Journal of Pakistan Association of Dermatologists

Ixekizumab, An Effective Biologic Agent Therapy in Various Cases of Psoriasis: A Narrative Review

Nanda Daiva Putra — 2025-06-30

Psoriasis is a chronic inflammatory skin condition with immune involvement, characterized by skin inflammation and epidermal hyperplasia, increased risk of arthritis, cardiovascular disorders, and psychosocial burden. In the current management of psoriasis, the use of biologic therapy is increasingly being studied. This paper is aimed to increase understanding of ixekizumab in psoriasis management, so that its utilization can be optimized. Currently, the main biological agents have action on two crucial pathways in the psoriasis development and its chronicity, namely the IL-23/Th17 pathway and the TNF-? signaling pathway. Biological agents targeting the IL-17 receptor have shown higher efficacy and safety compared to those targeting TNF-? and IL-23 receptors in treating moderate to severe plaque-type psoriasis. Ixekizumab, one of the selective IL-17A pathway inhibitor, plays a crucial role in managing the occurrence of psoriasis. FDA has approved the use of ixekizumab for moderate to severe psoriasis (PsO) and psoriatic arthritis (PsA) . Numerous clinical trials have demonstrated the safety and efficacy of ixekizumab in treating both plaque psoriasis and PsA. The side effects are generally mild, in the form of nasopharyngitis, pain at the injection site, and upper respiratory tract infections.

Tattooing Granuloma: Upsurging Cases as an Early manifestation of Sarcoidosis

Khalifa E Sharquie — 2025-06-30

Background: Cutaneous manifestations of sarcoidosis may occur secondarily by a precipitating factor such as scars, infections, or even tattoo ink. Tattoo pigment can precipitate many inflammatory states; however, cutaneous sarcoid granuloma is a rare reaction.

Objectives: To record all cases of tattooing granuloma and do a full evaluation regarding the clinical and histopathological pictures.

Methods: This is a case series descriptive study where all cases with tattooing granuloma were collected during the period from 2021-2023. Full demographic and clinical evaluations were done. A complete physical checkup was carried out, especially the chest and eyes examination. Biopsies for histopathological assessment were performed.

Results: Fourteen female patients were subjected to the present work, their ages ranged from 22-48 years with a mean ±SD of 32±38.7 years. All gave a history of tattooing using mostly black ink and a rash appeared a few months to one year after the procedure. Almost all patients noticed swelling and itching. The sites of tattooing were located on both eyebrows except for 2(14.3%) patients, where their tattooing was located on the upper arms and trunk. Three patients had extra-eyebrows granulomatous rash involving the trunk. One (7.1%) patient was confirmed to have bilateral hilar lymphadenopathy. The consistency of the rash was almost firm rubbery plaque. The histopathology of the rash showed non-necrotizing granuloma and many of them were naked with little or no inflammatory reaction, pigmented particles were observed inside the granuloma.

Conclusion: There has been an upsurge of cases of eyebrow tattoo sarcoidosis in the last few years. The clinical and histopathological pictures of these cases have some features of cutaneous sarcoidosis. This increased frequency of tattooing sarcoidosis goes parallel with upsurge of cases of cutaneous sarcoidosis.

Advancements in Pediatric Dermatology: Balancing Ethics and Ensuring Patient Safety

Tahir Kamal — 2025-06-30

Significant improvements in diagnosis and treatment of childhood skin disease have been made in pediatric dermatology for children with complex skin disease. At the same time, however, these advancements beget ethics problems like consent in pediatric care, equitable access to treatment and the application of new therapies with long term safety profiles proven during staged testing. This article discusses the ethical challenges and safety issues in pediatric dermatology and outlines that the patient centered approach, research integrity and clinical guidelines should be considered during practice.

The pediatric dermatology specializes in diagnosis and treatment of skin, hair, and nail disorders of children with unique physiological and psychological conditions. Since the prevalence of pediatric skin disorders such as atopic dermatitis, psoriasis and rare genodermatoses is growing, a need has arisen for a special treatment. These advances come along with ethical challenges and patients safety concerns, and thus, a more nuanced understanding of pediatric care’s moral and clinical aspects.

Frequency and Severity of Vitamin D Deficiency among Vitiligo Patients in Karachi

Rabia Rafique — 2025-06-30

Background: Depigmented macules of various shapes are a hallmark of vitiligo, an autoimmune condition brought on by the destruction of melanocytes in the skin. All skin types and both sexes may be affected by the condition, which has been linked to other systemic autoimmune disorders such scleroderma, lupus erythe-matosus, alopecia areata and autoimmune thyroiditis.

Objectives: The aim of this study was to assess the frequency and severity of vitamin D deficiency among patients diagnosed with vitiligo.

Methods: This Cross-Sectional study was conducted in the Department of Dermatology Pakistan Navy Station (PNS) Shifa Hospital, Karachi for six months from June 2018 to December 2018. Patients with a clinical diagnosis of vitiligo were enrolled in the study following strict adherence to the defined inclusion and exclusion criteria. A predesigned questionnaire documented demographic factors such age, name, disease duration and gender. These patients' blood samples were obtained the same day and sent to the pathology lab of PNS Shifa hospital, Karachi to determine their vitamin D levels by radioimmunoassay. Vitamin D levels were docu-mented using a predesigned proforma on the day of reporting.

Results: The patients mean age was 33 ± 19.36 years. A total of 124 patients were included in the study. Among them, 52 (42%) were male and 72 (58%) were female. Vitamin D deficiency was observed in 91 (73%) patients, while 33 (27%) patients had sufficient vitamin D levels.

Conclusion: Vitamin D deficiency was highly prevalent among patients with vitiligo, highlighting the need for routine screening and potential correction as part of comprehensive management strategies.

Effectiveness of Topical Microbiome Containing Lactococcus Ferment Lysate 5% in Acne Vulgaris Patients

Anis Irawan Anwar — 2025-06-30

Background: Acne vulgaris is a type of persistent inflammatory dermatosis and can be manifested on varying levels, ranging from mild to very severe, but even moderate cases can cause psychological and emotional suffering. Several skin microbiomes are involved in the pathophysiology of acne vulgaris, and alterations in the microbiome composition (dysbiosis) will contribute to the breakdown of the skin barrier as well as immunological activation and inflammation. Lactococcus ferment lysate is a probiotic that has been shown to have anti-inflammatory properties. Topical probiotic treatments are considered safe and without adverse effects, when compared to topical and systemic standard therapies.

Objective: The purpose of this study was to investigate the efficacy of treating acne vulgaris with a microbiome comprising 5% Lactococcus ferment lysate.

Methods: The study employed a double-blind randomized controlled trial design. A total of 70 research participants were separated into two groups: placebo (A) and therapy (B). To determine the correlation between the two variables, the Pearson correlation test was used.

Results: The average number of lesions in the intervention group decreased from 48.5 (before intervention) to 24.5 (after intervention). Furthermore, it was discovered that lowering sebum levels on the forehead (week-6) and cheeks (week-8) was more effective in the intervention group than in the control group (placebo). Pro-inflammatory cytokines (IL-12, IL-8, and TNF-a) decreased in both the treatment and placebo groups, but not significantly (P > 0.05).

Conclusion: It has been demonstrated that topical microbiomes containing 5% Lactococcus ferment lysate lower the severity of acne vulgaris, sebum levels, pro-inflammatory cytokines, and enhance anti-inflammatory cytokines.

Efficacy of Terbinafine Versus Itraconazole in the Treatment of Tinea Corporis

Sumreen Hafeez — 2025-06-30

Background: Tinea corporis, sometimes referred to as 'ringworm,' is a superficial illness caused by dermatophytes that affects the skin.

Objective: To compare the efficacy of terbinafine versus Itraconazole in the treatment of tinea corporis.

Methods: This Randomized Control Trail was conducted at Department of Dermatology, DHQ Hospital ,Sheikhupura, during the duration of July 2023 till December 2023. Total 50 cases (25 in both groups) with Tinea corporis were included. Then patients were randomly divided into two groups. In group A, patients were given terbinafine. In group B, patients were given itraconazole. Then, the patients were followed-up for 2, 4, 6 and 8 weeks. On each visit, patients were examined for complete resolution of tinea, by using total body surface area index and they were assessed for resolution of leions. All the data was recorded in proforma and then entered & analyzed through SPSS version 26.

Results: In the terbinafine group, the mean age of the patients was 35.16 ± 8.76 years. In the itraconazole group, the mean age of the patients was 28.36 ± 10.65 years. In the terbinafine group, there were 15 (60%) males and 10 (40%) females. Whereas, in the itraconazole group, there were 8 (32%) males and 17 (68%) females. Moreover, in the terbinafine group, the baseline BSI score was 6.44 ± 3.19 and this score was reduced to 3.64 + 2.11 after 4 weeks of treatment. In this group the efficacy (complete cure within 4 weeks) was achieved in 6 (24%) cases. On the other hand, in the itraconazole group, the baseline BSI score was 7.20 ± 2.99, which was reduced to 1.75 + 0.50 after 4 weeks of treatment and the efficacy (complete cure within 4 weeks) was achieved in 13(52%) cases in this group.

Conclusion: We found that itraconazole has better efficacy than terbinafine for tinea corporis. Thus in future, itraconazole can be a drug of choice for such cases.

Comparison of Therapeutic Effects of 4% and 10% Purple Passion Fruit (Passiflora Edulis Sims Var. Edulis) Seeds Extract Cream with 4% Hydroquinone Cream on Epidermal Type Melasma

Yuli Kurniawati — 2025-06-30

Background: Purple passion fruit seed extract (PPFSE) is rich in antioxidant and photoprotective and therefore has potential as alternative treatment for melasma

Objective: This study aim to evaluate therapeutic effects of 4% and 10% PPFSE cream to 4% hydroquinone (HQ) cream for epidermal type melasma.

Methods: A randomized double-blind clinical trial was conducted. The study participants were divided into three groups, PPFSE cream 4%, 10% group and HQ cream 4% group. Severity of melasma was assessed with modified melasma area severity index (mMASI), melanin index (MI) with Mexameter® and Mark-Vu® skin analysis and quality of life index for melasma with melasQol at baseline, week 4, 8, and 12for each arm

Results: A total of 38 participants were included. There was a significant reduction in mMASI, MI, and melasQol scores before and after 12 weeks of treatment across all groups (p=0.000). The difference between mMASI and melanin index before and after 12 weeks of treatment was lower in the PPFSE 4% than the HQ 4% (p<0.05)

Conclusion: PPFSE cream 10% can be a viable option for treatment of epidermal type melasma

Clinical Spectrum of Cutaneous Leishmaniasis in Children of Southern Region of Pakistan

Kiran Naz Khan — 2025-06-30

Background: Cutaneous leishmaniasis (CL) has a wide spectrum of clinical presentations. Children are not considered as vulnerable as adults to acquire the disease and studies regarding clinical spectrum of CL in children population are sparse.

Objective: The study was aimed to explore the extended clinical spectrum of CL in children of southern region of Pakistan.

Methods: Children of all ages having lesions clinically suggestive of CL, anywhere on the body were included in the study (Jan 2019-Dec 2023).The diagnosis was established on the basis of clinical appearance, geographical origin and slit skin smear examination. Patients were treated with weekly intralesional injections of meglumine antimonite for 4-16 weeks. Various demographical features and clinical patterns were recorded. Descriptive statistics were used for analysis.

Results: 72 childhood cases were seen among 316 of total patients of cutaneous leishmaniasis. Age range was 3 months -15 years (mean age = 8.72 + 4.47). Male to female ratio was 1.5:1.Majority of the patients (75%) had solitary lesions. Maximum lesion count was >50 in one case and 90%had lesions on face. Cheeks were most common sites followed by nose and lips. Predominant clinical pattern was psoriasiform plaque followed by nodular, noduloulcerative. Some atypical morphologies like furunculoid, cheilitis, chancriform, verroucous and lupoid were also seen. All patients responded well to treatment without any significant side effect.

Conclusion: Childhood CL exhibits varied clinical spectrum. Lesions are characteristically seen on face as against on extremities in adults and respond favorably to weekly intralesional treatment with antimonial compound.

A Comprehensive Evaluation of Biofillers for Infraorbital Rejuvenation

Bushra Muneeb — 2025-06-30

Background: The increased demand of non-surgical cosmetic procedures has led to the popularity of infraorbital rejuvenation with autologous Biofillers because of their minimally invasive and biocompatible nature and cost-effectiveness. Dark circles around the eyes and loss of volume due to aging are relevant to facial aesthetics. Unlike hyaluronic acid fillers, Biofillers, having the origins in platelet-rich plasma (PRP), provide a regenerative and safer choice, as it uses own biological material to enhance the treatment of areas under the eye.

Objective: To evaluate the effectiveness of undereye Biofillers for infraorbital rejuvenation and with side effect profile and follow up.

Methods: Biofiller treatment was performed in 30 participants, 25-55 years of age who had mild to moderate undereye concerns. Biofiller was obtained by withdrawing blood followed by centrifugation, plasma separation and its heating and cooling to an opaque color before injection. Patients received two injections, 4 weeks apart. Subjective and photographic evaluation of outcomes such as improvement in hollowness, reduction in peri orbital hyperpigmentation and side effects were measured with visual analog scales before treatment, imme-diately after treatment and at 4 weeks and 12 weeks from the treatment.

Results: Overall satisfaction and improvement in aesthetic appearance reflected by the mean scores of 8.0 and 7.5 respectively was high. The side effects were not severe and were transient, lasting for a period of 3 to 5 days and a mean pain score noted was 6.5. The data points to the satisfactory to good response with low side effect profile in infraorbital rejuvenation with Biofillers.

Conclusion: Biofillers for infraorbital rejuvenation is an economically viable method effectively showing imp-rovement in appearance of under eyes, both in improvement of hollowness and reduction of pigmentation and is accompanied by mild side effects.

The Correlation between Anti-desmoglein Autoantibody Titers, IgG Antibody Levels, and the Pemphigus Disease Area Index by Location in Patients with Pemphigus Vulgaris

Quach Thi Ha Giang — 2025-06-30

Background: Quantifying anti-desmoglein (anti-Dsg) antibodies and indirect immunofluorescence (IIF) are valuable methods for diagnosing and assessing the severity of pemphigus vulgaris (PV). Location-specific Pemphigus Disease Area Index (PDAI) scoring may better reflect disease activity than total PDAI scores.

Objectives: To explore correlations between anti-Dsg1, anti-Dsg3 antibody levels, IIF titers, and location-specific PDAI scores in Vietnamese patients with PV.

Methods: A cross-sectional study was conducted on 48 PV patients, including newly diagnosed or those off immunosuppressive therapy for at least one month. Anti-Dsg1 and anti-Dsg3 levels were measured by ELISA, and IgG antibodies were assessed by IIF.

Results: Among 48 patients (mean age 56.15 years; 64.58% female), anti-Dsg1 positivity was 91.67%, and anti-Dsg3 positivity was 66.67%. Anti-Dsg1 positivity was significantly higher in patients with cutaneous lesions (97.73% vs. 25.00%; P=0.0009), while anti-Dsg3 positivity was higher in those with mucosal lesions (92.86% vs. 30.00%; P<0.0001). Anti-Dsg1 levels correlated with cutaneous PDAI (r=0.378; P=0.0081), and anti-Dsg3 levels strongly correlated with mucosal PDAI (r=0.795; P<0.0001). IIF titers correlated with total PDAI (r=0.377; P=0.0082) and mucosal PDAI (r=0.389; P=0.0062), and were associated with anti-Dsg3 levels (r=0.444; P=0.0015). Higher anti-Dsg1 levels were observed in IIF-negative patients compared to IIF-positive ones. Serum levels of anti-Dsg3 were higher in the IIF-positive group compared to the IIF-negative group (median 114.63 RU/ml vs. 13.9 RU/ml, P=0.0369).

Conclusion: Severity of PV, assessed by location-specific PDAI scores, correlates significantly with anti-Dsg ELISA levels and IIF titers. Integrating clinical scoring with serological and immunofluorescence assays enhances disease monitoring in PV.

Thread Lifting in Aesthetic Dermatology: Basic Concepts, Techniques, and Clinical Considerations

Kathrin Kezia Henry — 2025-06-30

Background: Skin aging is an emerging problem in the cosmetic field as life expectancy increases. There has been a trend to seek the least invasive techniques of facial rejuvenation. Thread lifting is one of them.
Objective: To discuss the basics of thread lifting in Aesthetic Dermatology.
Review: Thread lifting uses threads produced from the same material used to seal wounds in surgery to lift and straighten sagging tissue and define facial contours. The implanted thread could be utilized to tighten tissue and give volume to the applied area by being placed beneath the skin. Considered a minimally invasive procedure, it still possesses risks of injury for several anatomical structures in the targeted area. Several threads and techniques have been introduced for thread lifts with various efficacies and safety profiles. There is no one absolute type of thread or technique for thread lifting. However, absorbable and barbed threads are currently the most frequently chosen for thread lifting due to their minimal side effects and long-lasting results.
Conclusion: Thread lifting could be a choice for tackling the skin aging phenomenon.

Glucantime Resistant Cutaneous Leishmaniasis- A Case Report

Nadia Sultan — 2025-06-30

Leishmaniasis is a vector-borne disease caused by flagellated protozoans from the genus Leishmania. This disease is prevalent in tropical and subtropical regions and is found across 98 countries in Europe, Africa, Asia, and the America and has become a global health concern. Transmitted through the bite of female sandflies, Leishmania has become endemic in various regions around the world. According to the WHO, it is estimated that there are approximately 700,000 to 1 million new cases of leishmaniasis worldwide each year. Leishmaniasis manifests in three main forms: visceral (the most severe, often fatal without treatment), cutaneous (the most common, typically causing skin ulcers), and mucocutaneous (affecting the mouth, nose, and throat). However, Pakistan has a burden of cutaneous leishmaniasis. Here we report a case of 24 years old male, who presented from district Kashmore of Pakistan with multiple non healing ulcers on exposed body parts particularly suggestive of Cutaneous Leishmaniasis.

Urticaria as a Cutaneous Manifestation of SARS-CoV-2 Infection - A Case Report

Cut Putri Hazlianda — 2025-06-30

The Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) virus is responsible for causing the infection known as Coronavirus disease 2019 (COVID-19). Clinical manifestations of COVID-19 have been associated with various symptoms, but skin manifestations are rarely seen. A 25-year-old woman presented with complaints of erythematous urticarial plaques accompanied by itching over buttocks, waist, right arm, and right toe for one day, and confirmed positive for COVID-19. There is research on the timing of skin rash appearance in COVID-19 patients, with 46.1% of rashes appearing simultaneously with prodromal symptoms, 44.3% appearing after and 9.6% appearing before prodromal symptoms, with varying resolution time period.

Clinical Features of Bullous and Pustular in Systemic Klebsiella Pneumoniae Infection in Immunocompetent Patients

Nanda Shaskia Larasaty — 2025-06-30

K. pneumoniae is a rare cause of systemic infection but can lead to high mortality and poor prognosis in immunocompromised patients. However, reports of skin manifestations that occurrences in immunocompetent patients are rare. We are reported here A 33-year-old female presented with red patches accompanied by papules and blisters all over her body for one week, with previous complaints of fever and productive cough. Dermatological examination revealed multiple generalized pustules and bullae. Positive Nikolsky sign and Asboe-Hansen sign were observed. Blood and wound culture confirmed the presence of K. pneumoniae. The bullae regressed rapidly within five days after antibiotic therapy. The purpose of this case report is to enhance knowledge about cases of K. pneumoniae infection presenting clinically as generalized bullous and pustular lesions. Clinicians should consider systemic K. pneumoniae infection when evaluating patients with generalized bullous and pustular lesions.

Combination of Low-Dose Methotrexate with Cyclosporine as Management for Generalized Pustular Psoriasis

Muhlis Muhlis — 2025-06-30

Generalized pustular psoriasis (GPP) is a rare, life-threatening dermatosis marked by sterile pustules, systemic inflammation, and multi-organ involvement. We report a 26-year-old obese female with sudden-onset erythematous plaques, pustules, and erosions covering >90% of her body, accompanied by fever and arthralgia. Histopathology revealed Kogoj pustules and neutrophilic infiltrates, confirming GPP. Initial methylprednisolone therapy failed to prevent recurrence. Combination therapy with low-dose methotrexate (7.5–15 mg/week) and cyclosporine was initiated, alongside topical corticosteroids and wet dressings. Notable clinical improvement was seen within 30 days without any negative effects. This case highlights the synergistic effectiveness of methotrexate-cyclosporine treatment in refractory GPP cases, considering hyperproliferation is managed with methotrexate and T-cell activation is managed with cyclosporine. The response was quick, along with a good safety profile suggesting the treatment may be used instead of biologics where resources are limited. More research needs to be done to develop combination therapy protocols for GPP.

Concurrent of Pemphigus Vulgaris and Pemphigus Foliaceus in the Same Patient : Rare Case

Cut Putri Hazlianda — 2025-06-30

Easily ruptured superficial vesicles or bullae are a hallmark of the chronic autoimmune illness pemphigus. The two primary subtypes of pemphigus are pemphigus vulgaris (PV) and pemphigus foliaceus (PF), which can infrequently coexist or even change from one to the other. Changes in the autoantibody profile for desmoglein that are both qualitative and quantitative may help to explain this process. We describe a case of PF and PV present at the same time on a 73-year-old woman from clinical findings revealed multiple flaccid bullae on the face, neck, left and right arm and thigh, stomach, and back. Erosions, excoriations, and crusts were present. Nikolsky's sign was positive. Her histopathological examination showed subcorneal and suprabasal acantholysis. Basal cells were formed in a “row of tombstones” appearance.