Clinical Patterns of Primary Dystonias among Hospitalized Patients in Baghdad and Kut in Iraq

Aim of study: This study was carried out to describe characteristics of 22 primary dystonic patients and their response to therapy. Patients and method: Twenty-two patients were entered into the study from Baghdad teaching hospital, Al-Kadhymia teaching hospital in Baghdad, privet nursery home teaching hospital in Baghdad, and Alzehraa teaching hospital in Kut south to Baghdad from January 2005 to January 2008. All cases were primary dystonia, secondary dystonia has been excluded from our study. Neuroimiging and slit Lampe examination have been done for all cases, L-Dopa in dose of 10/mg/kg/day for 2 weeks was giving for all patients. Type of study is a retrospective cohort study. All patients were followed in the outpatient clinics of the hospitals mentioned previously with frequent neurological examinations. Results: Out of 22 patients, 15 (68%) patients were females, 7 (32%) were males. According to descriptive classifications of dystonia by age of onset, fourteen patients (64%) were of early onset and eight (36%) being late onset (26 years and older). Three patients had generalized dystonia, 19 patients had focal dystonia {11 (58%) cases were cervical (TORTICOLIS) type, 5 (26%) blepharospasm type and segmental (LIMBES) dystonia 3 (16%)}. All cases were given L-DOPA in dose 10/mg/kg for 2 weeks, only two cases shown clinical response for the drug inform of absence of abnormal movements and improve quality of life. Conclusion: Dystonia is rare;however, early onset dystonia are more common than late onset. Dystonia are more common in females than in males and focal dystonia is more common than generalized dystonia.

Debulking of Keloid Combined with Intralesional Injection of 5-Flurouracil and Triamcinolone versus Intralesional Injection of 5-Flurouracil and Triamcinolone

Background: A wide range of therapies exist for keloids. But despite the multiple treatment modalities available, keloids still remain a significant challenge for both the clinician and the patient. Objective: To assess the effectiveness and safety of debulking of keloid with intralesional injection of 5-flurouracil and triamcinolone in comparison to intralesional injection of 5-flurouracil and triamcinolone alone. Patient and Methods: This single blinded comparative therapeutic outpatient based study was done at the Department of Dermatology, Baghdad Teaching Hospital during the period from February 2011 to February 2013. Twenty-three patients with 52 lesions were enrolled in the study and consisted of two groups: Group A (26 lesions): Treated by intralesional injection of combination of 5-flurouracil and triamcinolone acetonide and repeated every month;Group B (26 lesions): Debulking was carried out first and then injection of combination of 5-flurouracil and triamcinolone acetonide at time of operation and then repeated injection monthly. Evaluation was performed by scoring system with 5 criteria (redness, elevation, hardness, itching and tenderness). The response was graded as no response, minimal, moderate or complete response. Results: Both modalities of treatments showed significant results in treating keloid, but the intralesional therapy alone was slightly better than debulking plus intralesional and no systemic adverse effects were noticed in both groups. Conclusion: Both modalities of therapy were effective in treatment of keloid, and there was no much difference between them.

Therapeutic Evaluation of 2% Tea Lotion in Comparison with 5% Zinc Sulfate Solution in the Treatment of Acne Rosacea

Background: There are many effective topical and systemic therapies for acne rosacea. Topical zinc sulfate and tea lotion have been used in treatment of acne vulgaris. Objectives: To evaluate effectiveness of 2% tea lotion in comparison with 5% zinc sulfate solution in the treatment of acne rosacea. Patients and Methods: This single, blinded, comparative therapeutic clinical trial was carried out in the Department of Dermatology—Baghdad Teaching Hospital from June 2006-December 2007. Twenty two patients with acne rosacea were divided into two groups and were instructed to apply the following lotions for two months, Group A used 2% tea lotion twice daily while Group B used 5% zinc sulfate solution twice daily. Patient with severe acne rosacea were excluded from the study. Clinical improvement was evaluated every 2 weeks by determination of the disease severity score (Sharquie’s score) before and after treatment. Results: Eighteen patients with acne rosacea completed the study with their ages ranging from 26 - 70 (40.5 ± 10.9) years. For Group A and Group B were 39.7 ± 8.2, 41.2 ± 13.1 years respectively, with eight patients in Group A, ten patients in Group B. Five percent zinc sulfate solution was statistically significant in reducing the disease severity score in acne rosacea, while 2% tea lotion was beneficial but did not reach statistically significant level as zinc sulfate solution. Conclusion: Five percent zinc sulfate solution was a good alternative remedy to be used in patients with acnerosacea.

Treatment of Acute Cutaneous Leishmaniasis by Oral Zinc Sulfate and Oral Ketocanazole Singly and in Combination

Background: Cutaneous Leishmaniasis (CL) is an endemic disease in many countries and caused by different species of Leishmania parasite. It results in a deformed scar after a relatively long period. Many therapies have been tried in treatment of this disease. Objective: To compare the effect of oral zinc sulfate and oral ketoconazole singly and in combination in the treatment of acute cutaneous leishmaniasis. Patients and Methods: This single, blinded, therapeutic, controlled study was conducted in the Department of Dermatology, Baghdad Teaching Hospital, Baghdad, Iraq, during the period, January 2015 to July 2015. Seventy-five patients with acute CL were enrolled in this study. The total numbers of lesions were 327, and the duration of lesions ranged from 4 to 12 (6.9 ± 0.7) weeks. The diagnosis was confirmed by smear and histopathology. Patients were divided into three groups: 24 patients in Group A were treated with oral zinc sulfate capsules 10 mg/kg/day for 6 weeks;24 patients in Group B were treated with ketoconazole tablets 200 mg twice daily for 6 weeks and 27 patients in Group C were treated orally with a combination of zinc sulfate and ketoconazole for 6 weeks. All patients were seen regularly every 2 weeks for 6 weeks of treatment period, then monthly for the next three months as follow up period. Healing of the lesions was assessed by using Sharquie’s modified Leishmania score to assess the objective response to the topical or systemic therapy. Results:After six weeks, 75 patients have completed the treatment, 24patients received zinc sulfate capsule, 24 patients received oral ketoconazole and 27 patients received a combination of both treatments. The cure rate was (60%) in the group receiving oral zinc sulfate capsuleand (50%) in the one receiving oral ketoconazole tablet (P = 0.146) and (96%) in the combination group (P ? 0.04). Conclusion: The combination therapy using oral zinc sulfate and oral ketoconazole gave a high cure rate. The combination therapy is a new mode of therapy as both drugs act in a synergistic way.

Direct Transplant of Melanocytes from Normal Donor Area into Vitiligenous Recipient Area by Intralesional Injection of Melanocytes Using Spade Like Needle Technique

Background: Vitiligo is a common autoimmune inflammatory skin disease, where there are different surgical techniques for treatment of stable patches of vitiligo .Objective: To find non-costly, minimally invasive, simple technique by direct melanocytes transplant by spade needle technique in treatment of vitiligo. Patients and Methods: This interventional, therapeutic, comparative study was done in Department of Dermatology, Baghdad Teaching Hospital, Baghdad, Iraq from April 2014-March 2015. Twenty patients with localized, generalized and segmental vitiligo were included. Full history and examination for each patient was done with 4 (20%) males and 16 (80%) females and their ages ranged from 9 - 40 (23.15 ± 11.44) years. Forty one patches in 20 patients treated by spade grafting technique and the donor and recipient sites were demarcated and anesthesia done by xylocaine 2% with adrenalin 1:100,000. Transplantation was started by using disposable needle gauge 18 (the sharp end of needle was cut by a scissor to make it a spade like) with medical syringe 5 ml supplied with normal saline. The micro-pieces were taken from donor site and transplanted directly, easily and rapidly into dermis of recipient site and followed by pushing normal saline and the procedure was repeated to cover all recipient sites with 5 mm distance between injection points. The surface area of the lesions was calculated and the reduction rate was estimated every month till the end of the 4th month period of the treatment. Results: Including 41 patches in 20 patients with the surface area of the patches ranged from 1.5 - 90 cm2 (13.78 ± 17.57) cm2. The mean ±SD of surface area of lesions was decreased from 13.78 ± 17.57 cm2 at baseline visit to 13.61 ± 17.48 cm2 at the second visit (after 2 weeks ) which was statistically significant (p value ≤ 0.001). The mean surface area continued to be reduced till reaching 12.20 ± 15.68 cm2 at the third visit and 12.01 ± 15.55 cm2 at the fourth visit. All were statistically significant when compared to baseline visit. There was reduction in surface area 1.1% at two weeks, 9.93%, and 12.5% at the 2nd, 4th months respectively. Conclusions: Intradermal injection of melanocytes in patients with vitiligo by spade like needle was very quick and simple non-costly technique, and gave 12.5% reduction which could be repeated at different times until satisfactory re-pigmentation of vitiligenous skin is achieved.

Tuberculin as Intralesional Therapy for Viral Warts—Single-Blind, Split, Placebo, Controlled Study

Background: BCG vaccine as an antigen has proved its effectiveness as an immunotherapy for viral warts. Tuberculin is an antigenic extract of M. tuberculosis capable of eliciting an immunological skin reaction. Objective: To assess the efficacy of tuberculin intralesional injection in the treatment of viral warts. Patients and Methods: This single ,blind, placebo controlled study was conducted at the Department of Dermatology, Baghdad Teaching Hospital, Baghdad, Iraq from March 2010 to July 2011.Forty-one patients with different types of viral warts were enrolled in this study;tuberculin test was done to patients prior to instillation of intralesional treatment. Then the patients treated by intralesional tuberculin in each lesion located on the right side of the body, and intralesional distilled water in each lesion located on the left side of to a maximum of 3 injections, at 2 weeks interval or until full resolution of these lesions. Patients were evaluated every 2 weeks to assess the regression of their lesions and to record any local and systemic adverse effects. The response to treatment was evaluated by decrease in size and reduction in number of warts. Scoring of response to treatment was as follow: 1) Responders: including patients who showed complete cure or those with good response (>50% reduction). 2) Non responders: including patients who showed minimal response (<50% reduction), or those with no improvement (stable disease and disease progression). The follow up period lasted up to 2 months after the last dose. Results: Thirty out of 41 patients had completed the study, of them 14 (46.66%) patients showed response of their lesions on the right side of the body that were treated with tuberculin;15 patients showed no response, 1 patient showed minimal response, 7 patients showed good response and 7 patients showed complete cure (23.33%). Regarding the lesions treated with intralesional distilled water, 25 patients showed no response, 3 patients showed minimal response, 2(6.66) patients showed good response and no patient showed complete cure of their warts. Of the 14 responder patients to intralesional tuberculin, 10 patients were tuberculin tested positive, and 4 patients were tested negative, and of the 16 non responder patients to intralesional tuberculin, 3 patients were tuberculin tested positive, and 13 patients were tuberculin tested negative which was statistically significant difference. No side effects reported from tuberculin therapy apart from mild pain at site of injection. Conclusion: Intralesional injection of tuberculin is an effective therapy for viral warts when compared with control, possibly through its local immunological action and had no systemic immunological response. Patients with previous BCG vaccine showed better response to tuberculin injection.

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 Patients with Vitiligo by Intradermal Pricking of Vitiligenous Skin Using Sharp and Blunt Needle

Background: Vitiligo is a well known autoimmune disease, both cell mediated and humeral reaction are implicated in its etiopathogensis. Pricking of marginal pigmented of vitiligo skin to stimulate normal melanocytes to migrate into vitiligenous area and induce new melanogenesis and this is well known mechanism to induce repigmentation and supported by publications. Objective: To use needling technique by using blunt and sharp needle by doing pricking completely white vitiligo skin in order to stimulate residual melanocytes of basal layer and or the melanocytes of outer root sheath of hair follicles to proliferate and induce active melanogenesis. Patients and Methods: This is an interventional, therapeutic, comparative, study that was done in Department of Dermatology-Baghdad Teaching Hospital, Medical City, Baghdad, Iraq from April 2014-March 2015. Thirty five patient with vitiligo were enrolled in this study, their ages ranged from 5 - 55 (22.28 ± 12.09) years;15 patients treated with sharp needle, 2 males and 13 females and 20 patients treated with blunt needle, 4 males and 16 females. All clinical types of vitiligo including the generalized, localized and segmental were treated. The number of vitiligo patches varied between patients and the treated patches by sharp needle were 22 and by blunted needle were 20 patches. In both groups, needling was done geometrically, softly and rapidly in systemic horizontal rows away from pigmented margin and pigmented spot inside the patches and was not repeated. In Group A needle gauge 18 hold at 45° to skin surface and the distance between each pricking was 5 - 10 mm and similarly was done in Group B by using blunt needle. Each patient was advised to have daily sun light exposure for at least 15 min. Measuring the surface area of the lesions and calculating the reduction rate was done by using transparent with square paper and this was carried out every month till the end of the 4th month period of the treatment. All patients in both groups were evaluated every 2 weeks for the 1st month and then monthly for 3 months and the rate of reduction in surface area was measured. Also to record any side effects and complications. Results: After 2 week, 2 months, and 4 months of treatment, there was 0.5%, 4.31%, and 10% respectively reduction in the surface area of lesions in Group A, while in Group B, there was 7%, 18.42%,and 13.5% respectively reduction in the surface area. Conclusions: Pricking the vitiligo skin by needle, gauge 18 gave success rate 10% and 13.5% at four months after therapy and needling could be repeated once a week to accelerate melanogenesis and until get complete repigmentation.

Clinical and Biochemical Evaluation of Facial Acanthosis Nigricans

Background: Acanthosis nigricans is a well known cause of facial melanosis in Iraqi males and usually it is a part of ordinary acanthosis nigricans. It is commonly associated with many metabolic derangements. Objectives: To evaluate cases of acanthosis nigricans of the face for all metabolic disturbances including fasting blood sugar, fasting serum insulin, total cholesterol, triglyceride, growth hormone and serum leptin. Patients and Methods: Twenty seven cases of acanthosis nigricans of the face were included in this case descriptive, clinical and biochemical study. This was conducted in Department of Dermatology-Baghdad Teaching Hospital and Department of Clinical Biochemistry, College of Medicine, Baghdad, Iraq during the period from November 2012-August 2014. It consisted of 26 males and one female, their ages ranged from 16 - 58 (39 ± 4.9) years. The diagnosis was established by clinical and histopathological evaluation. Sharquie’s ANSI scoring of acanthosis nigricans of face was carried out for all patients, also body mass index was assessed. Biochemical evaluation was carried out for all patients including total cholesterol, triglyceride, fasting blood sugar and insulin, insulin resistance, growth hormone and leptin enzyme immunoassay. Twenty seven healthy control non obese individuals with comparable ages and gender were assessed for all tests. Results: Biochemical results showed that fasting blood glucose, fasting serum insulin, insulin resistance, fasting serum triglyceride, total cholesterol, growth hormone and serum leptin were statistically significantly high in patients with acanthosis nigricans of the face in comparison with control individuals and all were positively correlated with the scoring of acanthosis nigricans of the face apart from high density lipoprotein was negatively correlated. Conclusion: Acanthosis nigricans of the face is a good marker for the associated metabolic diseases and these metabolic changes were statistically significantly correlated with the severity of acanthosis nigricans.

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.

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.

Frictional Melanosis of Rubbing Thighs in Iraqi Patients

Background: Frictional melanosis of rubbing inner thighs is a common problem among Iraqi females causing great psychological and cosmetic impact. It might simulate lifa disease but it is a different entity. It is unfortunately not reported in the medical literatures although commonly encountered in daily clinical practice. Objective: To evaluate the hyperpigmentation of inner aspects of thighs in Iraqi females as an isolated pigmentary problem. Patient and Methods: Sixty patients with frictional melanosis of rubbing thighs were seen in Department of Dermatology, Baghdad Teaching Hospital in this case descriptive, clinical and histopathological study, during the period from April 2011 to March 2012. Any associated skin problems were also noticed like folliculitis and boils at area of friction. Forty individuals were enrolled in the present work as the healthy control group. The pigmentation was assessed by clinical, Wood’s light and histopathological examinations (H&E and Fontana stains). Body mass index was obtained for all patients and obesity was graded according to WHO recommendations. Results: The ages of patients ranged between 19 - 52 (32.86 ± 7.65) years, with 59 (98.3%) females and 1 (1.6%) male. By Wood’s light examination, accentuation in pigmentation was observed in 39 (58%) patients, while 21 (42%) of lesions showed no change. Body mass index was ranged from 23.3 - 43.6 (34.04 ± 4.13), history of vigorous rubbing of pigmented area with washing tool (lifa) was positive in 46 (76.6%) patients. Skin biopsies in 10 patients showed pure dermal melanophages in 3 of biopsies with slight melanosis of basal layer of epidermis, while the other 7 biopsies showed mainly increase in basal melanin. There was a statistically significant association between obesity and the severity of pigmentation of the inner thighs. Forty control individuals (2 males and 38 females) were assessed, their ages ranged from 19 - 50 (31.72 ± 6.40) years. All females were within normal weight while males were overweight and BMI was ranged from 19.7 - 28.2 (22.49 ± 1.84). All control individuals showed no pigmentation of inner aspects of thighs. Conclusion: Frictional melanosis of rubbing thighs is considered a new entity which had been not reported before in the medical literatures. This is a disease of mostly young obese females and the effective therapy is weight reduction and possibly liposuction.

Genital Warts in Infants and Children <br>—Re-Evaluation of Podophylline 15% as an Effective Topical Therapy

Background: Condylomataacuminata is an infection caused by Human Papilloma Virus, rarely reported in infants and children. Podophylline as a treatment for this condition has been used cautiously in this age group. Objective: To report the cases of anogenital warts including condy lomataacuminata in infants and children and to evaluate the effectiveness and side effects of 15% podophyllin in treatment of genital warts. Patient and Methods: Thirty infants and young children were seen in Department of Dermatology and Venereology—Baghdad Teaching Hospital in this case descriptive and therapeutic trial, in the period from January 2011 to August 2012. Their ages ranged from 8 - 72 (30.43 ± 15.85) months, 20 females and 10 males with a female:male ratio of 2:1. The duration of the disease ranged from 1 - 12 (5.26 ± 4.00) months. All demographics data were recorded in this study. History and examination were carried out to all patients. Family members including mothers were assessed about the presence of any type of viral warts in other location of body. Podophyllin (15%) in tincture benzoin was applied once weekly to all viral warts and the parents advised to wash out after 2 hours of application. The number of applications was repeated until full recovery. Follow-up after recovery was carried out for 6 months to watch for any relapse and to record local or systemic side effects. Results: The clinical pictures were mostly acondylomata acuminata in a form of cauliflower like warts in 20 (73.33%) patients, while in 10 (26.77%) patients there were ordinary verruca vulgaris like warts. The location of warts was perianal in 23 (76.66%) patients, genital only in 2 (6.66%) patients, and mixed in 5 (16.66%) patients. Topical applications of podophyllin 15% gave a full recovery in 27 (90%) patients, while in 3 (10%) patients there was partial response. The number of applications ranged from 1 - 4 (2.7 ± 1.42) applications. Follow up for 6 months after recovery showed relapse in only one patient, and no side effects were reported in any patients. Conclusion: There is upsurge of cases of anogenital warts among infants and children. Podophyllin (15%) in tincture benzoin is an effective therapy and no local or systemic side effects were recorded in any case.

Topical Therapy of Acute Cutaneous Leishmaniasis Using Zinc Sulphate Solution 25% versus Podophyllin Solution 25%

Background: Zinc sulphate as intralesional and oral therapy was used as a successful therapy in treatment of cutaneous leishmaniasis while 25% topical podophyllin is now commonly used in the treatment of cutaneous leishmaniasis. Objective: To treat acute cutaneous leishmaniasis using topical zinc sulphate solution 25% to be compared with topical podophyllin solution 25%. Patients and Methods: This is a single, blind, interventional, comparative study done in the Department of Dermatology, Baghdad Teaching Hospital, Baghdad, Iraq during the period from January 2015 to June 2015. Forty patients with a total 88 lesions of acute cutaneous leishmaniasis were enrolled in this study;54 (61.36%) were dry lesions and 34 (38.6%) were ulcerative type. The duration of lesions ranged from 2 - 11 (7.7 + 2.483) weeks. The size of the lesions ranged from 0.3 to 8 (2.13 ± 1.53) cm. There were 21 females and 19 males, female to male ratio (1.1:1) and their ages ranged from 1 to 60 (25.92 ± 16.59) years. Diagnosis was confirmed by tissue smear and histopathology. Lesions were divided into two groups with matching types and sizes, and ??scored according to Sharquie modified Leishmania score to assess the objective response to the topical or systemic therapy and then during follow up responses were graded into mild, moderate, marked response and complete clearance. Group A treated with topical 25% podophyllin solution once weekly for a maximum of 6 weeks, while group B was treated with topical 25% zinc sulphate solution twice daily for 6 weeks. Follow up was every 2 weeks during therapy, and once monthly for 3 months after therapy. Results: A total of 40 patients with clinical diagnosis of acute cutaneous leishmaniasis were included in this study, with a total of 88 lesions. Fifteen (37.50%) patients had single lesion and 25 (62.50%) patients had multiple lesions. Family history of CL was positive in 42.5% of patients. At the end of six weeks after starting therapy, the total cure rate in patients treated by topical podophyllin (both marked and complete responses) was seen in 32 (82%) lesions, while the cure rate in patients treated by topical zinc sulphate was in 36 (73.4%) lesions. There was no statistical significant difference between the cure rates of both groups. No important local or systemic side effects were seen in any patients. Conclusion: Topical zinc sulphate 25% is an effective simple non-invasive non-costly safe topical therapy for cutaneous leishmaniasis and without any contraindications for its use and free of side effects and was as effective as topical podophyllin.

Cutaneous Leishmaniasis as Imitator of Skin Diseases and a Diagnostic Challenge

Background: Cutaneous leishmaniasis (CL) usually has a well clinical presentation that rarely confused with other dermatological diseases, but when it presents with atypical picture, it may be a diagnostic challenge to dermatologist. Objective: To record the cases of CL those have very unusual presentations or sites in the Iraqi patients that might be confused with other dermatoses. Patient and methods: This is a clinical descriptive study that has been performed in the outpatient of Department of Dermatology Baghdad Teaching Hospital, Baghdad, Iraq, during the period from January 2015-February 2017, where fifty six patients were enrolled in the study. The age of the patients ranged from 1 - 67 years old with median is 30 years, 32 males and 24 females with M:F ratio is 1.3:1, the diagnosis was confirmed by skin smear and/or biopsy. Results: Fifty six cases of CL with atypical presentations and unusual sites that categorized as follow: diffuse nodular 4 cases, paronychia like 1 case, sausage-like CL 4 cases, lupus vulgaris like 2 cases, rosacea like 1case, squamous cell carcinoma-like 3 cases, keratoacanthoma like 1 case, pyoderma gangrenosum-like 2 cases, erysipeloid like 1 case, B-cell lymphoma like 1 case, grouping pattern 1 case, panniculitis-like 2 cases, dermatitis like 2 cases, ecthyma like 1 cases, verruca like 1 case, keloid like 1 case, CL on the scalp 1 case, palmer CL 1 case, CL on the eyelid 1 case, CL on the ear 1 case, CL on the lips 3 cases, one genital CL case and twenty cases of sporotrichosis like spread. Conclusion: Unusual presentations of the CL with atypical lesions should be well recognized and investigated to confirm the diagnosis so that not to be confused with other skin diseases especially in countries where cutaneous leishmaniasis is not endemic

Mycosis Fungoides in Iraqi Patients—Clinical, Histopathological and Immunohistochemical Study

Background: Mycosis fungoides (MF) is not an uncommon T-cell lymphoma in Iraqi population which is increasing over years. There are many diagnostic techniques to confirm the diagnosis including histopathological and immunohistochemical tests. Objectives: To evaluate all cases of MF including clinical, histopathological and immunohistochemical tests with CD markers. Patients and Methods: This clinical, histopathological, immunohistochemical outpatient based study took place in the Department of Dermatology, Baghdad Teaching Hospital, Medical City, Baghdad, Iraq during the period from May 2012-September 2013. Twenty five patients with MF were included in the present work. History was obtained from each patient regarding all socio-demographic aspects related to the disease. Also, clinical evaluation was carried out for all patients. Incisional biopsies for ordinary histopathology and immunohistochemical tests were done. Then staging was carried out depending on TNMB classification for all patients. Results: All cases of MF were confirmed after clinical evaluation, histopathology and immunohistochemical examination. Male to female ratio was 1.5:1. The mean age of onset at presentation was 47.45 ± 16.9 years. Itching was found in 84% of cases. The patch stage was seen in 36% patients. The hypopigmentaed MF was presented in 12% cases. The lower extremities were seen in 80%. Lymph node involvement as a manifestation of the disease was seen in 44% cases. The histopathological features of MF went parallel with the clinical stage of disease. Immunohistochemical study aids in the diagnosis of patch and erythrodermic stages. The most patients presented with stage IB (36%). Conclusion: MF seems to be not uncommon problem in Iraqi population and is increasing over years. The disease was diagnosed early commonly with patch stage (stage IB) while hypopigmented MF was not a common variant when compared with neighboring countries.

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.

The Safety of Oral Ketoconazole in the Treatment of Skin Diseases (Single Blinded, Therapeutic, Comparative Study)

Background: Ketoconazole was introduced in 1981 as the first in a series of antifungal agents that are characterized by nitrogen-containing ring. Ketoconazole acts against many different kinds of fungi such as candida, dermatophytes and as pergillus. Also oral ketoconazole had proved its effectiveness in the treatment of cutaneous Leishmaniasis. Objective: To evaluate the safety of oral ketoconazole in the treatment of different skin diseases like cutaneous Leishmaniasis (CL), tineacapitis, tineacorporis and tineaversicolor. Patients and Methods: This is a single, blinded, therapeutic, controlled study that was carried out in the Department of Dermatology, Baghdad Teaching Hospital, Baghdad, Iraq, during the time, January 2015 to July 2016. In total, 951 patients with acute cutaneous leishmaniasis, tineacapitis, tineacorporis and tineaversicolor were enrolled in this study. The diagnosis was confirmed by smear and histopathology. Patients were divided into two groups: 51 patients in Group 1;24 of them were treated with oral ketoconazole tablets 200 mg twice daily for 6 weeks and 27 of them were treated orally with a combination of zinc sulfate 10 mg/kg/day and ketoconazole for 6 weeks. All patients were seen regularly every 2 weeks for 6 weeks of treatment period, then monthly for the next three months as follow up period. Liver enzymes monitoring was done for every patient in this study every two weeks. Elevated liver enzymes were considered as features of hepatotoxicity in the examined patients. While group 2 included 900 patients and was divided into 3 subgroups: A: 600 patients with tineacapitis and tineacorporis, B: 100 patients with tineaversicolor, and C: 200 patients with CL. All patients in group 2 were treated with oral KC tablets 200 mg twice daily for 6 weeks. The dose of oral KC in children is 3.3 - 6.6 mg/Kg/day. All patients in group 2 were not investigated for ketoconazole biochemical side effects but watched for any clinical symptoms and signs of any side effects. Results: After six weeks, 951 patients had completed the treatment. In the first group (51 patients), only two out 27 patients (7.4%) from the combined group showed elevated liver enzymes while the ketoconazole treated group showed no increase in liver enzymes, hence only 3.9% showed elevated liver enzymes that went to normal during follow up. In the second group (900 patients) there were no clinical symptoms and signs in favor of hepatic toxicity or other related organs. Conclusion: Ketoconazole has been used tremendously in treating of different skin diseases including fungal and Leishmania infection but without side effects, accordingly this drug seems safe to be used in treatment of different skin diseases whether adults or children.

Burn Hemangioma (BH) (Scalded Pyogenic Granuloma) versus Infantile Hemangioma: Report of Six Cases of BH and Its Effective Therapy with Oral Propranolol

Infantile hemangioma and burn hemangioma have many similarities in clinical pictures, pathology and treatment. As infantile hemangioma appears usually after birth and then rapidly grow within few months and then a statue state and then involutes within few years while burn hemangioma so called burn pyogenic granuloma usually appears within days after burn with liquid and grow rapidly into many giant angiomatous masses and then after short time usually weeks or months will involute in more than 37.5% of cases. Hence burn hemangioma and infantile hemangioma sharing many similar features as both are angiomatous with dramatic rapid proliferation of blood vessels that followed by involution but with different time periods and both carry CD133 and CD34 for infantile hemangioma and CD34 for burn hemangioma. Also infantile hemangioma rapidly responds to systemic propranolol and similarly do in cases of burn hemangioma. Accordingly it is more better scientifically to call scalded pyogenic granuloma burn hemangioma. The objective of the present report is to review these conditions and do comparison between them and also to record 6 cases of burn hemangioma and its effective therapy with oral propranolol.

Targetoid Polycyclic Concentric Hair Regrowth Pattern Is a Sign of Immunological Recovery in Alopecia Areata

Background: Alopecia areata is a common autoimmune disease, where there are many topical and systemic therapies, during which hair growth appears in a uniform pattern. In certain cases, hair regrowth takes a polycyclic pattern simulating a target, so called targetoid phenomena. Objective: To screen all cases of treated alopecia areata for hair targetoid regrowth pattern. ?Methods: This is an observational study, was conducted in Dermatology Department of Baghdad Teaching Hospital in Iraq, during the period, August 2017 to October 2017. All cases treated for alopecia areata with IM triamcinolone 20 - 40 mg injection every 2 weeks with topical clobetasone ointment and zinc sulfate 2 mg/kg/day for 2 months, were examined for the targetoid concentric hair regrowth pattern. Result: Among all cases of alopecia areata, seven patients were recorded to have the targetoid concentric hair pattern, which seen 2 - 4 weeks after therapy, their ages ranged from 4 to 25 years old with a mean 14.5, all of them were males. All these patients returned back with hair growth in a form of rings of hair growth alternating with rings of little or no hair growth forming a typical picture of target. Conclusion: Targetoid polycyclic concentric hair regrowth pattern is an important phenomenon seen in patients receiving treatment for alopecia areata, which is a good sign of recovery where its etiopathogenesis could not well be elucidated but alternating immunological reactions could explain this targetoid pattern.