is characterized by nonscarring localized or diffused hair loss. In this study we assessed the efficacy of 308-nm Excimer laser in the treatment of alopecia areata in children. A total of 9 children with 30 recalcitrant patches alopecia areata and two children with alopecia areata totalis were enrolled in this study which included seven male and four female patients, aged between 4 and 14 years and the durations of their disease were between 7 and 25 months. All of these patients had more than one lesion of alopecia areata and at least one of them was left as a control for comparison. The lesions were treated with the 308-nm Excimer laser twice a week for a period of 12 weeks. Regrowth of hair was observed in 18 (60%) alopecia patches in the scalp, while there was no response in the control patches and over the extremities. Only four patients with scalp lesions showed a recurrence of alopecia after 6 months post laser therapy. So, 308-nm Excimer laser is considered an effective safe therapeutic option for patchy alopecia areata in children.

Familial Coexisting and Colocalized Psoriasis and Vitiligo Responding to Alefacept

Background:

Psoriasis is an immune-mediated, chronic, inflammatory disease that significantly impairs both physical and emotional aspects of an individual's quality of life. Vitiligo leads to depigmentation of skin, in which some or all melanocytes in the interfollicular epidermis and occasionally those in the hair follicles are selectively destroyed. The coexistence of the two disorders is rarely seen.

Objective:

To report two cases of the rare coexistence of psoriasis and vitiligo in a family.

Methods:

After providing informed written consent, both patients were given alefacept 15 mg/kg weekly injections for 12 weeks. The patients were monitored both clinically and with all relevant laboratory investigations. These patients were then followed up once a month for 2 years.

Results:

Treatment with alefacept led to complete clearance of vitiligo along with the expected improvement in psoriasis. In the 2-year follow-up, vitiligo did not recur, although psoriasis relapsed and was appropriately treated.

Conclusion:

Use of alefacept in vitiligo may turn out to be a possible novel off-label treatment option in vitiligo. But the results need to be reproduced in larger studies

Unusual presentations of molluscum contagiosum

BACKGROUND

Molluscum contagiosum is a common viral skin infection. Unusual presentations of this condition among immunocompetent individuals have rarely been reported.

OBJECTIVE

To highlight atypical clinical presentations of molluscum contagiosum in immunocompetent individuals.

METHODS AND RESULTS

An analysis of all cases of molluscum contagiosum with unusual presentation seen over a period of 2 years in the Farwaniya Department of Dermatology was conducted. Four patients (two males, two females), aged 13 to 35 years, with atypical molluscum contagiosum were encountered. Diagnosis was confirmed histopathologically. All of them were healthy, immunocompetent individuals without any underlying skin condition, except one who had preceding hand dermatitis. Clinical clues that could be helpful in making a diagnosis of molluscum contagiosum with an atypical presentation were looked for.

CONCLUSION

A histopathologic examination may be necessary to make the diagnosis.

Ecorisk evaluation and treatability potential of soils contaminated with petroleum hydrocarbon-based fuels

We used a series of toxicity tests to monitor oil degradation in the Kuwaiti oil lakes. Three soils from different locations with a history of hydrocarbon contamination were treated in bench-scale microcosms with controlled nutrient amendments, moisture content, and temperature that had promoted mineralization of total hydrocarbon and oil and grease in a preliminary study. Two hundred days of bioremediation treatment lowered hydrocarbon concentration to below 2 and 5 mg g(-1) for soils A and B, respectively, while in soil C hydrocarbon concentration remained at 12 mg g(-1). Although 85% of the total petroleum hydrocarbons (TPHs) in soil A were reduced 50d after treatment, results of the seed germination and Microtox tests suggested an initial increase in toxicity, indicating that toxic intermediary metabolites may have formed during biodegradation. Also, the significant decrease of TPHs and corresponding high toxicity levels were noted in soil B 200d after bioremediation. Clearly, toxicity values, and not just hydrocarbon concentration, are a key factor in assessing the effectiveness of bioremediation techniques. Field chemistry data showed a significant reduction in hydrocarbon levels after the biological treatment. We concluded that the toxicity assessment of the contaminated soil with a battery of toxicity bioassays could provide meaningful information regarding a characterization procedure in ecological risk assessment.

Spectrum of cutaneous vasculitis in adult patients from the Farwaniya region of Kuwait

OBJECTIVE

To determine the clinical profile, etiologic factors, disease associations, and the laboratory profile of adult patients with cutaneous leukocytoclastic vasculitis (LV) presenting to the Dermatology Department at Farwaniya Hospital, Kuwait.

SUBJECTS AND METHODS

The medical records of 57 adult patients (>18 years) with biopsy-proven cutaneous LV from January 2004 to June 2006 at Farwaniya Hospital were reviewed.

RESULTS

Of the 57 patients studied, 21 (36.8%) were classified as having primary cutaneous small vessel vasculitis. The most common type of skin lesions found was palpable purpura seen in 29 (50.9%) patients. No possible cause for the cutaneous vasculitis could be identified in 21 patients. Extracutaneous involvement was seen in 32 (56.1%) patients of which 29 had joint involvement. The most frequent laboratory abnormality was an elevated erythrocyte sedimentation rate (ESR). Altered laboratory evaluation in the form of leukocytosis, raised antistreptolysin O titers and urine abnormalities were found in association with systemic vasculitis. IgA deposits were present in 33 patients. Risk factors for chronicity of cutaneous LV were female sex, advanced age, unidentified etiology, absence of fever and presence of joint involvement.

CONCLUSION

The commonest type of LV in Kuwait is primary cutaneous small vessel vasculitis. The most frequent laboratory abnormality associated with LV was increased ESR.

308-nm excimer laser for the treatment of alopecia areata

BACKGROUND

Alopecia areata is loss of hair from localized or diffuse areas of hair-bearing area of the skin. Recently there are reports of efficacy of the 308-nm excimer radiation for this condition.

OBJECTIVE

To study the effect of the 308-nm excimer laser in the treatment of alopecia areata.

MATERIALS AND METHODS

Eighteen patients with 42 recalcitrant patches (including 1 adult with alopecia totalis) were enrolled in this study. The lesions were treated with the 308-nm excimer laser twice a week for a period of 12 weeks; one lesion on each patient was left as a control for comparison.

RESULTS

There were 7 males and 11 females in this study. Regrowth of hair was observed in 17 (41.5%) patches. Thirteen of the 18 lesions in scalp showed a complete regrowth of hair. The extremity regions failed to show a response. Atopic diatheses had an unfavorable effect on the outcome in our patients.

CONCLUSION

The 308-nm excimer laser is an effective therapeutic option for patchy alopecia areata of the scalp and for some cases with patchy alopecia areata of the beard area. It does not work for patchy alopecia areata of the extremities.

Clinical patterns of sexually transmitted diseases, associated sociodemographic characteristics, and sexual practices in the Farwaniya region of Kuwait

BACKGROUND

Sexually transmitted diseases (STDs) are common worldwide, but there are few studies available on STDs from the Gulf countries, including Kuwait. Our goal was to determine the clinical patterns, sociodemographic factors, and sexual practices of patients with STDs who attended a government hospital in the Farwaniya region of Kuwait.

METHODS

All patients seen over a 1-year period (July 2003 to June 2004), who presented with signs and symptoms suggestive of STDs, were included. Sociodemographic details and clinical findings were recorded. The diagnosis of each STD was based mainly on standard World Health Organization (WHO) criteria and available data. Serologic tests for syphilis and human immunodeficiency virus (HIV) were offered to all patients.

RESULTS

One thousand and ninety-six patients (1068 male, 28 female) with STDs constituted 2.84% of all new dermatology patients seen; most (866) were in the 21-40-year age group. The STDs were acquired from commercial sex workers in 844 patients (77%). Heterosexual encounter (99.3%) was the most common mode of acquiring STDs. Urethral discharge was noted in 54.1% of patients, followed by genital ulcers (17.8%), papules/growths (16.4%), and urethral/pubic pain without associated discharge/ulcers (5.9%); these were the four most common presenting complaints. Evaluation revealed gonorrhea in 31.5% of patients, nongonococcal urethritis in 23.6%, chlamydia in 4.1%, nonspecific urethritis in 19.5%, concomitant gonorrhea and chlamydia urethritis in 2.7%, genital warts in 13.7%, chancroid in 13.0%, genital herpes in 4.8%, molluscum contagiosum in 2.7%, and lymphogranuloma venereum in 1.4%.

CONCLUSIONS

Urethral discharge, gonorrhea, and nonspecific urethritis (presenting with urethral discharge), followed by genital warts, chancroid, and genital herpes (ulcers), were the most common STDs among male patients in the Farwaniya region of Kuwait. Although no case of HIV or syphilis was detected, health authorities and physicians need to remain vigilant.

Nail changes in childhood psoriasis: a study from Kuwait

Psoriasis is a widespread skin disorder in which nail involvement can be seen in up to two-thirds of those affected. Childhood psoriasis is a distinct entity and the literature focused on nail changes associated with childhood psoriasis is scant. Our objectives were to evaluate the frequency of nail involvement in childhood psoriatic patients, assess the types of nail changes in childhood psoriasis, and compare our clinical findings with the few reports available in the literature. Two hundred and one consecutive new patients with childhood (age < or = 16 years) psoriasis of both sexes were selected for the study of nail changes. The diagnosis of psoriasis was made on clinical grounds. Each patient underwent a thorough dermatologic examination with special attention paid to the nail changes. If a clinical suspicion of fungal infection of the nails existed, further mycologic investigations were performed. We found the prevalence of nail changes to be 37.81% (boys > girls) in children who had psoriasis. Nail pitting was found to be the most common manifestation (61.84%) followed by onycholysis (30.26%), subungual hyperkeratosis (13.16%), and discoloration of the nail plate (7.90%). Nail involvement had no relationship to the type of psoriasis, patient's sex, or duration or extent of disease.

Cutaneous manifestations of diabetes mellitus. Study from Farwaniya hospital, Kuwait

OBJECTIVE

To study the prevalence of cutaneous disorders in patients with diabetes mellitus.

SUBJECTS AND METHODS

All diabetic patients attending the Department of Dermatology, Al-Farwaniya Hospital, Kuwait, and diabetic in-patients with skin disorders were examined over a period of 18 months from March 2004 to August 2005. A total of 106 diabetic patients displaying 1 or more dermatological manifestations were identified and thoroughly examined for any skin disorder. The diabetic profile of the patients was obtained from medical records.

RESULTS

Of the 106 patients, 69 had only 1 cutaneous manifestation, 27 had 2, 6 had 3 and 4 had 4. Infections (68.0%) were the major cutaneous manifestations with fungal infection occurring in 41 patients followed by bacteria in 27. The second most common presenting symptom was pruritus. Hypertension (74%) was the most common systemic complication, and most of the diabetic patients who developed cutaneous manifestations were in the 40- to 60-year age group.

CONCLUSIONS

The data show that infections were the most common cutaneous manifestation and hypertension the most common systemic complication.