Journal of Pakistan Association of Dermatologists

Breastfeeding in Decreasing Atopic Dermatitis Incidence in Infants: A Systematic Review

Wed, 31 Dec 2025 00:00:00 +0000

Breastfeeding has been linked to the avoidance of allergies, including atopic dermatitis (AD). Numerous studies have demonstrated that breastfeeding for at least six months can lower the incidence of AD in young children. The purpose of this study is to assess how breastfeeding may reduce the prevalence of atopic dermatitis. We searched and retrieved material from 2019 to 2024 using the PRISMA 2020 recommendations in the following databases: PubMed, CORE, Science Direct, Cochrane and Google Scholar search engine. Relevance was asse-ssed in abstracts and titles. Primary research on breastfeeding as a strategy to reduce the occurrence of atopic dermatitis that was published at least five years ago and that can be translated into English are requirement for inclusion. The Newcastle-Ottawa Scale was used to assess the quality of the evidence. From 1,281 identified articles, 33 studies remained after the initial screening process. Following a thorough assessment of metho-dological quality, trustworthiness, and relevance, 9 studies were ultimately included in this systematic review. Data from the included studies were then critically analyzed and synthesized to provide a comprehensive overview of the available evidence. The preventive effect of nursing in lowering the incidence of AD in babies is highlighted by this comprehensive study. Compared to partial breastfeeding or formula feeding, exclusive breastfeeding, especially during the first six months of life, seems to reduce the chance of developing AD.

Merkel Cell Carcinoma: A Meticulous Literature Appraisal

Hiba Siddiqui, Laraib Khan, Mifrah Sherwani, Ahmed Nadeem Abbasi — Wed, 31 Dec 2025 00:00:00 +0000

Merkel cell carcinoma represents an uncommon yet highly aggressive cutaneous malignancy of neuroendocrine origin, with a steadily rising incidence reported worldwide. This review aims to evaluate and summarize current evidence on the diagnosis, staging, and management of Merkel cell carcinoma. A comprehensive literature search was performed across PubMed, Embase, and Google Scholar to identify studies published between 2005 to 2024 addressing the diagnosis, staging, and management of Merkel cell carcinoma. Search terms included “Merkel cell carcinoma” combined with “diagnosis,” “staging,” “surgery,” “radiotherapy,” and “systemic therapy.” Merkel cell carcinoma frequently presents as a rapidly enlarging, firm, violaceous nodule on sun-exposed skin. Diagnosis relies on histopathology and immunohistochemistry, with characteristic CK20 and neuroendocrine marker positivity. PET/CT outperforms conventional imaging for detecting nodal and distant metastases. Sentinel lymph node biopsy is critical for staging clinically node-negative cases. Treatment is stage-driven and multidisciplinary. Wide local excision with ≥1–2 cm margins remains the surgical standard. Adjuvant radiation enhances loco-regional control, particularly in cases with positive margins, LVI, or immunosuppression. While chemotherapy offers a limited benefit. Immunotherapy has redefined first-line therapy in advanced disease. Emerging targeted therapies hold promise for patients with refractory disease. Future directions in Merkel cell carcinoma management are predicted to emphasize the identification of predictive biomarkers for treatment response, the advancement of novel immune and molecularly targeted therapies, and the optimization of radiotherapy through hypo-fractionated and image-guided approaches. A multidisciplinary, timely, and personalized treatment approach is crucial for optimizing outcomes.

Reconstruction of the Nasolabial Fold Using Island Pedicle Flap: A Systematic Approach for Flap Design

Wed, 31 Dec 2025 00:00:00 +0000

Reconstruction of nasolabial defects following wide excision presents both functional and aesthetic challenges. We report the case of a 65-year-old female with basal cell carcinoma in the nasolabial region who underwent a 5-mm wide excision followed by reconstruction using an island pedicle flap. The flap demonstrated excellent viability, and follow-up revealed satisfactory wound healing with minimal scarring. This case highlights the versatility and safety of the island pedicle flap for defect repair in the nasolabial region. Successful outcomes depend on careful flap design with attention to anatomic distortion, vascular supply, technical execution, and aesthetic considerations. The island pedicle flap remains a reliable and effective option for reconstruction of nasolabial defects after tumor excision.

Erysipelas Bullosa in a Patient with Deep Vein Thrombosis: A Case Report

Dina Arwina Dalimunthe, Annisa Astari — Wed, 31 Dec 2025 00:00:00 +0000

Erysipelas is an extensive skin infection usually affecting the legs or face, caused by group A β-hemolytic streptococci. Erysipelas bullosa is a severe form of the disease. We report a case of Erysipelas Bullosa in a Patient with Deep Vein Thrombosis (DVT) in a 43-year-old Asian male who presented with well-demarcated erythematous macules with vesicles and bullae on an erythematous base in the left crural region. This case was diagnosed based on anamnesis, physical examination, and bacterial culture. The patient was treated with intravenous antibiotics.

Toxic Epidermal Necrosis with Complicating Course of Conjunctivitis and Synechiae of Labia to Rectovaginal Fistula: A Rare Case

Ronauli Agnes Marpaung, Lidwina Anissa — Wed, 31 Dec 2025 00:00:00 +0000

Toxic epidermal necrolysis (TEN) is a severe drug-related reaction characterized by mucosal erosion and epidermal detachment occurring on more than 30% of the body surface area. Vaginal complications have been reported in about 50% of patients with TEN. Here, we report a 58-year-old woman who presented with com-plaints of red peeling rashes that initially appeared in the armpits and then spread to all of the body include mucosa eyes, mouth, and vagina. The complaints arose after the patient took meloxicam and allopurinol. TEN complications in the mucosa of the eyes and mouth are frequently encountered, but vaginal synechia comp-licating into a rectovaginal fistula is a very rare case. The author could hardly find any references mentioning rectovaginal fistula as a subsequent complication of TEN. Therefore, further research is needed regarding rectovaginal fistula as a complication of TEN.

Cutaneous Lymphangioma in Adolescents: A Therapeutic Challenge

Wed, 31 Dec 2025 00:00:00 +0000

A 17-year-old girl, presenting as a blackish-red lump on her knee, present since birth. The lump occasionally caused itching, pain, and sometimes discharged blood or yellowish fluid. Dermatological examination rev-ealed multiple clusters of vesiculopapules and hyperpigmented patches. Dermoscopy and histopathological analysis confirmed the diagnosis as cutaneous lymphangioma. The patient had previously undergone laser treatment without complete resolution. Various treatment modalities, including cryotherapy, CO₂ laser, and vascular laser therapies (pulsed dye laser and long-pulsed Nd-Yag1064 laser), were explored. Among these, the long-pulsed Nd-Yag laser proved most effective, leading to lesion reduction and less recurrence.

Erosive Pustular Dermatosis of the Scalp Due to Afatinib: A Rare Case

Jose Suryanegara, Astindari Astindari, Nissa Avina Pilar, Cintya Dipta Riswatno — Wed, 31 Dec 2025 00:00:00 +0000

Afatinib is a tyrosine kinase inhibitor that irreversibly targets the epidermal growth factor receptor and is commonly associated with cutaneous adverse effects such as acneiform eruptions and paronychia. However, scalp involvement has rarely been reported. We present a case of a 57-year-old woman with stage IVA lung cancer who developed thick, yellowish scalp crusts without pain or itch, seven months after initiating afatinib therapy. Clinical, trichoscopic, microbiological, and histopathological examinations confirmed a diagnosis of erosive pustular dermatosis of the scalp (EPDS). Despite treatment with systemic corticosteroids and antibio-tics, significant improvement was only observed after dose reduction and eventual discontinuation of afatinib. This case highlights a rare but important adverse effect of afatinib on the scalp, emphasizing the need for clinicians to recognize and manage EPDS early in patients receiving this therapy.

Ultraviolet B Phototherapy Worsened Psoriasis Vulgaris

Wed, 31 Dec 2025 00:00:00 +0000

Psoriasis vulgaris is a chronic, complex, immune-mediated inflammatory disease with a genetic predisposition and a global prevalence of 2%–4%. One treatment option for psoriasis is narrowband ultraviolet B (NBUVB) phototherapy. Phototherapy can reduce cytokines and chemical mediators that trigger psoriasis. However, there is a clinical subset of photosensitive psoriasis in 5.5%–24% of cases, wherein NBUVB exposure at sub-minimal doses can worsen psoriasis lesions. Herein, we present a case of a 23-year-old man with a seven-year history of psoriasis and who completed eight sessions of the secukinumab injection protocol with full re-mission. The patient complained of worsening psoriasis lesions, and his psoriasis area and severity index score increased to 6.5. He was scheduled to undergo two sessions of whole-body NBUVB phototherapy at 500 mJ/cm² for, which then further worsened the lesions, progressing into erythrodermic psoriasis. Phototherapy was withheld, and the patient was hospitalized. In 5.5%–24% of psoriasis cases, UV light exposure can worsen psoriasis. This condition is related to the genetic predisposition of HLA-Cw*0602 and CARD14 mutation at locus 2 (PSORS2), which causes a different immune response when the skin is exposed to UV light, including phototherapy. In these cases, there is no physiological suppression of propsoriatic cytokines and mediators. Instead, propsoriatic mediators are increased through various pathways, including tumor necrosis factor-alpha, interferon gamma, interleukin (IL)-1, IL-6, or IL-17, after UV exposure. Thus, understanding photosensi-tive psoriasis is essential, and further studies are needed to determine the best course of treatment in these patients.

Profile of Contact Dermatitis in Elderly Patients

Wed, 31 Dec 2025 00:00:00 +0000

Background: Contact dermatitis (CD) is one of the most common inflammatory skin disorders. Decreased skin function in the elderly, such as decreased collagen synthesis, hydration, and sebum production that causes dry skin and changes in immunological responses, are risk factors for CD in the elderly.

Objective: To determine the profile of contact dermatitis in the elderly.

Methods: This study is a descriptive retrospective study conducted at the Dermatology and Venereology outpatient unit of Dr. Soetomo General Academic Hospital Surabaya, with a population of contact dermatitis patients aged 50 years or older, using total sampling methods in a 3-year period.

Results: The number of elderly patients was 9,063 out of 32,226 patients (0.28%) at the Dermatology and Venereology outpatient unit of Dr. Soetomo General Academic Hospital Surabaya for 3 years (2019-2022). Out of the 9,063 elderly patients, there were 90 elderly CD patients (0.90%), representing 18.33% of the total 491 CD patients, consisting of allergic contact dermatitis (53.3%) and irritant contact dermatitis (46.7%), with an age range of 50-90 years (mean 61.1±7.9). The most causative agents in ACD were cosmetics (40.1%) and medicated oils (33.3%), while in ICD were herbal oils (25.9%), detergents (22.4%), and dishwashing soap (18.9%).

Conclusion: The prevalence of CD among the elderly for a period of 3 years was 18.33% out of patients diagnosed with CD. Females, aged 55 to 65 years, and working as housewives made up the majority of elderly CD patients, with hand and face dermatitis as the most common manifestation.

Efficacy of 100 % TCA (Trichloroacetic Acid) in the Treatment of Atrophic Facial Post Varicella Scars

Anum Sadia, Saima Manzoor, Ayesha Mumtaz, Madiha Siddique — Wed, 31 Dec 2025 00:00:00 +0000

Background: Atrophic facial scars from varicella can affect confidence and quality of life. Among treatments, 100% TCA peels show encouraging results in improving skin texture and scar appearance. Although international evidence supports their effectiveness, local data are limited. This study aims to evaluate TCA peel outcomes in our population.

Objective: Assessment of therapeutic outcomes of 100% TCA CROSS application in treatment of atrophic facial post-varicella scars

Methods: After approval of synopsis and permission from ethical review committee, one hundred (100) patients form both the genders with age between 10-40 years presenting with post-varicella atrophic facial scars falling under Goodman Grade III or IV were included. All participants provided informed consent in written form. These patients were treated by CROSS using 100% TCA every fortnight for 4 sessions. Study variable was outcome of treatment which was assessed 3 months after the last session and was graded as excellent (3 grades decline from baseline), good (2 grades decline from baseline) and fair (1 grade decline from baseline) depending upon final Goodman Grade.

Results: The patients had a mean age of 25.4±7.7 years, mean scar duration of 3.5±1.5 years and 10.2±4.5 scars. Overall, 45% were married. Excellent outcomes were observed in 71% and good in 29%, with no significant differences across subgroups based on age, gender, marital status, scar duration, or number.

Conclusion: The use of 100% TCA for CROSS was found safe and effective approach for managing atrophic facial scars following varicella. Most patients demonstrated excellent improvement after four treatment sessions, confirming TCA CROSS as a practical, well-tolerated option in routine dermatological practice.

Evaluation of Serum Androgen levels and BMI in Young Female Patients with Acne Vulgaris

Ali Naji Al Hamza, Marwa Jasim Abdulqader , Ghadah Lateef Jasim — Wed, 31 Dec 2025 00:00:00 +0000

Background: Acne is an inflammatory disease with a complex pathogenesis that is influenced by genetic and hormonal factors. Androgen hormones affect sebocytes proliferation, differentiation and lipid synthesis. Increased sebum excretion is considered a major factor in the pathogenesis of acne vulgaris and elevated serum androgen levels have been linked with acne resistant to conventional therapy. Another reported risk factor for developing acne is overweight or obesity.

Methods: This is a case-control study in which twenty- five acne female patients aged 18-24 years and another age and sex -matched healthy individuals were included. Serum Testosterone, DHEAS and BMI were measured for all participants. Statistical analysis for the collected data was performed using appropriate statistical tests.

Results: There was significant elevation of serum DHEAS level (347.4 ±167.8 μg/dl) in acne patients comparing to the control , p value 0.016 ,with a non significant elevation of serum testosterone(0.56 ±0.49 ng/ml), p value 0.055 . Both parameters showed no significant differences among acne patients in concern with the disease severity , P value 0.63 and 0.2 for testosterone and DHEAS respectively. Also, no significant differences were observed in BMI (p value 0.94) or menstrual cycle irregularity (p value 0.18) between Acne patients and the control in this age group.

Conclusion: Acne vulgaris is a common disorder of pilosebaceous unit that mainly affects young age individuals. Hyperandrogenism, mainly DHEAS, is a potential risk for developing acne in female less than 25 years, however no significant correlation was found between body mass index (BMI), Testosterone or DHEAS and acne severity.

The Quality of Life and its Relationship to Disease Severity in Children with Atopic Dermatitis

Mariam Khurshid, Shayan Rizwan, Muneeza Rizwan , Sajida Bibi — Wed, 31 Dec 2025 00:00:00 +0000

Background: Atopic dermatitis (AD) is a common chronic inflammatory skin condition in children, characterized by pruritus, recurrent eczematous lesions, and fluctuating severity. Beyond its dermatological manifestations, AD imposes a significant psychosocial and functional burden on patients and their families.

Objective: This study aimed to determine the correlation between quality of life and

disease severity among Pakistani children with atopic dermatitis.

Methods: This descriptive cross-sectional study was conducted in the Department of Dermatology, Pakistan Airforce (PAF) Hospital, Islamabad, over six months (January–June 2022). Seventy children aged 5–15 years, diagnosed with AD by Hanifin and Rajka criteria, were enrolled. Disease severity was assessed using the Scoring of Atopic Dermatitis (SCORAD) index, and quality of life was measured using the Children’s Dermatology Life Quality Index (CDLQI). Data were analyzed using SPSS version 25, with Pearson’s correlation applied to evaluate relationships between SCORAD and CDLQI scores.

Results: The mean age of participants was 10.2±2.8 years . According to SCORAD, 22.9% had mild, 70% moderate, and 7.1% severe disease. The mean SCORAD and CDLQI scores were 25.3 ± 8.0 and 9.8 ± 4.0, respectively. A statistically significant positive correlation was observed between disease severity and quality-of-life impairment (r = 0.289, p = 0.015).

Conclusion: Greater disease severity is associated with a higher degree of quality-of-life impairment among Pakistani children with atopic dermatitis. Regular use of standardized tools such as SCORAD and CDLQI can help clinicians identify patients requiring holistic care, including psychological and social support.

Unraveling the Connection between Occupation, Sun Exposure, and Basal Cell Carcinoma: A Cross-Sectional, Single Center Study

Nugrohoaji Dharmawan, Osdatilla Esa Putri — Wed, 31 Dec 2025 00:00:00 +0000

Background: Prolonged sun exposure is a major risk factor for basal cell carcinoma (BCC) due to cumulative UV-induced DNA damage. Studies have shown that outdoor workers face a significantly higher likelihood of developing BCC, with the risk further amplified by inadequate protective measures.
Objectives: This study investigates the impact of sun exposure duration and occupational risk on BCC at Dr. Moewardi General Hospital.
Methods: A cross-sectional study was conducted from September to December 2024 involving 78 subjects meeting the inclusion criteria. They were allocated study into two groups, BCC and non-BCC groups. Occupational risk was assessed by type of work, length of work, use of protective equipment, and duration of sun exposure. Sun exposure was expressed in hours/day, p value <0.05 was statistically significant.

Results: There were 32 subjects with BCC and 46 subjects non-BCC. Our analysis obtained that occupational risk in the form of outdoor work type (p = 0.001; OR = 4.85), length of work > 20 years (p = 0.005; OR = 3.81), and use of protective equipment (p = 0.032; OR = 2.74) were associated with the incidence of BCC. The duration of sunlight exposure in the BCC group was found to be longer, at 5.31 hours/day than the non-BCC group, 2.78 hours/day (p <0.001). The ROC curve obtained the cutoff point of sun exposure duration of 3.5 hours / day (p <0.001; OR = 10.12).

Conclusion: Daily sun exposure of 3.5 hours or more, outdoor work, and length of work >20 years, and not using protective equipment during work effect on the development of BCC.

Eye Manifestations among Atopic Dermatitis in Children

Zahid Rafiq, Ahmad Zeeshan Jamil, Shahana Hoor, Muhammad Nawaz, Urfa Shafi — Wed, 31 Dec 2025 00:00:00 +0000

Background:

Atopic Dermatitis is the most common type of dermatitis among children. In severe form besides skin changes, patient is prone to develop eye changes due to excessive rubbing on eyes. In such situations, ophthalmologist consultation is needed to reduce ocular comorbidities.

Objective:

To determine the association of eye manifestations of Atopic Dermatitis with the severity of Atopic Dermatitis in children up to 14 years of age.

Methods:

This retrospective study was conducted in Dermatology and Ophthalmology department, Sahiwal Teaching Hospital, Sahiwal from Jan to Dec 2024. Patients fulfilling the Atopic Dermatitis diagnostic criteria (Williams UK working party) of age less than 14 years and either sex were selected in the study. A sample size of 114 patients and nonprobability consecutive sampling technique was used. Clinical severity of Atopic disease were categorized into mild, moderate and severe by using SCORAD index. All data regarding patient demographics, cutaneous and eye examination findings were recorded on a specially designed proforma. The data was analyzed by using SPSS version 25. The association between eye changes and different severity (mild, moderate, severe) of Atopic Dermatitis (SCORAD index) was determined by using χ2 test. If p-value is equal to or less than 0.5, it will be considered significant.

Results:

Out of total 114 participants, majority belonged to male (65%) gender and mean age with SD was 4.68 ± 2.67 years. Most of children were of moderate (58%) severity. Eyelid changes frequently observed were dryness of eyelid (65%) followed by blepharitis (42%). Among conjunctival finding, keratoconjunctivitis were most commonly reported (33%). No statistically significant (p-value=0.897) association of eyelid changes with disease severity was observed. Although conjunctival changes and disease severity association was statistically demonstrated significantly (p-value 0.005).

Conclusion:

Ocular changes were common in children with atopic dermatitis. While eyelid findings did not correlate with disease severity, conjunctival involvement increased with more severe dermatitis.

Professionalism in Dermatology

Prof. Moizza Tahir — Wed, 31 Dec 2025 00:00:00 +0000

Dermatologists encounter many challenges in technology and business, especially in aesthetic practices. Professional ethics include personal, organizational, and corporate standards of behavior. The core constituents of professional ethics include honesty, integrity, transparency, accountability, confidentiality, objectivity, respectfulness, obedience to the law, and loyalty^.Professionalism and ethics should be a mandatory component of the dermatology residency program. A 2023 survey of dermatology residency programs revealed that there is no formal ethics curriculum [1]. This emphasizes instructional strategies for future generation of dermatologists, especially when professional education is left to observation [2].

The mentor-resident relation allows professional development. The structured mentorship programs lead to residents' satisfaction, progress in career development, efficient research, and workforce retention [4]. Institutions should encourage and plan mentoring programs. These programs may include formal matching processes, mentoring bonds, workshops, and time for mentor-mentee interactions in this way academia will uphold professional standards.