Laser therapy of freckles and lentigines with quasi-continuous, frequency-doubled, Nd:YAG (532 nm) laser in Fitzpatrick skin type IV: a 24-month follow-up

BACKGROUND

Newly developed lasers produce excellent results with minimal complications compared with traditional treatments for freckles and lentigines.

OBJECTIVES

To assess the efficacy and safety of the frequency-doubled Nd:YAG (532 nm) laser in the treatment of freckles and lentigines in type IV skin.

PATIENTS AND METHODS

Twenty adult patients (14 with freckles and six with lentigines) were subjected to a variable number of treatments with a minimum 4-week interval until no additional improvement occurred or > 75% improvement was obvious. Patients manifesting > 50% improvement were followed up once every 3 months for 24 months. The rest were regarded as treatment failures and not followed up.

RESULTS

Sixteen (80%) of 20. patients (freckles, n = 10; lentigines, n = 6) manifested more than 50% improvement. They were treat- irradiated between three and eight times with a 4-12-week interval. Complications included hypopigmentation (25%), mild textural changes (15%) and hyperpigmentation (10%). All these were mild and resolved within 2-6 months. Of 10 patients with freckles followed up for 24 months, four (40%) patients showed partial recurrence. However, all the patients maintained > 50% improvement. None of the patients with lentigines showed recurrence.

CONCLUSION

The quasi-continuous, frequency-doubled Nd:Y AG (532 nm) laser safely and effectively treats freckles and lentigines in Fitzpatrick skin type IV.

Tinea unguium in Lahore, Pakistan

During a period of 1 year, out of 202 clinically suspected cases of tinea unguium, 53 (26%) were confirmed by mycological cultures for dermatophytes. Trichophyton rubrum was the most common fungus isolated in 46 (87%) patients, followed by T. violaceum in four (7%), T. interdigitale in two (4%) and Epidermophyton floccosum in one (2%). The disease was more common in adult males and fingernails were found to be affected more often than toenails. The distal and lateral variety was seen in 41 (77%) patients, total secondary dystrophic type in 11 (21%) and proximal subungual type in one (2%). Clinical diagnosis alone is not reliable and mycological confirmation is mandatory for this potentially curable disease.

Psoralen-ultraviolet A therapy vs. psoralen-ultraviolet B therapy in the treatment of plaque-type psoriasis: our experience with fitzpatrick skin type IV

BACKGROUND

Oral psoralen, when combined with UVB, shows an increased response in psoriasis. In this study, conventional psoralen-UVA (PUVA) therapy was compared with psoralen-UVB (PUVB) therapy in plaque-type psoriasis in patients with Fitzpatrick skin type IV.

PATIENTS AND METHODS

Equal numbers of patients with stable, plaque-type psoriasis were treated with either PUVA (n = 22) or PUVB (n = 22), three times weekly until 90% clearance was achieved. A final evaluation was made 3 months later.

RESULTS

The two groups showed no significant differences in terms of clearance of disease, mean number of exposures, or the average duration of therapy; however, the cumulative dose of UVB required for clearance was significantly lower than that of UVA. Both groups had a similar acute side-effects' profile.

CONCLUSIONS

PUVB therapy is as effective as conventional PUVA in the treatment of stable, plaque-type psoriasis in patients with Fitzpatrick skin type IV. A significantly lower dose of UVB is required for clearance as compared with UVA.

Onychomycosis in Lahore, Pakistan

BACKGROUND

Onychomycosis, a common nail disorder, is caused by yeasts, dermatophytes, and nondermatophyte molds. These fungi give rise to diverse clinical presentations. The present study aimed to isolate the causative pathogens and to determine the various clinical patterns of onychomycosis in the population in Lahore, Pakistan.

PATIENTS

In 100 clinically suspected cases, the diagnosis was confirmed by mycologic culture. Different clinical patterns were noted and correlated with causative pathogens.

RESULTS

Seventy-two women (mean age, 32.6 +/- 14.8 years) and 28 men (mean age, 40.6 +/- 15.8 years) were studied. Fingernails were involved in 50%, toenails in 23%, and both fingernails and toenails in 27% of patients. The various clinical types noted were distolateral subungual onychomycosis (47%), candidal onychomycosis (36%), total dystrophic onychomycosis (12%), superficial white onychomycosis (3%), and proximal subungual onychomycosis (2%). Candida was the most common pathogen (46%), followed by dermatophytes (43%) (Trichophyton rubrum (31%), T. violaceum (5%), T. mentagrophytes (4%), T. tonsurans (2%), and Epidermophyton floccosum (1%) and nondermatophyte molds (11%) (Fusarium (4%), Scopulariopsis brevicaulis (2%), Aspergillus (2%), Acremonium (1%), Scytalidium dimidiatum (1%), and Alternaria (1%).

CONCLUSIONS

Onychomycosis is more common in women of 20-40 years of age. Distolateral subungual onychomycosis and candidal onychomycosis are the most common clinical presentations, and Candida and T. rubrum are the major pathogens in Pakistan.

A clinico-etiologic correlation in tinea capitis

BACKGROUND

Tinea capitis is a dermatophytosis with diverse clinical manifestations. The causative fungi of tinea capitis vary with geography and time. This study aimed to identify the etiologic agents and to determine the clinico-etiologic correlation of tinea capitis in Lahore, Pakistan.

METHODS

From clinically suspected cases of tinea capitis, skin scrapings and hair samples were taken and subjected to microscopy and culture.

RESULTS

Of 100 evaluable patients, 95% were children below 12 years of age with almost equal sex incidence. Noninflammatory and inflammatory lesions were seen in 56.4% and 43.6%, respectively. Trichophyton violaceum was the most common etiologic agent, responsible for 82% of infection, followed by T. tonsurans (8%), T. verrucosum (5%), and T. mentagrophytes (5%).

CONCLUSIONS

T. violaceum is the predominant pathogen causing tinea capitis in this part of the world, and gives rise to a varied clinical picture.

A randomized, comparative trial of treatment of kerion celsi with griseofulvin plus oral prednisolone vs. griseofulvin alone

Glucocorticoids are often recommended along with oral antifungals in the treatment of kerion celsi. In this randomized study, the efficacy of combination therapy with oral griseofulvin and oral prednisolone (n =17) was compared to oral griseofulvin alone (n=13) in the treatment of kerion celsi. Both groups were treated with oral griseofulvin for 8 weeks whereas oral prednisolone was given in tapering doses for 3-4 weeks to the first group only. The final evaluation at week 12 showed a cure rate of 100% in both groups without any significant difference in terms of clinical or mycological cure (P>0.05). No adverse events were noted in either group. In our opinion the combination of oral prednisolone with griseofulvin does not result in additional objective or subjective improvement compared to griseofulvin alone in cases with kerion celsi.

Drugs causing fixed eruptions: a study of 450 cases

BACKGROUND

Drug eruptions are among the most common cutaneous disorders encountered by the dermatologist. Some drug eruptions, although trivial, may cause cosmetic embarrassment and fixed drug eruption (FDE) is one of them. The diagnostic hallmark is its recurrence at previously affected sites.

OBJECTIVE

We evaluated 450 FDE patients to determine the causative drugs.

RESULTS

The ratio of men to women was 1:1.1. The main presentation of FDE was circular hyperpigmented lesion. Less commonly FDE presented as: nonpigmenting erythema, urticaria, dermatitis, periorbital or generalized hypermelanosis. Occasionally FDE mimicked lichen planus, erythema multiforme, Stevens-Johnson syndrome, paronychia, cheilitis, psoriasis, housewife's dermatitis, melasma, lichen planus actinicus, discoid lupus erythematosus, erythema annulare centrifugum, pemphigus vulgaris, chilblains, pityriasis rosea and vulval or perianal hypermelanosis. Cotrimoxazole was the most common cause of FDE. Other drugs incriminated were tetracycline, metamizole, phenylbutazone, paracetamol, acetylsalicylic acid, mefenamic acid, metronidazole, tinidazole, chlormezanone, amoxycillin, ampicillin, erythromycin, belladonna, griseofulvin, phenobarbitone, diclofenac sodium, indomethacin, ibuprofen, diflunisal, pyrantel pamoate, clindamycin, allopurinol, orphenadrine, and albendazole.

CONCLUSIONS

Cotrimoxazole was the most common cause of FDE, whereas FDE with diclofenac sodium, pyrantel pamoate, clindamycin, and albendazole were reported for the first time. FDE may have multiform presentations.

A double-blind, randomized, comparative trial of itraconazole versus terbinafine for 2 weeks in tinea capitis

In this randomized, double-blind study, the efficacy and safety of oral itraconazole (n = 28) and terbinafine (n = 27), each given for 2 weeks, was compared in patients with tinea capitis. Trichophyton violaceum was the major pathogen in both groups (82.1% and 88.9%, respectively). The final evaluation at week 12 showed a cure rate of 85.7% and 77.8%, respectively (P > 0.05). Adverse events noted were mild and did not warrant discontinuation of therapy.

Physiologic skin changes during pregnancy: a study of 140 cases

BACKGROUND

The endocrine, metabolic, and immunologic changes during pregnancy give rise to a number of physiologic cutaneous changes.

OBJECTIVE

We evaluated 140 pregnant women to determine the pattern of pregnancy-induced physiologic skin changes in our community.

RESULTS

The various changes observed include: increased pigmentation (90.7%), striae (77.1%), edema (48.5), melasma (46.4%), vascular changes (34.2%), and others.

CONCLUSIONS

Pigmentary changes were the most common finding, whereas the incidence of vascular changes was quite low (p < 0.01).

Erythroderma: a clinico-etiologic study of 90 cases

BACKGROUND

The difficulty with erythroderma lies in finding the underlying cause. Almost all the published original clinical series of erythroderma originate from western countries. Our aim was to evaluate various causes of exfoliative dermatitis in our community and compare the findings with previous studies.

METHODS

Ninety patients with erythroderma of either sex and any age, were studied at the Dermatology Department, Mayo Hospital, Lahore, Pakistan, between April 1992 and May 1995. A through clinical examination and relevant laboratory investigations, including skin biopsies, were performed.

RESULTS

The mean age of onset was 41.6 years with a male:female ratio of 2.8:1. The onset was acute in 69% of patients. The salient features included nail changes (80%), mucosal involvement (36.6%), alopecia (30%), islands of normal skin (14.4%), and the "deck chair sign" (5.5%). The most frequent cause of erythroderma was pre-existing dermatoses (74.4%), including psoriasis (37.8%), dermatitis (12.2%), ichthyoses (7.8%), and pemphigus foliaceus (5.6%). Drugs and malignancy each induced erythroderma in 5.5% of cases. No cause could be found in 14.6% of cases.

CONCLUSIONS

Etiologically, pre-existing dermatoses showed the highest incidence and drugs the lowest compared with previous studies. Dermatitis was less common. There was a greater variety of causes of erythroderma in our series. Hair and nails were more frequently involved. Mucosal involvement, not mentioned in other studies, was present in 36.6% of our cases. The "deck chair sign" and islands of normal skin were seen in dermatoses not reported previously.

A randomized double-blind comparative study of terbinafine for 1, 2 and 4 weeks in tinea capitis

We report a randomized, double-blind study, comparing the relative efficacy and tolerability of oral terbinafine, given for 1, 2 or 4 weeks, in tinea capitis. Of 161 evaluable patients, 53 were treated with terbinafine for 1 week, 51 for 2 weeks and 57 for 4 weeks. Isolated pathogens included Trichophyton violaceum (71.5%), T. tonsurans (14.9%), T. verrucosum (4.3%), Microsporum audouinii (4.3%), M. canis (2.5%), T. schoenleinii (1.9%) and T. mentagrophytes (0.6%). The final evaluation, at 12 weeks, showed cure rates of 73.6, 80.4 and 85.9%, in the respective groups. The adverse effects noted, were not drug related. In our opinion, terbinafine given for 1, 2 or 4 weeks, is equally effective for most cases of tinea capitis.

Cutaneous manifestations of systemic lupus erythematosus: study from Lahore, Pakistan

BACKGROUND

Systemic lupus erythematosus (SLE) is an autoimmune disorder in which cutaneous lesions occur in 85% of patients. This study from Lahore, Pakistan, was conducted to determine the pattern and incidence of such lesions in SLE.

METHODS

Forty patients with SLE fulfilling the clinical and laboratory criteria of the American Rheumatism Association (ARA) (1982) were examined between October 1992 and September 1993 for the presence of cutaneous manifestations.

RESULTS

Skin changes noted were: noncicatricial diffuse alopecia (82.5%), malar rash (60%), mucosal lesions (60%), discoid eruption (57.5%), photosensitivity (60%), nail involvement (55%), vascular lesions (50%), pruritus (45%), and pigmentary changes (37.5%). Peripheral gangrene, chronic ulcers, Raynaud's phenomenon, urticaria, chilblains, thrombophlebitis, palmar erythema, and erythema multiforme were rare. Antinuclear antibody reaction was positive in 80% and anti-dSDNA antibodies in 70%.

CONCLUSION

A different clinical pattern was noted in our patients than reported previously.

Tinea capitis in Lahore, Pakistan

BACKGROUND

The causative fungi of tinea capitis vary with geography and time. This study was planned to identify the etiologic agents and determine clinicoetiologic correlations of tinea capitis in Lahore, Pakistan.

METHODS

From clinically suspected cases of tinea capitis, skin scrapings and hair samples were taken and subjected to microscopy and culture.

RESULTS

Of 180 evaluable patients, 95% were children below 12 years of age with equal sex incidence. Noninflammatory lesions were seen in 62.2% of cases. Trichophyton violaceum was the most common etiologic agent responsible for 69.4% of infection, followed by T. tonsurans (16.7%), T. verrucosum (10%), Microsporum audouinii (2.2%), and T. mentagrophytes (1.7%).

CONCLUSIONS

T. violaceum is the predominant pathogen causing tinea capitis in children and adults in this part of the world and gives rise to a varied clinical picture. Our findings agree with data from other parts of Pakistan and many countries abroad.

An open clinical pilot study of the efficacy and safety of oral terbinafine in dry non-inflammatory tinea capitis

Ten patients with dry non-inflammatory tinea capitis were evaluated in a pilot study which ran from September 1989 to February 1990. Each patient was given oral terbinafine for 6 weeks; each was followed up 2 weeks later. Eight (80%) were completely cured, one (10%) was mycologically cured and showed minimal signs and symptoms, and another (10%) showed improvement (negative mycology, but persistent clinical signs and symptoms). No topical or systemic side-effects were noted. Terbinafine appears to be an effective and safe antifungal agent in the treatment of non-inflammatory tinea capitis.