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A 12 years old girl was presented with bilateral swellings on angle and body of mandible. On general physical examination, there were polydactyly and papular lesions on arm. Histopathology of mandibular lesions revealed odontogenic keratocysts. Marsupialization of the cysts followed by enucleation was done. The patient was reviewed every six months and there was no recurrence at the end of two years.

Pyogenic granulomas (Granuloma telengiectaticum) or lobular capillary haemangioma are classically described as solitary lesions, occurring in young individuals, usually at the site of previous trauma, with a tendency to recur after treatment. We describe an unusual case of multiple disseminated pyogenic granulomas in an elderly male caucasoid of Pakistani origin in whom more than 400 lesions occurred de novo without any antecedent history of trauma or skin disease, responded well to treatment and showed no tendency for recurrence. Multiple eruptive pyogenic granulomas are probably a rare subset of the disease, which can occur at any age, arise de novo or in association with a skin or systemic disease and do not exhibit a tendency to recur after treatment.

All new cases of vitiligo reporting to Dermatology Outpatient of Combined Military Hospital, Panu Aqil, were included in the study. Of the 230 patients, 124 were male (53.9%) and 106 were female (46.1%). Males were more commonly affected. The disease affected all age groups. Mean age at presentation was 27.02 + 18.34 years and age at presentation ranged from 5.5 months to 82 years. The mean age at onset was 22.03 + 16.97 years with majority 30.4% (n=70), developing vitiligo in first decade of life. Generalized vitiligo was the most common type (n=132, 57.4%) followed by focal (n=53, 23%) and acro-facial vitiligo (n=16, 7%). Head and neck was the most common initial site of onset (n=100, 43.48%). Koebner phenomenon was observed in 72 patietns (31.3%), family history was present in 64 patients (27.8%) and 16 patients (7%) had associated diseases.

Harlequin ichthyosis is a rare and extremely severe form of congenital ichthyosis. The affected neonates usually do not survive beyond first few days after birth, but several long-term survivals have been noted. The inheritance is thought to be autosomal recessive. It has recently been shown that the vast majority of affected individuals are homozygous for mutations in the ABCA12 gene, which cause a deficiency of the epidermal lipid transporter and result in hyperkeratosis and abnormal barrier function. Prenatal diagnosis is possible. We report a case of a newborn with Harlequin ichthyosis, a product of consanguineous marriage, with a history of similar disease leading to early neonatal death previously in a sibling.

Black brown hyperpigmentation of the mucosae, sunexposed skin, palmar creases and frictional sites (Addisonian pigmentation) is characteristic of Addison disease. However, it can also occur as a paraneoplastic manifestation of tumours like bronchogenic carcinoma. Acquired ichthyosis starts later in life and can also be a paraneoplastic presentation. We report a unique combination of paraneoplastic Addisonian pigmentation and acquired ichthyosis as presenting features in a patient with undiagnosed multiple myeloma. To the best of our knowledge this combination of paraneoplastic dermatosis has not been documented before in multiple myeloma. It is concluded that the presence of more than one suspicious dermatosis may be an indicator of being paraneoplastic requiring necessary work-up.

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN, Lyell's disease) are severe, episodic, acute mucocutaneous reaction that may be caused by various factors particularly drugs. Treatment is primarily supportive care and there are no specific therapy regimens. Intravenous immunoglobulin (IVIG) has recently been shown to be a useful and safe therapy in paediatric patients with SJS/TEN, though no such case has so far been reported from Pakistan. The authors report the experience with low dose IVIG (0.1 g/kg/day for four consecutive days for treating a 3 years old boy with toxic epidermal necrolysis with favourable outcome without early complications.

Objective: To determine the association of low serum zinc levels with persistent, progressive or recurrent viral warts., Study Design: A comparative study., Place and Duration of Study: Dermatology outpatient department of Combined Military Hospital, Abbottabad in collaboration with Department of Chemical Pathology, Army Medical College, Rawalpindi, from June 2006 to May 2007., Methodology: Seventy five patients having warts of more than six months duration, more than 10 in number, who either not responded to or had recurrence after previous treatments for viral warts and not having other chronic dermatological or systemic illness were included in the study after informed consent. Seventy five age and gender matched healthy individuals were taken as control. Serum zinc analysis was carried out by atomic absorption spectrometry using Perkin elmen (USA) apparatus. Independent sample t-test was used to compare mean zinc levels in microgram/litre with significance at p < 0.05., Results: Age of the patients as well as controls ranged from 12-65 years with a mean of 25.88 + 8.90 years. Serum zinc level was low in 42 (56%) patients and 24 (32%) controls (p=0.003). Among the patients, serum zinc level ranged from 695-1090 micro-gram/litre with a mean of 804.38 + 100.60, whereas the level ranged from 690-1100 microgram/litre with a mean of 836.17 + 91.04 among controls (p 0.044)., Conclusion: Zinc deficiency is associated with persistent, progressive or recurrent viral warts in the studied patients. Randomized controlled trials with careful dose adjustment of oral zinc sulphate may be helpful to formulate guide lines to manage such patients.

Objective: To determine the etiology and frequency of different types of urethritis in adult males., Study Design: A case series., Place and Duration of Study: The Dermatology Department of PNS Shifa Hospital, Karachi, from June 2004 to December 2007., Methodology: One hundred male patients having complaints of urethral discharge and dysuria reporting in the skin OPD were included in the study. Patients who had received systemic treatment for their complaints and those who had other systemic infections were excluded. A detailed history including history of sexual contact was taken. Dermatological examination including examination of external genitalia was also performed. All these patients were subjected to complete physical examination, complete urine examination, urethral pus for gram staining and culture, endo-urethral swab with urethral loop for seeing Chlamydia antigen by fluorescent microscopy, cultures for ureaplasma and Wet mount specimen microscopy for trichomonas along with HIV (serum ELISA) test. Non-gonococcal urethritis was diagnosed on the presence of more than five polymorphonuclear leucocytes per high power field in at least five fields of Gram stained urethral smear, in the absence of Gram negative diplococci., Results: The mean age was 29.2 + or - 5.8 years. Seventy (70%) cases were diagnosed as gonococcal urethritis and 30 (30%) cases as non-gonococcal urethritis (NGU). History of illicit sexual exposure was available in 25 (25%) patients. The interval period between initiation of symptoms and reporting of patient in gonococcal urethritis was 4 to 30 days (mean 12.8 days) and 4 days to 2 months (mean 20.7 days) in non-gonococcal urethritis. The patients with gonococcal urethritis presented with purulent discharge in 66 (84%) cases, and dysuria in 49 (70%) cases. In the NGU group, 25 (80%) cases had mucoid discharge and 18 (65%) had dysuria. in 70%, Neisseria gonorrhoeae was isolated, Chlamydia trachomatis in 16%, ureaplasma in 8%, and Trichomonas vaginalis in 4%. No organism could be detected in 2% cases. HIV test was negative in all cases., Conclusion: Gonococcal urethritis was the commonest urethritis seen followed by Chlamydia infection in the studied group of adult males.

The clinical manifestations of secondary syphilis are variable and can mimic many skin diseases, mostly being generalized and symmetrical in distribution. Localized lesions of secondary syphilis are rarely seen in dermatology clinics. We report an unusual presentation wherein a patient had localized lesions over face and soles only. There is a need for increased awareness on the part of physicians to recognize new patterns of syphilitic infection, together with a willingness to consider the diagnosis of syphilis in patients with unusual clinical features.

Objective: To compare the efficacy and safety of Jessner's solution with 30% salicylic acid as superficial chemical peeling agents in treating epidermal melasma in Asian skin., Study Design: Double blind, randomized, interventional comparative study., Place and Duration of Study: Department of Dermatology, Combined Military Hospital, Malir Cantt, Karachi, from January to December 2004., Patients and Methods: Sixty consenting patients with epidermal melasma were randomly divided into two groups. Group A was treated with Jessner's solution and Group B with 30% salicylic acid. Baseline Melasma Area Severity Index (MASI) score was noted and peeling started at 2-weekly intervals. Sunscreen in morning and moisturizer at night were prescribed in all patients. MASI score and adverse effects were recorded biweekly. Treatment was stopped at 12 weeks and patients were followed-up at 4 weekly intervals for further 12 weeks. Final MASI score and adverse effects were noted at the end of follow-up period. Mean MASI scores were compared using paired sample t-test and one-way ANOVA., Results: Difference in baseline, treatment end and follow-up end MASI scores was not statistically significant between the two groups (p 0.54, 0.26, and 0.55 respectively). On the other hand, within group analysis of difference between pre and posttreatment MASI score was highly significant in both groups (p<0.0001). Adverse effects were mild and comparable in both groups., Conclusion: Jessner's solution and 30% salicylic acid are equally effective and safe peeling agents for use in epidermal melasma in Asian skin.

Papulonecrotic tuberculids represent an immunological expression of an internal focus of tuberculosis in an individual with a moderate or high degree of immunity. It responds to anti-tuberculosis treatment and is characterized by an eruption of necrotizing papules occurring in symmetrical crops, particularly affecting the elbows, knees, buttocks and face. A case of papulonecrotic tuberculids associated with immune mediated unilateral uveitis is reported in which all investigations were negative for tuberculosis except a strongly positive tuberculin test. There was an excellent response to anti-tuberculosis treatment. The association of immune mediated uveitis with papulonecrotic tuberculids has not been described before.

Objective: To determine the clinical features and demographic profile of the patients having papular urticaria., Study Design: A case-series., Place and Duration of Study: Dermatology Department of Combined Military Hospital, Abbottabad from January to December 2006., Patients and Methods: Individuals of all age groups and either gender either suspected of or having definite history of insect bite were included in the study. A specially-designed proforma was filled for each patient separately. The proforma included demographic features, information regarding clothing and sleeping habits, personal or family history of atopy and clinical patterns of the lesions. Computer programme SPSS 10 was used to manage and analyze the data., Results: Out of 280 patients, 201 (71.8%) were children upto 12 years of age, 178 (63.6%) were males, 91 (32.5%) had atopy, 194 (69.3%) were non-locals, 212 (75.7%) came from urban/peri-urban areas and 173 (61.8%) presented during May-August. Lesions were present over exposed parts of the body in 36 (12.9%), arranged in groups in 152 (54.3%) and were papular urticaria in 185 (66.1%) patients., Conclusion: Children, adult males, non-locals and those belonging to urban/peri-urban areas are more vulnerable to papular urticaria in a particular region. Papular and urticarial lesions arranged in groups over both exposed as well as covered body parts of a single patient is the most common clinical pattern.

Objectives: To determine area of origin of adult varicella patients, whether rural or urban, to compare the mean interval between leaving the area of origin and onset of varicella in adults of rural origin in comparison with those of urban origin and to observe its complications., Study Design: A cross-sectional study., Place and Duration of Study: Combined Military Hospital, Abbottabad, from January to December 2006., Patients and Methods: All patients over the age of 18 years, presenting with acute illness clinically, suggestive of varicella were included in the study. A specially designed proforma was filled for each patient separately, which included demographic features as well as area of origin, whether rural or urban, and the age at which they left the area of origin. These patients were examined, treated and assessed clinically on regular basis for the progress of the disease as well as for its possible local or systemic complications. Data analysis was done by using statistical programme SPSS-10., Results: Out of 9155 adult patients, 156 (1.70%) had varicella, including 128 (82.1%) males and 28 (17.9%) females. Origin was rural in 125 (80.1%) and urban in 31 (19.9%) patients. Mean interval between leaving area of origin and developing varicella in those of rural origin was 01.79+/-01.78 years and that in patients of urban origin was 03.37+/-05.72 years (p+/-0.009). None of the patients developed any complication of the disease., Conclusion: Varicella in adults is generally a benign illness. It is more common among adult males of rural origin and the interval between leaving the area of origin and onset of varicella in these patients is significantly less as compared to that in adults of urban origin.

Objective: To determine the throat carriage rate of Streptococcus pyogenes in patients having chronic plaque psoriasis and the effect of antibiotics as compared with that of oral methotrexate., Design: Quasi-experimental study., Place and Duration of Study: Dermatology Department, Combined Military Hospital, Abbottabad, from January to December 2006., Patients and Methods: Forty patients and 40 age and gender-matched controls were selected. Throat swab for culture of Streptococcus pyogenes was taken from each patient and control. All patients were treated with oral Penicillin V 250 mg, 6 hourly, and oral Rifampicin, 600 mg daily, for 10 days. Pre- and posttherapy 'Psoriasis Area and Severity Index' (PASI) were compared. Thirty of these 40 patients were later given oral methotrexate, 5-10 mg weekly, for 04 weeks and pre- and post-therapy PASI were compared. Chi-square and paired-samples t-test were used for data analysis., Results: Throat swab cultures were positive for Streptococcus pyogenes in 05 (12.5%) patients and none (0%) of the controls (p=0.02). Mean pre- and postantibiotic therapy PASI were 15.92 +/- 05.94 and 15.19 +/- 06.17 respectively (p=0.078). Mean pre- and postmethotrexate PASI were 15.81 +/- 5.55 and 8.79 +/- 4.19 respectively (p < 0.01)., Conclusion: Throat carriage of Streptococcus pyogenes is common in patients with chronic plaque psoriasis. Short-term antibiotic treatment has no role in routine treatment of chronic plaque psoriasis. However, it would be worthwhile to consider the effects of long-term antibiotics on chronic plaque psoriasis.

Juvenile onset classical Pityriasis Rubra Pilaris (PRP), although rare, is the most common presentation of PRP in children. It has good prognosis and resolution over a few months. Use of potentially hazardous systemic drugs in a disease, that is likely to resolve spontaneously, needs to be assessed carefully. We report a 09 years old boy suffering from this rare disorder, whose disease is well under control with emollients and a combination of diluted topical steroids and keratolytics, for over 06 months.

Various conservative methods for treatment of labial swelling in patients with granulomatous cheilitis have been attempted, often with only moderate success. We report a case of granulomatous cheilitis who showed excellent sustained response to combination of intralesional steroids, metronidazole and minocycline for initial one month followed by prolonged maintenance treatment with minocycline alone.

Rothmund-Thomson syndrome is a rare autosomal recessive poikilodermatous disorder with various inconsistent features. Clinical features of two siblings are described, which raised only just cosmetic concerns for the parents. The parents were counseled and advised regular follow-up for early detection of complications including malignancies and to protect the children from sun exposure by using broad spectrum sun screens and physical barriers.

Hydroa vacciniforme (HV) is a rare photosensitivity disorder with onset in childhood. Recurrent vesicles, bullae and crusting occur on sun-exposed skin that heals with vacciniform scarring. This rare disorder is hereby reported in an adolescent girl who developed a severe episode of hydroa vacciniforme on a hot sunny day during harvesting season. She had repeated episodes afterwards in succession until she was appropriately sun-screened. Her lesions healed without scarring because of early reporting, short-lived episodes, early diagnosis and response to appropriate therapy.

Objective: To assess the knowledge, attitude and practice regarding dandruff among soldiers., Design: Cross-sectional study., Place and Duration of Study: Departments of Dermatology at Combined Military Hospitals, Abbottabad, Malir and Gujranwala from January 2006 to March 2006., Patients and Methods: Serving male soldiers posted at Abbottabad, Malir and Gujranwala Cantonments were included in the study. Convenience sampling was used to distribute the questionnaire. All soldiers included in the study were asked or assisted by the trained staff to fill the close-ended questionnaire in Urdu, which included information about demographic profile and questions relevant to the objectives of the study. The ethical requirements for the study were fulfilled. SPSS-10 was used for data management., Results: A total of 800 serving male soldiers were surveyed. Five hundred and twenty-one soldiers (65.1%) answered yes to dandruff, whereas 279 (34.9%) replied in negative. Dandruff was considered a disease by 433 (83.1%) respondents. Hair fall (n=392, 75.2%) and scalp itching (n=380, 72.9%) were the common symptoms and 330 (63.3%) respondents were embarrassed by dandruff. Bad water (n=93, 17.8%), winter (n=40, 07.6%) and lack of sleep (n=30, 05.7%) were considered the most common causes of dandruff. Majority of the individuals (n=487, 93.4%) used different hair oils and household remedies for the treatment of dandruff. One hundred and fourteen (21.9%) and 50 (09.6%) participants consulted doctors and traditional healers respectively for their dandruff. Advertisements in electronic or print media and wall hoardings etc. influenced 213 (40.9%) respondents to use various anti-dandruff shampoos, hair tonics and oils., Conclusion: Dandruff is a common problem and there is a need for education programmes and formulation of a policy regarding the positive role of media on health matters.

Erythrokeratodermas are inherited or sporadic disorders of keratinization, with many variants. Progressive symmetrical erythrokeratoderma presents as large, erythematous or hyperpigmented, hyperkeratotic, fixed symmetrical plaques over various parts of the body along with many other inconsistent features. Periorificial keratotic lesions have very rarely been reported in progressive symmetrical erythrokeratodermas. We report a 9 years old boy with progressive symmetrical erythrokeratoderma having perioral involvement besides fixed hyperpigmented, keratotic plaques. He was started with oral etretinate but he stopped the treatment due to no-response after two weeks and is presently using topical keratolytics without marked improvement.

Xeroderma pigmentosum patients are advised to strictly avoid sun exposure to prevent ultraviolet-induced DNA damage. We describe a 2 1/2 years old boy having xeroderma pigmentosum, who also developed rickets. He was given one injection of vitamin D along with dietary vitamin D supplements to which he responded. He is being followed- up regularly in outdoor clinic with the advice to the parents to continue dietary vitamin D supplements and to avoid sun exposure.

Cutaneous pseudolymphoma is an aggregate of mature or abnormal looking lymphocytes in the dermis, which clinically and /or histologically simulates lymphoma but has a benign course and outcome. Systemic drugs, especially anti-epileptics, are an important cause of cutaneous pseudolymphomas. Pseudolymphoma of the skin, secondary to topical drug application, is very rare. We report a case of cutaneous pseudolymphoma induced by local application of 4% hydroquinone cream to melasma over the cheeks.