Journal of

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Background and Aim: Pregnancy affects all organs and systems in the body including skin. Some skin changes are physiologic, whereas others are pathologic such as the dermatoses of pregnancy. The purpose of this study was to determine the frequency of physiological skin changes during pregnancy in hospitalized women at postpartum unit at Shabih Khani Hospital in Kashan/Iran in 2009.
Methods: One-hundred and eighty women were evaluated during their post partum periods for evidence of skin changes. Excluding factors were foreign citrizens, multiple pregnancies and gestational age under 20 weeks. Data were collected by using questionnaires before discharge from hospital.
Results: The frequencies of various observed changes included: melasma (33.9%), striae (82.3%), edema of eyelid (30%), increased acne severity (26.7%), hirsutism (17.2%) and decreased acne severity (1.7%).
Conclusion: Considering the high incidence of skin changes during pregnancy, it is recommended to instruct the mothers on skin care.

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Background and Aim: Hirsutism is defined as the presence of terminal hairs in androgen dependent areas in women. It is a common clinical condition and affects 5% to 10% of women of reproductive age. The aim of this study was to determine the clinical features and etiologic factors of hirsutism in premenopausal women.
Methods: In this cross-sectional study, 200 premenopausal women with hirsutism who were admitted at our dermatologic clinic during a 2-year period were nivestigated. After a careful history and physical examination, a transabdominal ultrasonography of the ovaries and laboratory evaluation including early morning total testosterone, prolactin, dehydroepiandrosterone sulfate (DHEA-S) and 17-hydroxyprogestron in all patients and thyroid stimulating hormone (TSH) in 10 patients were performed.
Results: Polycystic ovary syndrome (PCOS) was the most common cause of the hirsutism (54.5%) followed by idiopathic hirsutism (40%). Other causes of hirsutism were prolactinoma (2%), hypothyroidism (1%) and drugs intake (2.5%). Hirsutism was mild in 109 patients (54.5%), moderate in 85 patients (42.5%) and severe in 6 patients (3%). Family history of hirsutism was present in 105 (52.5%) patients. Clinical conditions associated with hirsutism were: acne (52.5%), menstrual irregularity (35%), androgenetic alopecia (15%), acanthosis negricans (7.5%) and obesity (37.5%).
Conclusion: PCOS and idiopathic hirsutism are the most common cause of the hirsutism in premenopausal women. A detailed history and physical exam often provide enough information to determine the etiology of hirsutism.

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Background and Aim: Tumor angiogenesis is essential for tumor growth and appears to play an importating role both in invasive growth and metastasis. Basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs) of the skin are derived from a similar cell type but differ in the invasive and metastatic potential. Basal cell carcinoma generally shows a relatively benign course in contrast to squamous cell carcinoma .This study investigates whether the behavior of these tumors could be explained by differences in their angiogenesis pattern.
Methods: Vessel counts were made of blood vessels in stroma and the body of 50 variants of BCC of skin samples including: nodular, micronodular, sclerosing and superficial, both after H&E and immunohistochemical staining for CD31 and CD34 markers.
Results: The body vessel counts of invasive variants (sclerosing & micronodular) differed significantly from the counts of noninvasive variants (nodular and superficial) using both CD31 & CD34 markers. The stromal vessel counts compared between invasive and noninvasive variants showed no significantly difference using CD31 & CD34 markers, respectively.
Conclusion: The invasive growth pattern of BCC variants correlated with the microvascular density and according to results, vessel counts of the body play a more important role.

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Background and Aim: The heterogenous population of memory T lymphocytes is distinguished based on surface markers and effector functions such as cytokine secretion. Recently, two subsets of memory T cells are defined by expression of chemokine receptor CCR7 and CD45RA designating as "central memory" T cells (T_CM) and "effector memory" T cells (T_EM). The objective of this staudy was to evaluate the phenotype and function of these lymphocytes in healed cases of cutaneous leishmaniasis.
Methods: The phenotype of lymphocytes were determined in blood samples of 13 volunteers with history of self healing cutaneous leishmaniasis (HCL) and in 6 healthy controls.
Results: No significant difference was found in memory T cell subsets between HCL volunteers and healthy controls using flow cytometry. However, following sorting of different memory subsets, a significantly higher proliferation was seen in cells of HCL volunteers comparing to the control group. A significantly higher IFN-γ response in T_EM and a significantly higher IL-2 response in T_CM were observed in cell culture of HCL volunteers comparing controls.
Conclusion: The responses were elicited when the cells were stimulate with SLA in vitro, it is concluded Leishmania-specific T_EM and Leishmania-specific T_CM subsets exist in HCL volunteers and since the volunteers with history of CL presumed to be protected against reinfection, it seems that both T_CM and T_EM play role in the protection against Leishmania infection in these individuals.

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N-acetylcysteine (NAC) is the acetylated metabolite of cysteine and is approved by the Food and Drug Administration (FDA) for treating acetaminophen toxicity. By boosting glutathione, NAC acts as an antioxidant and through replenishing glutathione, it can also prevent paracetamol toxicity. From the other hand, NAC has mucolytic and antiinflammatory effects and also is a glutamate precursor and therefore can be used in a variety of diseases. Regarding the various pharmacological effects of NAC and its low rate of adverse events, NAC has attracted increasing interest for a range of indications during the recent years. Here, the possible applications of this drug in dermatology are reviewed.

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Pseudo-Kaposi sarcoma (PKS) or acroangiodermatitis is a benign angioproliferative disease which shares many clinical and histopathological features with Kaposi sarcoma. Clinical presentations include violaceous macules, papules or plaques in the lower extrimities, which is usually associated with chronic venous insufficiency or congenital or acquired arterio-venous malformations. Its pathogenesis is not well recognized yet but the ischemia due to venous insufficiency or arterio-venous malformation is considered to play a role. The diagnosis is made through the histopathologic examination of biopsy specimens. Different treatment modalities have been suggested including conservative treatment or correction of vascular abnormalities.This paper introduces a 28-year old man with a brown linear plaque in a scar of 3-month duration due to trauma on the anterior of left thigh. A biopsy was performed and the histopathologic examination confirmed the clinical diagnosis of Pseudo-kaposi sarcoma.

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Background and Aim: Pruritus is usually caused by a primary skin disorder or a systemic disease. Causes of groin pruritus are fungi, eczema, bacterial diseases, neurodermatitis, scabies and many other skin disorders. This study was performed to find the common causes of groin pruritus in female patients that referred to dermatology and gynecology clinics of Yahya-Nejad hospital in Babol.
Methods: This descriptive study was performed on patients with groin pruritus from the begining of winter 2006 until the end of autumn 2007. Other information including name, age, height, weight, previous drug consumption, simultaneous infection in partner or other members of the family, duration of infection, underlying disease and result of examination were recorded in a questionnaire for each patient.
Results: 115 patients were studied. The average age of patients was 41.2 years (15-75 years old). The highest disease frequency was seen in 48 cases (41.7%) in summer. Most cases (33 patients [28.7%]) were between 46-55 years of age. Most of patients (28.7%) had a BMI from 25 to 29.9 (over weigh). The most common causes of groin pruritus in all seasons, ages and BMIs were tinea cruris in 55 cases (47.8%) and seborrheic dermatitis in 29 cases (25.1%).
Conclusion: Considering common causes of groin pruritus, season and patient's weight can be helpful in diagnosis and early treatment of groin pruritus.

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Background and Aim: Chronic renal failure is a clinical state which results in declining the kidney function. Chronic renal failure has numerous cutaneous manifestations, when the process of hemodialysis begins, new changes may appear as a result. The aim of this study was to assess the prevalence of cutaneous problems among patients with chronic renal failure undergoing hemodialysis in Bandar Abbas, Iran.
Methods: In this cross-sectional study, 60 patients with chronic renal failure under hemodialysis in Shahid Mohammadi Hospital Dialysis Center were examined by a dermatologist. The data were gathered and analyzed by SPSS software (version 16) using descriptive statistics, t and chi2 tests. P less than 0.05 was considered significant.
Results: The most common skin findings were dry skin (78.3%), followed by pallor (71.7%) and pruritus (58.3%). Other common cutaneous manifestations were half-half nail (35%), idiopathic guttate hypomelanosis (33.3%), yellowish skin color change (31.7%), subungal hyperkeratosis (30%), onycholysis (20%), beau's line (15%), cherry angioma (15%), skin hyperpigmentation (15%) and purpura (13.3%).
Conclusion: Chronic renal failure is associated with various cutaneous manifestations caused by hemodiaysis or the disease itself. The most common ones are dry skin and pallor. The early diagnosis of cutaneous changes may decrease the morbidity and eventually lead to quality of life improvement in these patients.

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Background and Aim: As a blistering agent, mustard gas causes a variety of disorders in different body organs, including the skin, such as altrations in DNA and clinical manifestations like pruritus. TGF-β1 molecule is a cytokine with anti-cell growth and inflammation suppression effects in skin inflammation. The aim of this study was to determine TGF-β1 gene exprtession in victims exposed to mustard gas and the correlation with the severity of their pruritus.
Methods: 17 victims exposed to mustard gas, 17 patients with chronic contact dermatitis and 10 healthy individuals were included in the study. The assessment of TGF-β1 expression in their skin samples was conducted by semi-quantitative RT-PCR followed by immunohistochemistry and classification of patients was done by pruritus severity scoring system (0-3).
Results: There was a significant decrease in TGF-β1 gene expression in mustard gas exposed victims comparing to chronic contact dermatitis group and the control group (P<0.05). In addition, in the absence of TGF-β1 expression, the severity of pruritus in the patient group significantly increased (P<0.05).
Conclusion: TGF-β1 has a significant role in chronic inflammatory skin lesions caused by mustard gas.

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Background and Aim: The correlation between diseases and psychiatric problems had been evaluated recently. The aim of this study was to determine the prevalence of skin diseases in patients in psychiatric department of Yahya-Nejad Hospital in Babol, North of Iran, in 2008.
Methods: This cross sectional study was performed on 250 patients hospitalized in psychiatric department of Yahya-Nejad Hospital in Babol. They were examined by a dermatologist and laboratory examinations (skin smear and biopsy) were done if needed. Then a questionnaire including information about sex, age, job, past medical history and history of addiction, major stress, general appearance, psycological problems, previous and new dermatological diseases and treatment protocols was completed for every patient. Data were analyzed by SPSS 11 and P<0.05 was significant.
Results: Among two hundred and fifty patients (109 male and 141 female) with psychological problems, 166 patients had dermatologic diseases. Sixty six were male and 100 cases were female. Major depression and obsessive-compulsive disorders had highest frequency in psychologic disorders. Seventy patients had treated their skin disorders.There was a significant relationship between stressors in the last six months with eczema, lichen simplex chronicus, acne, and rosacea. Correlations between schizophrenia and herpes simplex labialis (P=0.02), and PTSD with pediculosis were significant (P=0.004).

Conclusion: Dermatological disorders are associated with a variety of psychological problems that can affect patients. Increased understanding of biopsychosocial approches and laision among physicians, psychiatrists and dermatologists can be very useful and highly beneficial.

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Background and Aim: Melasma is an acquired symmetrical brown hyperpigmentation of the face or neck. Melasma has been shown to have a significant emotional and psychologic distress on affected patients. Although this pigmentary disorder is more prevalent among women of reproductive age, the effect of melasma on quality of life in this population is unknown. The aim of this study was to evaluate health-related quality of life in patients with melasma attending to dermatology clinics in Kerman city, Iran.

Methods: A cross-sectional study was carried out by clinical examination and questionnaire on 200 patients with melasma. Melasma area and severity index (MASI), Dermatology Life Quality Index (DLQI) and Melasma Quality of Life Scale (MELASQOL) were used to assess melasma severity and quality of life.
Results: There were 200 women with mean age 31.86±6.42 years old (range: 18-55 years). The mean score of DLQI and MELASQOL were 6.90±4.48 and 40.24±14.95, respectively. In 113 (56.5%) patients, melasma had very large effect on their quality of life. There was a significant correlation between the scores of quality of life questionnaires and MASI (P<0.001). In DLQI scale the most frequent impairment was related to emotional well-being and based on MELASQOL questionnaire, embarrassment due to skin appearance had an important impact on quality of life.
Conclusion: This study revealed that physicians must consider the devastating psychosocial impact of pigmentary imperfections in addition to pharmacological and physical treatment.

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Background and Aim: Treatment of cutaneous leishmaniasis, especially when caused by L. tropica, is challenging. Meglumine antimoniate (Glucantime^®) is used as the standard treatment, but multiple injectiond are necessary. The objective of this study was to compare the efficacy of weekly intralesional injections with twice weekly injections of Glucantime for the treatment of anthroponotic cutaneous leishmaniasis (ACL).
Methods: This randomized open clinical trial was conducted, in Bam, Kerman province, Iran. 96 eligible patients according to inclusion and exclusion criteria who were willing to participate were included. The included patients were randomly assigned into two groups, one group treated with weekly intralesional injections of Glucantime^® and the other group treated with intralesional Glucantime^® twice a week. Type and size of each lesion (induration, ulcer and scar) were recorded weekly. Complete healing was defined as complete re-epithelialization and absence of induration in all lesions and was considered as the primary outcome measure.
Results: A total of 48 patients completed the study complete cure was seen in 24 of 27 (89%) patients who received weekly intralesional MA with a mean duration of healing equals to 70±10 days. Complete cure was seen in 24 of 31 (77%) patients who received intralesional MA twice a week, the mean duration of healing in the latter group was 58±5 days. There was no significant difference between the two groups (P=0.23).
Conclusion: It seems that the efficacy of intralesional injections of Glucantime^® once a week is similar to efficacy of twice a week Glucantime^® injections.

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Fabry disease is a X-linked lysosomal storage disorder due to alpha galactosidase A deficiency leading to abnormal accumulation of glycosphingolipids in different parts of body. This case report introduces a 35-year-old man with diffuse keratotic erythematous papules. Histopathological evaluation of the skin biopsy suggested the diagnosis of angiokeratoma. With attention to his nephropathy and the same skin lesions and renal involvement in his brother, which led him to receive renal transplantation, the diagnosis of Fabry disease was suggested. 

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Eruptive syringoma is a rare benign tumor of eccrine sweat gland. Clinically, it presents as successive crops of symmetric, small yellow-brown to erythematous or skin-colored papules on the anterior body surfaces. It usually occurs in young women. Definitive diagnosis can be made on histopathological findings. The pathogenesis of eruptive syringoma is unclear but there are few reports about its association with antiepileptic drugs, radiation, trisomy 21, depilation and hyperthyroidism. The presented case was a 25-year-old woman who had referred with papules in forehead, periorbital regions, cheek, chin, chest, abdomen and forearm. Eruptive syringoma was confirmed based on its distinctive pathological findings. She thought her skin lesions were related to consumption of oral contraceptives. The importance of this disease is its cosmetic problem.

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Sulfur mustard (SM) or mustard gas is a chemical weapon which for the first time was employed during world war I later on it was used by Iraqi military forces against Iranian army and civilians (1980-88). This agent injured over 100000 Iranians and one-third of them are still suffering from its complications. SM is an alkylating agent with cytotoxic, mutagenic and vesicating properties, which targets the skin, eyes and respiratory systems. In this study we review the acute and chronic effects of SM on the skin. We obtained information of this paper from a search of PubMed. Google, Iran Medex, Irandoc and SID until beginning of 2011. The most common acute effects of SM on skin were: pruritus and burning (26%-96.8%), pain (25%-77.4%), erythema (20.6%-83.9%), hyperpigmentation (20%-83.9%), and vesicle and bulla (15.4%-80.6%). The most common chronic effects were: pruritus (24.7%-94.7%), burning (9.9%-52.1%), scar (4.5%-70%), hyperpigmentation (5.9%-55%), hypopigmentation (3.2%-40%), xerosis (2.1%-43.7%) and cherry angioma (12.2%-70.5%). After passing more than 20 years of the end of the Iraq-Iran war, the victims still suffer from many skin complications of SM and some of them such as itching and dry skin have negative effects on the performance and quality of their life. Up to now, serious skin complications like malignant skin tumors have been rare and a longer time may be required to establish. Therefore further follow-up is needed to detect and treat any kind of skin cancers promptly.

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In the recent years, advances in different fields of technology have been resulted in a dramatic increase in the diagnostic methods and tests in different branches of clinical medicine with a consequent increase in the number of scientific publications related to the application of those tests and methods in the diagnosis or prevention of diseases. Dermatology is not an exception. Since, evidence-based medicine emphasizes on the appropriate use of the current best clinical research evidence in the diagnosis or treatment of each individual patient acknowledging his/her values, the capability of dermatologists in appraisal and application of the publications, which reports the results of diagnostic test accuracy studies cannot be ignored. In this article, after a brief review on basic issues in diagnostic test accuracy studies, principles of critical appraisal of these studies, from an evidence-based viewpoint, will be discussed. General strategies for evaluation of validity, applicability and quality assessment of a diagnostic test study will be provided.

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Background and Aim: Cutaneous drug reaction is a common side effect of antiepileptic drugs and a frequent cause of treatment discontinuation. These reactions ranges can be a mild maculopapular rash to Stevens-Johnson Syndrom and toxic epidermal necrolysis. Among the traditional anticonvulsant drugs the aromatic compounds Phenytoin, Phenobarbital and Carbamazepin have been associated with relatively higher incidences of cutaneous reactions which can hospitalized the patient. Some of the newer drugs also can induce this problem, especially lamotrigine.
Methods: All records of patiens who were hospitalized at hospitals related to Islamic Azad as well as Rasol Akram hospital with a diagnosis of cutaneous drug reaction to anticonvulsant therapy in 8 years period were reviewed.
Results: The most common culprit was phenytoin (32%) and the least common drug was lamotrigin (3%).
Conclusion: Cutaneous reaction to anticonvulsant drugs is common and sometimes may be life threatening which needs serious treatment options.

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Background and Aim: Today, despite numerous advances in medical sciences, the number of complaints against physicians shows an increasing trend. Studying the causes of these complaints and identify contributing factors may reduce medical litigation. The aim of this study was to assess the reasons of complaints in the field of dermatology and cosmetic.
Methods: In this retrospective cross-sectional study, we investigated the medical malpractice records related to dermatology and cosmetics, registered in the office of Forensic Medicine, province of Tehran from 2002 to 2010.
Results: In 63.4%, 35.3%, and 1.2% of cases, verdicts of malpractice, acquittal and closing the file without a verdict, were issued respectively. The most common types of negligence were related to improvidence (63.4%), lack of proficiency (27%), and disregarding of governmental provisions (5.7%). Most frequent causes of complaints were related to scar and darkening of skin after laser therapy (24.4%), dissatisfaction of hair transplantation (19.5%), and complications after injection of filler gels, botollonium toxin, etc (15.8%). Most plaintiffs were women, in their 20s, with a highschool diploma and were housewives. The most frequent age range of the physicians was 30-39 years old and most of them were male.
Conclusion: Considering medical ethics and professionalism, good communication between physician, medical personnel and patient including his entourage, full examination, adequate explanations about therapeutic procedures and possible complications, lack of exaggerating the results of therapy, continuous study and updating medical knowledge, improvement of medical skills and experiments, refrain from dealing with procedures that did not pass its training courses, properly selected patient, take informed concept and innocence may reduce the number of complaints.

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Background and Aim: Vitiligo is a common skin disorder that presents as depigmented patchs and associated with psychosocial morbidity. Photochemotherapy with methoxsalen plus ultraviolet A (PUVA) is an effective and commonly used modality in treatment of vitiligo and is available in Khorasan Province since more than ten years ago.
Methods: This uncontrolled clinical trial included patients with vitiligo referred to phototherapy center in Emam Reza Hospital in Mashhad during 1998-1999. Treatment was done topically on patients with involvement less than 2% of the body area and systemic in cases with involvement more than that. Data including improvement rate and side effects were analyzed by SPSS software version 11.5.
Results: One-hundred and thirty-five patients, 79 female and 56 male, were enrolled.  One-hundred and twenty-six patients were treated systemically and 9 patients underwent topical therapy. Complete (100%) repigmentation was observed in one patient. Repigmentation of 80-99%, 60-79%, 40-59%, 20-39% and less than 20% were observed in 53, 43, 12, 6 and 20 patients respectively. Results were significantly better in generalized vitiligo, face involvement, and cases whom recieved more than 200 treatment sessions, but there was not significant relationship between improvement and patients' age, family history, the first involved area, beginning time of repigmentation, the observed interval between initiation of treatment and disorder appearance, and skin type. Common side effects were pruritus (69.6%), erythema (52.6%), nausea and vomiting (28.9%), and headache (17.8%).
Conclusion: PUVA therapy is an effective and safe treatment in patients with vitiligo, and has good results in nonsegmental vitiligo and facial involvement.

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Background and Aim: Cutaneous leishmaniasis (CL) is endemic in Iran, where it is one of the most important health problems. Both anthroponotic CL (ACL) caused by L. tropica and zoonotic CL (ZCL) caused by L. major are reported. Antimoniate derivatives as the standard therapy for CL need multiple injections and are not easy to tolerate for the patients. This study was conducted in Mashhad to compare the efficacy of weekly versus twice a week intralesional injections of meglumine antimoniate (MA) in the treatment of ACL.
Methods: This randomised controlled trial was performed during 2006 to 2008 in Mashhad, Iran. Using computerized sequence of random numbers, participants were randomly allocated in the two arms of the study: one receiving weekly and the other receiving twice-a-week intralesional injections of MA. The lesion size, induration and healing rate were assessed, recorded and compared. Healing was defined as complete re-epithelialisation and disappearance of induration.
Results: A total of 252 suspected CL patients with 372 lesions were screened. 82 parasitologically proven cases with 121 lesions caused by L. tropica were included and 74 patients with 113 lesions completed the study. At 12^th week after initiation of treatment, complete healing was observed in 38 out of 44 lesions (86.4%) in the group which received weekly intralesional MA injection. The median time-to-heal in this group was 36 days (95% confidence interval [CI]: 32.0-39.9). Complete healing was recorded in 60 out of 69 lesions (86.9%) in the group which received twice a week intralesional injections of MA with a median time-to-heal of 25 days (95% CI: 20.9-29.1). While no significant difference was observed between the two groups in terms of complete healing rate (P=0.999), time-to-heal was significantly different between the 2 groups (P=0.003).
Conclusion: It seems that the effectiveness of twice-weekly intralesional injections of MA is similar to once-weekly regimen while the former regimen causes more rapid healing of lesions.