Melasma, Melasma-Like Lichen Planus Actinicus, and Butterfly Lichen Planus Actinicus Build up One Spectrum (Clinico-Histopathological Study)

Background: Facial melanosis is a major pigmentery problem seen in the daily clinical practice. Melasma and lichen planus actinicus are among these common causes. Still some facial melanosis that had features of melasma and butterfly lichen planus actinicus but could not be classified to either of them. Objective: To evaluate melasma, lichen planus actinicus and cases that could not be classified into one or either of them using clinical picture, Wood’s lump examination, and histopathological assessment. Patients and Methods: This is a case descriptive, comparative, clinical and histopathologicasl study carried out in Department of Dermatology, Baghdad Teaching Hospital, Baghdad, Iraq during the period from December 2012-May 2014. Forty patients with facial hyperpigmentation were included in this study. Twelve (30%) were males and 28 (70%) were females with female to male ratio: 2.3:1. Mean age ± SD of studied patients was 37.07 ± 9.63 years. History, physical examination, Wood’s lump examination and photographic pictures were done for all patients. Punch biopsy was taken from each patient, and processed and stained with Hematoxylin-Eosin (HE) and Fontana-Masson (FM) for histological evaluations. Results: These diseases were classified into: melasma with 11 patients, female to male ratio: 4.5:1 with mean age ± SD was 33.64 ± 6.516 years, melasma-like lichen planus actinicus with 21 patients, female to male ratio: 2.5:1,mean age ± SD: 39 ± 8.349 years, butterfly lichen planus actinicus with 8 patients, female to male ratio: 1:1, mean age ± SD: 36.75 ± 15.088 years. This classification depends on the following findings: some of these results could be more frequent and intense in one than others;they were the diseases of young age group, that had more tendency to affect females than males, sun light exposure and outdoor activities were the main etiological factors, but these factors were more triggering in lichen planus actinicus followed by melasma-like lichen planus actinicus and to lesser extent in melasma. The skin types were mostly III, the location and distribution of pigmentation were almost similar, Wood’s lamp findings were similar although was not conclusive. The histopathological findings especially the level of melanin deposition and inflammatory infiltrate were comparable but the melanin deposition was more intense in butterfly lichen planus and melasma-like lichen planus actinicus and to lesser extent in melasma. Conclusion: From the epidemiological, clinical and histopathological findings of the present work, we can suggest a conclusion that melasma, butterfly lichen planus actinicus, and melasma-like lichen planus actinicus were inflammatory skin diseases that build up one spectrum where melasma at one pole and lichen planus actinicus at the other pole and melasma-like lichen planus actinicus at the middle. The young age group, during their active reproductive life, will have these diseases in relation to sun light exposure with seasonal variations.

A Comparative Study of Topical Azailic Acid Cream 20% and Active Lotion Containing Triethyl Citrate and Ethyl Linoleate in the Treatment of Mild to Moderate Acne Vulgaris

Background: Acne vulgaris is a common disorder affecting 79% - 95% of the adolescent population. The choice of treatment depends on the severity, patients with mild to moderate acne should receive topical therapy such as azelaic acid. Rising antibiotic drug resistance consequent to the widespread use of topical antibiotics is causing concern and effective non-antibiotic treatments are needed. Objective: To compare the efficacy and side effects of topical azelaic acid cream 20% versus active lotion containing triethyl citrate and ethyl linoleate (TCEL) in treatment of mild to moderate acne vulgaris. Patients and Methods: This single, blinded, comparative, therapeutic study was done in the Department of Dermatology-Baghdad Teaching Hospital, Baghdad, Iraq;from May 2013-July 2014. Scoring of acne was carried out and the patients were examined every 2 weeks for 10 weeks of treatment. One month after stopping drugs, patients were evaluated for drug complications and disease recurrence. Sixty patients fulfilling enrollment criteria were included in this study. Patients were divided into 2 groups: Group A (30 patients) treated twice daily with TCEL lotion and Group B (30 patients) treated twice daily with topical azelaic acid cream 20%. Results: Both topical TCEL lotion and azelaic acid cream were statistically an effective therapy for treatment of mild to moderate acne vulgaris. TCEL lotion was more effective and act earlier than azelaic acid cream starting from 4 weeks of therapy till the end of treatment (after 10 weeks) and even after 4 weeks after stopping the treatment (P-value < 0.04). No systemic side effect for both groups was noted while the following side effects were reported;burning, pruritus and erythema, all these side effects disappeared after 8 weeks from starting treatment. After one month of follow up there was no significant relapse in both groups. Conclusion: The TCEL is non-antibiotic based, it had quicker onset of action and observable improvement of both inflammatory and non-inflammatory acne lesions. Its use would reduce the risk of antibiotic resistance developing within the skin flora.

Pityriasis Alba versus Vitiligo Clinical and Histopathological Study

Background: Most recently there was a well established study showed that pityriasis alba of ten progresses into vitiligo (Sharquie et al.). These findings were considered a new thought that might support a new hypothesis regarding the pathogenesis of vitiligo. Objective: In order to do further work on hypothesis which is in favor that pityriasis alba might progress into vitiligo, so the present research including clinical and histopathological study to confirm that pityriasis alba might progress to vitiligo. Patients and method: This is a descriptive clinical and histopathological comparative study carried out in Department of Dermatology, Baghdad Teaching Hospital during the period from January 2015 to August 2016. Thirty eight patients with pityriasis alba (group A) and twenty eight patients with vitiligo stage I (group B) and twelve patients with both pityriasis alba and vitiligo (group C) were included in this study. All patients were fully interviewed and full history was taken from all the patients. Also careful asking about personal and family history of vitiligo was taken. Blunt trauma was done to induce Koebner’s phenomenon. Punch biopsies were taken from skin lesion of all patients and ten biopsies from 10 persons were taken from normal skin. Each biopsy specimen was processed and stained with Hematoxylin-eosin (H & E) and Fontana-Masson (FM) for histological evaluations. Results: Clinical study-Group A: Pityriasis alba patients: The mean of age of patients in pityriasis alba ± SD was 8.68 ± 5.94 years including 33 (86.84%) males and 5 (13.16%) females. Koebner’s phenomenon was positive in 2 (5.26%) patients and family history of vitiligo was positive in 17 (44.74%) patients. Group B: stage I vitiligo patients: The mean of age ± SD was 15.46 ± 12.50 years with 15 (57.14%) male patients and 12 (42.86%) female patients. A Koebner’s phenomenon was positive in 11 (39.28%) patients and family history of vitiligo was found in 11 (39.29%) patients. Group C: pityriasis alba and vitiligo patients: The mean of age ± SD was 8.33 ± 2.78 years including 9 (75%) male patients and 3 (25%) female patients. Koebner’s phenomenon was positive in 6 (50%) patients and family history of vitiligo was positive in 7 (58.33%) patients. Histopathological study: Group A: pityriasisalba: </

Frequency of Benign and Malignant Tumors in Localized Vitiligo in Comparison to Generalized and Universal Vitiligo

Background: Autoimmune diseases like pemphigus and systemic lupus erythematosus are protective against skin malignancies like basal cell carcinoma and squamous cell carcinoma. Objective: As vitiligo is an autoimmune diseases, the aim of the present work is to record the frequency of all benign and malignant skin tumors among patients with different severity of vitiligo and to be compared with the skin tumors in healthy control. Patients and Methods: This is a case series, descriptive study done in the Department of Dermatology—Baghdad Teaching Hospital, Baghdad, Iraq, during the period from May 2014-May 2015. History was taken from each patient with vitiligo regarding age, gender, duration, personal and family history of vitiligo and other autoimmune diseases such as diabetes mellitus, thyroid dysfunction, and alopecia areata. Patients were assessed for past and present history of photodermatosis and any skin cancers. Healthy control was considered. Results: Three hundred and fifty patients with vitiligo were included in this study: 50 patients with universal vitiligo, 100 patients with generalized vitiligo, and 200 patients with localized vitiligo as well as 500 subjects as a healthy control. The ages of all studied subjects ranged between 31 and 77 years. Twenty four(48%) patients with universal vitiligo were males and 26 (52%) were females;49(49%) patients with generalized vitiligo were males and 51(51%) were females;101(50.5%) patients with localized vitiligo were males and 99(49.5%) were females and 235(47%) of control were males and 265(53%) were females. All skin tumors were seen to be high in healthy subjects and lower or absent in patients with vitiligo. Also patients with mild vitiligo had a higher frequency of skin tumors including benign and malignant than patients with severe vitiligo especially in patients with universal vitiligo. In addition, no photosensitivity or actinic reticuloid was detected in patients with vitiligo. Conclusions: Vitiligo especially generalized and universal type as an autoimmune disease had a protective action against photodamage, photosensitivity and skin tumors whether benign or malignant.

The Frequency of Skin Tumors and Infections in Patients with Autoimmune Diseases

Background: Autoimmune diseases are a vast array of organ-specific as well as systemic diseases, whose pathogenesis results from the activation of B and T lymphocytes reacting against antigens of the body’s own tissues (defined as self). Objective: To record skin tumors and infections in all autoimmune diseases gathered together in a one pathological state, compared with renal transplant recipients and normal control. Patients and Methods: Four hundred patients with different autoimmune diseases were examined. Fifty patients with pemphigus (15 males, 35 females) are aged from 20 - 70 (41.23 ± 3.89) years. Fifty patients with systemic lupus erythematosus (50 females) are aged from 17 - 45 (30.58 ± 10.08) years. One hundred patients with vitiligo (59 males, 41 females) are aged from 9 - 71 (42.89 ± 5.28) years. One hundred patients with alopecia areata (42 males, 58 females) are aged from 7 - 52 (38.67 ± 9.52) years. One hundred patients with psoriasis (56 males, 44 females) are aged from 7 - 71 (47.36 ± 8.62) years were evaluated. One hundred twenty kidney transplant recipients’ (101 males, 19 females) ages ranged from 14 - 70 (45.43 ± 4.63) years. All patients were examined thoroughly for any cutaneous manifestations and tumors and the findings were compared with the general population as a control group, which consisted of 500 healthy control individuals whose ages ranged from 20 - 71 (44.53 ± 11.48) years. This case series, descriptive, controlled study was performed in Baghdad Teaching Hospital from June 2014 to October 2015. Results: In renal transplant recipients, the findings were observed as follow herpetic infection in 30(25%), bacterial 12(10%) while fungal 24(20%) patients. These infections appeared early in the course of immunosuppression. While the tumors were noticed, the benign tumors were the commonest manifestations, which included viral warts in 45(37.5%) followed by actinic keratosis 15(12.5%), seborrheic keratosis 14(11.6%), sebaceous hyperplasia 13(10.8%) and keratoacanthoma 1(0.8%). While the malignant tumors were basal cell carcinoma 4(3.3%) followed by squamous cell carcinoma 3(2.5%), and kaposi’s sarcoma 4(3.3%), Bowen’s disease 1(0.8%). These malignancy usually appeared late in the course of immunosuppression. In pemphigus, viral warts were observed in 4(8%) cases;fungal infection was seen in 4(8%) cases and bacterial infections in 2(4%) of cases and herpetic infection in only 1(2%) of case;no tumors were found in all patients. In vitiligo, viral warts were observed in 2(2%) cases, while seborrhic keratosis and sebaceous hyperplasia were observed in 1(1%) case;herpetic and fungal infections were seen in 3(3%) of cases while bacterial infections were recorded in 2(2%) of cases but no tumors were found in all patients. In alopecia areata viral warts were observed in 9(9%) of cases, sebaceous hyperplasia in 1(1%) case, herpetic and bacterial in 3(3%) of cases and fungal in 4(4%) of cases;no tumors were found in all patients. In systemic lupus erythymatosus (SLE) viral warts were observed in 4(8%) of cases, herpetic infection in 12(12%) of cases, fungal infection in 10(20%) of cases, bacterial infection in 3(3%) of cases and sebaceous hyperplasia in only 1(2%) of case, but no tumors were seen. In psoriasis, viral warts were observed in 14(14%) of cases, herpetic infection in 10(10%) of cases, bacterial infection in 3(3%) of cases, fungal infection in 2(2%) of cases, sebaceous hyperplasia in 2(2%) of cases and seborrhiec hyperkeratosis in 1(1%) case, while no tumors were demonstrated. In healthy control individuals, herpetic infection was present in 36(7.2%) and viral warts in 52(10.4%) individuals, fungal infection in 29(5.8%) of individuals and regarding tumors solar keratosis was present in 24(4.8%);basal cell carcinoma and squamous cell carcinoma were present in 2(0.4%) individuals of each. Conclusions: Patients with autoimmune diseases were protected against infections and tumors while kidney transplant recipients had no such protection although all these groups were on prolonged immunosuppression.

The Major Psychocutaneous Disorders in Iraqi Patients

Background: Many skin diseases can be evoked by psychological problems. Dermatological conditions could also lead to psychological disorders;hence psychodermatology is an emerging subspecialty that focuses on the interface of psychiatry and dermatology. Objective: To assess the frequency of the major disorders of so-called psychocutaneous disorders which are commonly seen among Iraqi population. Patients and Methods: This case descriptive study had been done in Department of Dermatology-Baghdad Teaching Hospital, Medical City, Baghdad, Iraq during the period from March 2011 to October 2013. All cases were collected and categorized according to the disease problem. Patients were interviewed to search for the main triggering and precipitating factors involved in pathogenesis of these disorders. The clinical picture was well described in order to reach a final diagnosis. Psychological interview and analysis were performed for all patients to reach the specific emotional and psychiatric disease by consultant psychiatrist. Results: A total of 100 patients with major psychocutaneous disorders were seen and evaluated. Nineteen were males and 81 were females with female to male ratio: 4.26:1. Their ages ranged from 7 - 73 (26.5 ± 5.217) years. The frequency of these diseases was as follows: trichotillomania 53%, dermatitis artifacta 37%, delusion of parasitosis 6% and neurotic excoriation 4%. Conclusions: The major psychocutaneous diseases in Iraqi population were: trichotillomania, dermatitis artifacta and these are problems of mainly young females while delusion of parasitosis and neurotic excoriations were diseases of middle age females.

Treatment of Recurrent Aphthous Stomatitis by 100% Topical Pumpkin Seed Oil

Background: Recurrent aphthous stomatitis (RAS) is a major oral health problem, where its etiopathogenesis is not well understood. Accordingly, its therapy whether topical or systemic can induce clearance, but the relapse rate is high. Objective: To use 100% topical pumpkin seed oil in RAS as it has many actions as anti-inflammatory and antioxidant effects. Patients and Methods: This single, blind, clinical, therapeutic trial was conducted in the Department of Dermatology-Baghdad Teaching Hospital, Baghdad, Iraq, during February 2015-August 2016. Twenty-five patients with RAS were included in this work. After full history and clinical examination, the clinical diagnosis was established. Oral clinical manifestation index score (OCMI) was carried out before, during and after stopping therapy to assess the different parameters of this score. 100% Topical pumpkin seed oil was given two times daily for 3 months during which short term assessment for each patient was done by using OCMI before, after 4 days and after 8 days of therapy in addition to assessing the mean size of largest diameter of ulcers in each visit to evaluate the therapeutic efficacy of the therapy, while long term assessment of the OCMI was done every month for 3 months after starting of the therapy to evaluate the prophylactic effect of the therapy. After 3 months, pumpkin seed oil was stopped and assessment of OCMI was done monthly for another 3 months to evaluate the remission action of pumpkin seed oil. Results: Twenty-five patients were included in this study: 15 (60%) males and 10 (40%) females. While their ages ranged from 9 - 60 (27.48 ± 11.97) years. The mean of OCMI before pumpkin seed oil therapy was ranged from 9 - 15 (12.96 ± 1.42), while after the therapy the mean started to decline to lower level within 4 days of therapy and was statistically significant (p < 0.0001) and continued to decline significantly till the end of third month of therapy (p < 0.0001). The percent reduction was 79.30% after 4 days of therapy and 94.38% after 8 days of therapy. After stopping therapy, the mean of OCMI started to increase, but it is remained statistically highly significant (p < 0.0001) at the end of third months after stopping therapy when it is compared with baseline mean of OCMI. Conclusion: Pumpkin seed oil had an effective therapeutic and prophylactic action against RAS, in addition, it induced remission for at least 3 months after stopping therapy. No local or systemic side effects were observed during the course of therapy.