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   Table of Contents - Current issue
January-June 2022
Volume 26 | Issue 1
Page Nos. 1-60

Online since Thursday, June 30, 2022

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Efficacy and safety of 10,600 nm fractional carbon dioxide laser versus 88% phenol in treatment of idiopathic guttate hypomelanosis: A prospective study p. 1
K Deepadarshan, MR Harish, BM Shashikumar, Priyanka R Chandran
Background: Idiopathic guttate hypomelanosis (IGH) is a common benign acquired leukodermic dermatosis characterized by multiple, discrete, hypopigmented-to-depigmented macules. Various treatment modalities were tried for this condition with varied results. Purpose: This study was conducted to compare the efficacy and safety of fractional carbon dioxide laser and 88% phenol in the treatment of IGH. Methods: A total of 40 patients with five IGH macules on each side were treated with one session of fractional carbon dioxide laser on the right side and a single application of 88% phenol on the left side and were assessed monthly for 3 months. The improvement in pigmentation was graded as ≤25% - poor, 26%–50% - minimal, 51%–75% - good, and >75% - excellent response. Results: A total of 32 patients completed the study. Out of the 160 macules treated with laser, 16 (10%) macules showed an excellent response and 40 (25%) showed a good response, and 40 (25%) and 48 (30%) macules in the phenol group showed excellent and good improvement, respectively. Side effects such as persistent scabbing and ulceration were seen only on the phenol side. Conclusion: Single application of 88% phenol was more efficacious than one session of fractional carbon dioxide laser in inducing pigmentation in IGH macules in this study. However, fractional carbon dioxide laser can be considered a safer alternative modality.
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A comparison of autologous serum, plasma, and whole blood for intradermal autoreactivity testing in patients with chronic spontaneous urticarial: A cross-sectional study p. 6
Rasimah Ismail, Adawiyah Jamil, Norazirah Md. Nor, Mohammed F Bakhtiar
Background: Autologous serum (ASST) and plasma (APST) skin testing confirm autoreactivity in chronic spontaneous urticaria (CSU). Whole blood autohemotherapy has been used. Plasma and even whole blood may be used instead of serum with relatively quicker preparation and cheaper method especially using the latter in centers with limited resources. Purpose: The purpose of the study is to determine if similar intradermal skin reactions can be observed when using either serum, plasma, or whole blood in autologous skin tests and to determine factors associated with positive tests and wheal diameter. Methods: We performed a cross-sectional study of chronic urticaria patients in a dermatology clinic. Tests were performed according to EAACI/GA2 LEN Task Force recommendations. Urticaria Activity Score over 7 days (UAS7) was assessed. Statistical analyses included Chi-square, Mann–Whitney U, Spearman's, and Wilcoxon rank tests. Results: Twenty-six (77%) females and 8 (24%) males mean age 34 (26–42) years participated. ASST, APST and autologous whole blood for skin testing (AWBST) positivity rates were 24%, 29% and 27%, respectively (P = 0.86). 13 (38%) had at least 1 positive test; all tests were negative in 21 (62%). All tests were positive in 7 (21%), 3 (23%) were positive APST alone, 2 (15%) AWBST, 1 (8%) ASST. Pretest UAS7 was higher with those with test positive (P = 0.04). Test results were unaffected by age, gender, disease duration, atopy, anti-nuclear antibody, and thyroid status. Wheal diameter correlated with thyroid-stimulating hormone (P = 0.04). Conclusion: Autoreactivity rates were similar with ASST, APST, and AWBST. Positive tests were associated with severe CSU. Autologous whole blood may be a simpler and less costly alternative to plasma and serum for autoreactivity skin testing in patients with chronic urticaria.
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Skin cleansing and wound care practice in patients with epidermolysis bullosa: A cross-sectional study p. 13
Ashjan Alheggi, Leena Alzakry, Rawan Bin Khunayn, Rahaf Alshareef, Yara Al-Khalid
Background: Epidermolysis bullosa (EB) is a group of genodermatoses characterized by fragile skin that may progress to erosions, blisters, and open nonhealing wounds. Understanding home skincare practices and topical products use among patients with EB is necessary to optimize management outcomes and quality of life. Purpose: The purpose of this study was to assess home bathing, skincare routines, and topical product used in patients with EB. Methods: Cross-sectional, observational study data were collected from patient-directed questionnaires in the Saudi EB registry. Data collection and statistical analyses were conducted using Microsoft Excel and SPSS-V.25. Results: Thirty-seven patients (62% males; mean age 14; [2 months–36] years) were enrolled. EB subtypes included EB simplex (n = 13), junctional EB (n = 6), and dystrophic EB (n = 13); five patients had unknown type. Twenty-one patients (57%) dislike multilayer wound dressings and/or find that they exacerbate the blistering during summer and in hot climates. Almost one-quarter of participants reported lancing a few of the intact blisters, and 5.4% did not lance any. Bath additives ranged from barely effective to potentially cytotoxic solutions of vinegar and sodium hypochlorite solution. Around 1/3rd of participants reported the use of topical antibiotics with no alternation or rotation on dirty wounds, and 8.1% of our cohort reported the use of antibiotics on intact skin. Conclusion: Education is needed for EB patients and their families on lancing of blisters and topical antibiotic use, especially in light of increasing antibiotic resistance. Dressing modification for EB patients living in the Gulf region countries, particularly during hot and humid months, may be helpful.
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Assessment of the Saudi Arabian telemedicine experience during the COVID-19 pandemic: Dermatology-related consultations as a case p. 18
Sahar H Alsharif, Nizar Alsharif, Rimaz Alassiri, Ghaidaa Khouj, Noura Alshareef, Anwaar Aloufi, Arwa Hussain
Background: COVID-19 is a pandemic disease that spreads rapidly. The World Health Organization recommended social distancing to prevent disease transmission. Telemedicine was one of the most important tools used during the pandemic to provide health-care services. Different clinics, including dermatology clinics, tended to use telehealth and online tools. In addition, various dermatological conditions were diagnosed and treated by family physicians using the telemedicine applications of the Saudi Ministry of Health (MOH). Purpose: The present study aimed to evaluate the efficacy of family physicians using telemedicine to diagnose and manage different dermatological conditions. Specifically, we aimed to identify the common dermatological conditions that family physicians faced during the COVID-19 pandemic, as well as the use of the various telemedicine applications launched by the Saudi MOH. We also intended to assess the need for dermatologists in the telemedicine applications of the Saudi MOH and suggest possible improvements to the telemedicine process and related Saudi MOH applications for sustainable online health care. Methods: The cross-sectional study was conducted across Saudi Arabia among family physicians and general practitioners to assess their perception of using telemedicine for dermatology-related consultations. The self-administered survey questionnaire contained 16 questions in five sections. Results: A total of 302 family medicine and general physicians completed the questionnaire. Altogether, 165 (54.6%) physicians reported that they had never used telemedicine before the COVID-19 pandemic, while 12.9% reported frequent to continuous use. During the pandemic, 86.8% of family and general physicians used telemedicine for dermatological consultations. The most used methods were phone calls (57.6%) and the SEHA application (42.7%). A total of 96.4% of participants reported that they dealt with dermatological conditions before the COVID-19 pandemic. Interestingly, about 99% of family physicians reported that they faced difficulty diagnosing dermatology-related consultations. Telemedicine was frequently used by all physicians in the central region compared with 76.7% of those in the western region (P = 0.035). Conclusion: Family physicians in Saudi Arabia increased their telemedicine practicing during the pandemic. Different telemedicine tools were used, such as phone calls, virtual clinics, and Saudi MOH applications (SEHA, TETAMMAN, TABAUD, TAWAKKALNA). The majority of family physicians faced difficulty diagnosing dermatological conditions. In addition, most reported that dermatologists should be part of health-care facilities and telemedicine centers to deal with dermatology-related consultations.
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Trichoscopic findings in various alopecias at tertiary referral center: A cross-sectional study p. 25
Mamatha P , V Neha, Shishira R Jartarkar, Shalini Sampath, Rakesh R Madireddy
Background: Hair disorders are a common complaint that baffles dermatologists due to multiple causes. Trichoscopy is a noninvasive technique used to diagnose and monitor the progression of various hair disorders. Purpose: To observe the trichoscopic patterns of various hair disorders to assist with differentiation. Methods: This was a cross-sectional observational study done in 256 patients with alopecia. After a detailed history, clinical examination, and relevant investigations, trichoscopy was performed using a Dermlite (3Gen LLC, Sanjuan Capistrano, CA, USA) dermoscope. Results: Out of 256 patients, 154 were male and 102 were female. Most of the cases were in the age group of 21–40 years (66.4%). Nonscarring alopecias (93.35%) were common compared to scarring alopecias (5.8%). The most common alopecia noted in our study was Androgenetic alopecia 125 patients (48.82%), followed by telogen effluvium 48 patients (19.1%), the common trichoscopic follicular features noted were short vellus hair 161 (62.8%), yellow dots (61%), hair diameter variation 125 (48.82%), and black dots (21.87%). The commo interfollicular features are seen were arborizing vessels 109 (42.6%) and pigmentation in 12 patients (4.68%). Significant findings observed in each group were hair diameter diversity in androgenetic alopecia, exclamatory mark in Alopecia Areata, comma hair in tinea capitis. Cicatricial alopecias are characterized by loss of follicular ostia along with inflammatory signs such as perifollicular scales and casts. Conclusion: Trichoscopy is a very valuable and useful tool to diagnose various hair disorders by understanding the various trichoscopic patterns specific for each disease.
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Burnout syndrome in dermatology residents: A cross-sectional study p. 31
Asem M Shadid, Batal M Aldosari, Abdullah M Algarni, Abdulmajeed Bin Dahmash, Saad Altalhab, Ruaa Alharithy
Background: Burnout is defined by three dimensions: emotional exhaustion (EE), depersonalization (DP), and low personal feelings of achievement (PA). It is a prolonged response to chronic emotional and interpersonal stressors on the job. If unrecognized, the costs to the health-care system can be enormous. Purpose: The aim of this study is to investigate the prevalence of burnout levels and predictors among dermatology residents and the risk factors associated with it. Methods: Validated measure of burnout (Maslach Burnout Inventory–Human Services Survey), alongside the possible risk factors of burnout, was distributed to all dermatology board training residents in all affiliated centers in Riyadh, Saudi Arabia. The response rate was 96.2% with 51 residents completing the survey out of 53. Results: High EE was present in 41.2% of dermatology residents, a low sense of PA in 45.1%, while high DP was the least prevalent at 13.7%. Satisfaction with career was significantly associated with risk of high EE (odds ratios [OR] = 0.61, 95% Confidence interval [CI] = 0.15–22.3), risk of high DP (OR = 0.34, 95% CI = 0.08–0.316), and risk of low PA (OR = 0.86, 95% CI = 0.52–6.1). The average number of sleeping hours was also associated with risk of high EE (OR = 0.87, 95% CI = 0.54–3.88), risk of high DP (OR = 0.76, 95% CI = 0.5–1.41), and risk of low PA (OR = 0.86, 95% CI = 0.52–6.1). Our findings report high over all burnout in 7.8% of the respondents. Conclusion: EE and feelings of low PA were seen at a high rate among dermatology residents, while DP was the least prevalent across all burnout dimensions. Average daily sleeping hours alongside satisfaction with life/work balance, career, and salary showed a statistically significant association with DP, low PA, EE, and overall burnout. Protected time to pursue academic interests, for example, research and teaching, and a fair distribution of on-call hours per month, as well as a number of clinics per week may explain the rate of burnout in our study. These findings can be applied in the improvement of training programs to reduce the burnout rate among residents.
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Public perception and willingness to undergo cosmetic procedures during the COVID-19 pandemic: A cross-sectional study p. 38
Ibrahim Alreshidi, Assil Albrekeit, Ruaa Alharithy
Background: As a result of the spread of coronavirus disease (COVID-19) at the beginning of 2020, many governments, including Saudi Arabia, have suspended operations in many agencies. Most of the dermatologists have restricted their practice, including cosmetic procedures, to ensure social distancing. On May 7, 2020, Saudi authorities have reduced the restriction of COVID-19 virus preventative measures, allowing clinics to start accepting patients with following the ministry of health protocols. Purpose: To evaluate the public's perception and willingness to undergo cosmetic procedures during the COVID-19 outbreaks in Saudi Arabia. Methods: A descriptive, cross-sectional, questionnaire-based study was carried out among the individuals who lack typical symptoms of COVID-19 infection in Saudi Arabia. A self-designed web-based questionnaire was developed; content face validity and a pilot study were done. The questionnaire was distributed electronically from May 8 to May 31, 2020. Results: A total of 656 individuals who lack typical symptoms of COVID-19 infection were included in this analysis. Only 10.5% of participants expressed their will to do cosmetic procedures during the COVID-19 pandemic. More than 90% of the participants believed that the COVID-19 pandemic was either somewhat serious (52.9%) or very serious (38.7%). The willingness to do cosmetic procedures during the COVID-19 pandemic remained unaltered when the price was discounted (P < 0.001), and when infection control measures were ensured (P < 0.001). Conclusion: The COVID-19 pandemic had a negative impact on the practice of cosmetic dermatology. Fear of transferring the infection to a beloved home member is the main reason to avoid these procedures. Generating well-structured safety guidelines to decrease the risk of this unusual virus transmission in dermatology practice and creating financial incentives may help increase the public willingness to do these cosmetic procedures during this pandemic.
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Surgical pearl: A small handy apparatus for chemical cautery p. 43
Muhammed Mukhtar
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Neurotic excoriation presenting as solitary papule: Case report p. 45
Rawan M Aldhahwani, Khalid A Al Hawsawi
Neurotic excoriation (NE) is a repetitive manipulation of the skin that causes tissue damage. Here, we report on a 56-year-old male, otherwise healthy, who presented with a 1-year history of a recurrent slightly itchy skin lesion on his nose. Skin examination revealed a solitary round 0.5 cm × 0.5 cm pigmented crusted papule on his nose. A skin biopsy was taken, and it showed an epidermal crust with underlying mild inflammatory cell infiltrate in the upper dermis. On the basis of these clinical and pathological findings, the diagnosis of NE was made. The patient was reassured and prescribed Fucidin cream and betamethasone valerate ointment. Behavioral therapy was also initiated.
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Postmessenger ribonucleic acid COVID-19 vaccine delayed inflammatory reaction to dermal fillers: Case report p. 48
Ruaa Alharithy, Asim Alsaedi, Marwan Alsaedi
We report two cases of inflammatory reaction to postvaccination to Pfizer COVID-19 vaccine from Saudi Arabia: A case of delayed inflammatory reactions (DIRs) to hyaluronic acid (HA) dermal filler in the upper lip following the first dose of messenger ribonucleic acid Pfizer-BioNTech COVID-19 vaccine; the second case of DIR to HA filler underneath of eye following the second dose of Pfizer COVID-19 vaccine. The mechanism of this late reaction to HA fillers may be dependent on numerous factors and is not well understood.
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Recurrent papulonecrotic tuberculid in an adolescent male: A diagnostic dilemma p. 51
Arundhathi Shankaralingappa, Michael L Anthony, Tummidi Santosh, Kanakapudi Josephain, Prabhakaran Nagendran, Hima Gopinath
Tuberculids are considered to be a hypersensitivity reaction to endogenous tuberculosis (TB). Papulonecrotic tuberculid (PNT) is a rare tuberculid occurring in <5% of active TB. An 18-year-old male presented with recurrent necrotic papules for 6 years on limbs, trunk, and neck which healed with scars. Biopsy from lesion revealed caseating granulomas with lymphohistiocytic vasculitis. Ziehl–Neelsen stain was negative for acid-fast bacilli, but Mantoux was strongly positive. The polymerase chain reaction was not done due to monetary constraints. The final diagnosis of PNT was confirmed and he was started on anti-tubercular treatment (ATT) for which he responded. PNT should be treated as a sentinel lesion and a meticulous search for systemic involvement of TB should be carried out. Awareness about PNT is essential for its diagnosis and to institute ATT at appropriate time.
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Cavernous hemangioma resembling lymphangioma circumscriptum: The central role of dermoscope in diagnosis p. 54
Khairuddin Djawad
Vascular tumors and malformations are often called “angiomas.” Cavernous hemangiomas are more commonly found in adolescents, often on the face and rarely on the extremities. Surgery may be pursued for cosmesis in cases of cutaneous lesions that do not involute. A 12-year-old girl presented with a lump on her right knee 4 years ago. Initially, the lump was flat and appeared like a bluish bruise but then slowly enlarged. There were no complaints of itching, pain, and other discomfort. Physical examination showed a 3.2 cm × 2.1 cm mobile violaceous tumor composed of dark red or blue-black vesicles in the right knee, clinically resembling lymphangioma circumscriptum. Dermoscopic examination showed a pattern composed of central dark, red-blue lacunae, white structures, and a peripheral brownish homogeneous area, which was consistent for cavernous hemangioma. The patient underwent biopsy excision and the diagnosis was confirmed through histopathological examination.
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Lichen planus after COVID-19 vaccination: A report of two cases p. 57
Salman H Alotaibi, Ruaa Alharithy, Faisal A Alsharif, Norah Alkhayal
Lichen planus is a T-cell-mediated inflammatory disease that can be associated with preexposure to particular agents encompassing vaccines, viruses, and drugs. The origin of the disease is unknown and has varying clinical presentations, the recent manufactured COVID-19 vaccines have been linked with several cutaneous reactions that are similar to the cutaneous manifestations of COVID-19 virus infection, the majority of people developed cutaneous manifestations after the second dose of Pfizer vaccine, recent cases have been reported as a flare of a preexisting lichen planus following the administering of the Pfizer vaccine. We present a two interesting cases that developed a dermatological condition post Pfizer-BioNTech's COVID-19 vaccine. The first case is a 60-year-old man, with a past medical history of having lichen planus 15 years ago, that have been treated and controlled successfully with topical therapy, flared up following the administration of Pfizer-BioNTech's COVID-19 vaccine. The second case is a 57-year-old female with a past medical history of hypertension and hypothyroidism controlled. Develop the new onset of lichen planus after receiving the third dose of the COVID 19 vaccine. The lesions arise 3 weeks after the third dose.
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