Journal of

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Herein, we report a 22-year-old man who had been referred to a dermatology clinic for evaluation of his skin lesions. The patient had diffuse angiokeratomas, which were characteristic for Fabry disease as well as painful acral neuropathy. Histpathologic examination of one of his skin lesions was reported as angiokeratoma. Since cornea verticillata was observed in his eyes and he also suffered from sensory-neural hearing loss, he was diagnosed as a case of Fabry disease.

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Urticaria is a common and challenging skin disorder. Its diagnosis and treatment is not limited to the field of dermatology. General physicians, and allergologists and clinical immunologists are also commonly involved in the management of urticaria patients. One of the missions of the Iranian Society of Dermatology is to develop strategies to provide the best possible management for patients suffering dermatological conditions. To accomplish this mission, the Society assigned a committee to search and critically appraise the recent research evidence and available guidelines to develop a clinical practice guideline concerning diagnosis and treatment of urticaria.

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The function of the horny layer of the skin as a barrier is to protect the underlying tissues from infection, dryness, and mechanical stress. Disruption of this function results in increased transepidermal water loss (TEWL) and is associated with conditions like atopic dermatitis and other chronic skin diseases. Moisturizers have been shown to improve these conditions through restoration of the integrity of the stratum corneum, acting as a barrier to water loss and replacement of skin lipids and other compounds. Also, moisturizers are commonly used to reduce fine lines and make the skin appear smooth and soft. They contain varying combinations of emollients, occlusives, and humectants to achieve their beneficial effects, and there are an overwhelming number of formulations available.

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Malassezia species (previously Pityrosporum) are normal flora of human and warm-blooded animals skin. The genus Malassezia is now divided into 13 species. Most of the yeasts show an absolute requirement for long fatty acid chains and specific procedures are required for their isolation, conservation and identification. Under appropriate conditions, the fungi can cause various skin diseases. The aims of this review were to describe recent classification of genus Malassezia their virulence factors, and their association to dermatlogical diseases.

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David Lawrence Sackett, OC, MD, FRSC, FRCP was an American-Canadian physician, trialist, and teacher. He is best known as one of the pioneers of evidence-based medicine (EBM), which is arguably the most important movement in medicine over the past three decades. He founded the first clinical epidemiology department in McMaster University in Hamilton, Canada in 1967. In addition, he was the head of the Center for the Evidence-Based Medicine in Oxford, UK. He also was the first chair of Cochrane Collaboration and the first founding coeditor of the journal of Evidence-Based Medicine and had many other honors. He published 12 books, 60 chapters in other books, and about 300 articles in scientific and medical journals. He died on May 13, 2015 at age 80 because of cholangiocarcinoma. While Dr. Sackett will be missed by his friends, colleagues, mentees as well as EBM proponents and followers all over the world, his contributions to EBM in particular, and to medicine in general will never be forgotten.

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Background and Aim: Psoriasis is an inflammatory skin disease, which is related to the immune system and is characterized by the rapid growth of skin cells. The aim of this study was to investigate some risk factors in psoriasis and also to check that whether the rate of recurrence is fixed or variable in different seasons by using a time-dependent coefficients rate model. Methods: After reviewing the files of psoriasis patients that had been hospitalized in March 2011 to March 2014 in the dermatology ward of Imam Khomeini Hospital in Tehran, a total of 160 patients who had relapses leading to hospitalization, entered to the study. A rate model with time dependent coefficients by using R software version 3.1 was fitted and risk factors for recurrence were identified. Effect of the season on the recurrence of psoriasis was evaluated. Results: Recurrence rate of psoriasis was 7.2 times higher in winters than in springs, which had the lowest recurrence rate. Spring and summer were associoated with lower recurrence rates. Effect of season on the relapse of the disease was significantly different for different seasons (P<0.01). Also, infection, stress, positive family history, hypocalemia, the normal number of white blood cells and temperature changes were associated with psoriasis relapse (P<0.05). Conclusion: Recurrence rate of psoriasis is different in different seasons. Psoriasis recurrence rate was 7 times higher in winters in comparison with springs.

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Background and Aim: Mycosis fungoides (MF) is the most common primary cutaneous lymphoma. Diagnosis of early MF (eMF) is often difficult due to its resemblance of benign dermatoses. The aim of this study was to evaluate the role of provided clinical information on the histopathology request forms for diagnosis of eMF according to the International Society of Cutaneous Lympoma (ISCL) criteria. Methods: In this cross-sectional study, 108 patients admitted to Razi Hospital, Tehran, between April 2012 and November 2013, who were biopsied as eMF cases, were recruited. Based on partial application of ISCL algorithm, the checklist of clinical and histopathological findings were scored. Results: Eighty-five (78.7%) patients received maximum total clinical and histopathological scores (4) and their eMF were definitely diagnosed. Sixteen (14.8%) patients received a total score of 3, and suggestive eMF diagnosis was made. Further work up such as immunohistochemistry (IHC) evaluation were recommended. Seven patients (6.5%) received a total score of 2, which did not confirm eMF diagnosis. Follow up was recommended. In 14 (87.5%) of 16 patients who had received a total score of 3, the definite diagnosis of eMF was made according to the results of IHC. They were referred to receive treatment. In 2 patients (12.5%) diagnosis of eMF were not confirmed by IHC. They were recommended to undergo polymerase chain reaction (PCR) evaluation Conclusion: Many MF cases can be diagnosed in the early stages using a combination of clinical and histopathological criteria.

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Background and Aim: Skin cancer is one of the most common human cancers. Its incidence rate trend is increasing in Iran. The aim of this study was to investigate the prevalence, incidence rate and geographical distribution of skin cancer to identify the high risk areas in Kurdistan province, Iran. Methods: In this descriptive cross-sectional study, the collected data were analyzed using version 16 of SPSS software, and t-test and analysis of variance (ANOVA) were used for comparison of the means. The distribution map of skin cancer in the province was prepared using Geographic Information System (GIS) software, version 9.3 between the beginning of 2006 and the end of 2010. In order to investigate the reason for high rates of skin cancer in some cities, ultraviolet (UV) radiation distribution map was also prepared. Results: Sanandaj with 17.55/100000 had the highest and SarvAbad with 3.73/100000 had the lowest incidence rates. The number of male patients (542) was nearly two times of female cases (324), (P<0.0001). In addition, skin cancer was about two times more prevalent in urban (%68.01) than rural (%31.99) residents (P=0.008). Conclusion: Life style of men and their sun exposure because of their job seemed to be a major risk factor in increasing the incidence of skin cancer in Kurdistan province, Iran. There was no correlation between the skin cancer incidence at the district level and UV index. Further research is recommended to explain this finding.

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Background and Aim: The aim of this study was to compare the health status and perceived stress in patients with psoriasis and healthy individuals in Shahrekord, Iran. Methods: In this case-control study, 45 patients with psoriasis and 45 healthy individuals were recruited through convenient sampling. Healthy individuals and patients were matched according to their sex, age and education levels. The instruments of research were SF-36 and perceived stress questionnaires. Results: This study showed that the mean perceived stress in psoriasis patients (27.0±4.6) was higher than healthy individuals (20.5±12.2) (P=0.001). Mean score of health status in patients was 44.9±7.9 less than its average in normal healthy subjects (62.1±7.5) (P0.001). Conclusion: Psychological stress may play a role in the exacerbation of psoriasis because of visibility of psoriatic lesions. It is associated with deep effects on the health status of the patients.

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Background and Aim: The aim of this study was to investigate various aspects of the treatment in patients with cutaneous leishmaniasis in Iran in the first half of 2014. Methods: This cross sectional study was conducted on the existing data of 3684 patients with cutaneous leishmaniasis, whom were registered at the Disease Management Center of the Iranian Ministry of Health in the first half of 2014. Version 11 of Stata was used for statistical analysis and the level of significance was considered equals to 0.05. Results: Of 3684 patients entered into the study (%55.1) were male and the mean age of the patients was 27±18 years. More than 34% of patients were treated with intralesional injections of meglumine antimoniate (MA) and 25% of patients recieved systemic MA injections. There were statistically significant correlations between the size and number of the lesions and the chosen treatment regimen (P<0.001). Thirty-five percent of patients treated with systemic MA between 7 to 10 days and 43.3% of patients recieved intralesional MA injections for 5 to 8 weeks. Conclusion: More than %99 of patients fully recovered without complication or treatment failure. It seems that Iranian patients suffered milder CL in comparison with some other coutries.

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Topical corticosteroids (TCs) are very useful in the treatment of some skin disorders such as eczema and psoriasis. TCs exhibit potent anti-inflammatory and anti-proliferative effects responsible for their efficacy in the treatment of skin disorders. TCs can be classified into different groups according to their potency that depends on the intrinsic activity of the corticosteroid molecule, the characteristics of the vehicle (cream, ointment, lotion) that directly influence patient’s compliance and may modify penetration through the skin. British National Formulary classified them into four potency groups with Class I grouping the most potent molecules (e.g. clobetasol propionate) and Class IV the least potent (e.g. hydrocortisone). In contrast, the American classification considers seven potency groups, with super potent, potent, upper mid-strength, mid-strength, lower mid-strength, mild and least potent.

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Leprosy is a chronic infectious disease which mainly affects the skin and peripheral nervous system. It has been associated with significant fear and stigma because of causing disabilities and deformities. According to the latest reports by World Health Organization (WHO), there were more than 180000 registered leprosy cases in the first quarter of 2014 and over 214000 new cases were detected in 2013. In this brief review, updates on a new causative agent for leprosy, Mycobactrium leprosmatosis, armadillos and the possibility of existence of a zoonotic form of leprosy, new strains of M. leprae and their importance, and the latest available leprosy statistics in Iran will be presented.

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Background and Aim: Tinea unguium is a common disease with worldwide distribution most commonly seen in adult patients. Trichophyton rubrum and T. interdigital are the most common causes. The aim of this study was to investigate the frequency of tinea unguium causative agents in a referral dermatology hospital in Tehran, Iran. Methods: This cross sectional study was conducted in 2010 and 2011 on clinically suspicious patients for tinea unguium referred to the Mycology Laboratory, Razi Hospital, Tehran, Iran. Samples from 700 patients were examined using direct smear microscopy and culture. Direct microscopic examination of the specimens was carried out using 20% potassium hydroxide solution. The specimens were cultured on Sabourad dextrose agar culture media containing chloramphenicol and cyclohexamid (Scc). For identifying the species of dermatophytes, complementary tests were used. Frequencies and relative frequencies were demonstrated in tables and chi-square and Fisher's exact tests were used to investigate any association between the categorical variables. Results: Of 700 dystrophic nail samples, 53 samples (7.6%) were positive according to both direct examination and culture. Thirty-eight patients were males. The most common clinical type was distal subungual onychomycosis which was observed in 79.2% of cases. The most frequent detected dermatophyte species. was T. interdigital (39.6%) followed by T. rubrum (37.7%). Forty-seven patients had tinea unguium on their toe nails, 4 patients on their finger nails, and 2 patients had it on both finger and toe nails. Nineteen patients had underlying diseases, and the most common underlying disease was cardiovascular disease (26.3%). Conclusion: Tinea unguium is a disease with worldwide distribution and identifying the causative agents and predisposing factors are necessary for better management of the patients.

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Background and Aim: Skin cancer is the most common cancer in the Iran. The first step in planning for the prevention and treatment of cancers is collecting information about their incidence and trends. The present study aimed to investigate the epidemiology of skin cancer and its trend in southern Iran. Methods: This retrospective cross-sectional study was conducted by analyzing the existing data obtained from the National Cancer Registry System in Iran. The data included all records of skin cancer cases in southern Iran. Then, the incidence rates were standardized using direct method. The data were demonstrated in frequency tables and Cochrane-Armitage test for linear trend was used for evaluation of the incidence trend. Results: Skin cancer had a high incidence in the southern provinces of Iran. A total of 6230 cases of skin cancer during 6 years (2003-2008) were recorded in those provinces and the incidence rate of skin cancer was increasing (P=0.001). In all years of the study, skin cancer incidence was higher in males than women. In terms of frequency, Fars, Khuzestan, Bushehr and Hormozgan provinces had the highest age-standardized incidence. Conclusion: Considering the high incidence of skin cancer and its relationship to sun exposure, educating people on the correct sun protection, educating and empowering physicians and the people about early detection of skin cancers seems to be important in preventing its increasing trend.

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Background and Aim: Pemphigus vulgaris is a rare autoimmune intraepidermal blistering disease affecting the skin and mucous membranes. Copper and zinc are two necessary trace elements in the human body that have antioxidant activity in the wound healing process. The aim of this study was to determine the serumic level of zinc and copper in newly diagnosed patients with pemphigus vulgaris. Methods: In this study, 50 newly diagnosed patients with pemphigus vulgaris admitted to Razi Hospital in Tehran were studied with regards to their serum levels of copper and zinc alongside age, sex, body mass index (BMI), smoking and drug abuse status. Results: Eighteen percent (9 cases) and 50% (25 cases) of the patients showed copper and zinc deficiency, respectively. There was no significant association between copper and zinc levels and smoking, age, BMI or suffering from a chronic disease (P>0.05). Mean copper levels in women and men were not significantly with their respective different normal levels (P>0.05). Serum zinc level in men was lower than its normal range (P<0.05), but in women was not significantly different from its normal level. Conclusion: Serum concentration of copper and zinc did not show any association with pemphigus disease. Since decreased levels of copper and zinc may result in an increase of oxidative activity in autoimmune diseases enhancing disease severity, therefore conducting a robust case-control study for evaluating the their roles in disease severity may pave the way to treatment of those diseases.

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Background and Aim: Vitiligo is an skin condition that results in the skin depigmentation. The implementation of a basal cell layer suspension is a novel treatment in cases with recalcitrant vitiligo. In this study, the efficacy of topical calcipotriol on the implementation site with basal cell layer suspension versus basal cell layer suspension application alone was compared.

Methods: In this randomized, controlled clinical trial, 20 patients with recalcitrant vitiligo were randomly allocated in two 10-patient groups, undergoing the implementation of basal cell layer suspension alone (controls) or along with daily application of topical calcipotriol (intervention group). Results and possible complications were compared between the two groups 6 months after initiation of the treatment.

Results: Six months after initiation of the study, 2 patients (20%) in the control group had poor responses, and 8 patients (80%) had moderate/good responses. In the intervention group, 1 patient (10%) showed poor response, and 9 patients (90%) showed moderate/good responses (P>0.05). Complications were trivial and self-limiting.

Conclusion: Although topical application of calcipotriol did not signigicantly change the primary outcome of the study, it was associated with better results and no major side effects.

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Background and Aim: Pemphigus vulgaris is the most common autoimmune blistering disease. Prednisone, commonly in combination with an immunosuppressive adjuvant such as azathioprine or cyclophosphamide, is the standard treatment for pemphigus vulgaris. Approximately 5% to 15% of mortality of the disease is due to the complications of corticosteroids therapy. The aim of this study was to determine the prevalence and risk factors of steroid-induced diabetes in pemphigus patients hospitalized in Razi hospital, Tehran in 2009 and 2010.

Methods: In this cross-sectional study, 177 first-time admitted pemphigus vulgaris patients were studied regarding presence of risk factors for steroid-induced diabetes. Those risk factors were included age, sex, blood pressure, body mass index (BMI), family history of diabetes, medications used before and after initiation of treatment, fasting blood sugar (FBS) , triglyceride (TG) high density lipoprotein (HDL), low density lipoprotein (LDL) levels at the time of admission, and three weeks after the treatment was started.

Results: Twenty-nine patients (16.3%) were diagnosed with diabetes based on three weeks FBS levels evaluations. There were significant associations between BMI, HbA1c and taking nervous system agents and diabetes (P<0.05), but the differences between sex, family history, blood pressure, TG, LDL levels and occurrence of diabetes were not significant (P>0.05).

Conclusion: Close monitoring of FBS levels before and within the first three weeks of the initiation of steroid therapy allows early detection of storied-induced diabetes in pemphigus patients. Moreover, evaluation of other risk factors associated with diabetes may provide the opportunity of early diagnosis and treatment of steroid-induced diabetes.

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Background and Aim: Dermatophytoses are the infections caused by the fungi that are capable to invade and multiply within keratinized tissues such as the skin, hair and nails. Topical azoles are considered the first-line treatment in dermatophytosis, but systemic therapy may also be required in some cases. Fungal skin infections have become more common in recent years, and injudicious use of conventional drugs has led to emergence of resistant species. This study compared the therapeutic effects of topical colloidal silver with topical clotrimazole in the treatment of  tinea capitis and tinea corporis.

Methods: In this double blind, non-randomized clinical trial, 40 patients with tinea capitis and tinea corporis were allocated into two groups, receiving either topical colloidal silver or topical clotrimazole, twice daily for at least 4 weeks. Systemic antifungals were also administreerd if needed. The response to treatment (negative KOH smear and resolved symptoms) was compared between the two groups at the end of the treatment period.

Results: The mean response time was 5.26±1.56 (range: 3-8)  weeks in colloidal silver receivers and 5.00±2.20 (range: 3-12) weeks in the clotrimazole group (P=0.67).  The response rates were 84.2% in the topical colloidal silver group, and 90.0% in the topical clotrimazole group (P=0.66). None of the patients experienced a side effect.

Conclusion: Topical colloidal silver may be as effective and safe as topical clotrimazole in patients with tinea capitis and tinea corporis. Further studies with larger sample sizes are recommended.

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Background and Aim: Pemphigus is a chronic autoimmune blistering disease characterized by intraepidermal blisters.
These blisters damage the skin barrier and increase the risk of life-threatening infections. Nasal colonization of
Staphylococcus aureus can increase the risk of infections and delay the wound healing process.The aim of this study was to
determine the frequency of staphylococcal carriers in hospitalized patients with pemphigus.
Methods: In this prospective cross-sectional study, medical records of 72 hospitalized patients with pemphigus in the
period from March 2013 to March 2014 were reviewed.Samples were collected from anterior nares and cultured at the
time of admission and one week after hospitalization for evaluation of S. aureus colonization and Methicillin-resistant
Staphylococcus aureus (MRSA) types.
Results: Forty-five patients (62.5%) were male and 27 patients (37.5%) were female. The frequency of S. aureus
carriers was 58.3%. Thirty patients had colonization at the time of hospital admission among them, 22 (73.3%) patients
had MRSA. In forty (55.6%) patients colonization were found one week after hospitalization. Thirty-three (82.5%) patients
in this group were MRSA positive. There was no significant difference between S. aureus colonization at the time of
admission and one week after hospitalization (P>0.05).
Conclusion: S. aureus and MRSA carriers (communityacquired and hospital-acquired carriers) were prevalent
among patients with pemphigus. With identifiction and isolation of carriers of S. aureus in pemphigus patients, not
only could prevent spreading S. aureus and MRSA associated infections, bul also would facilitate wound healing. More
robust studies are required to assess the role of potential riskfactors.

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Background and Aim: Cicatricial alopecia refers to lesions that result in permanent and irreversible hair loss and are associated with destruction of hair follicles. In this alopecias the hair follicle is replaced with connective tissue. After remission of initial infection or inflammation, hair regrowth is unlikely.

Methods: In this retrospective cross-sectional study, 222 patients with cicatricial alopecia, admitted to Farshchian Hospital, Hamadan, Iran were investigated. Hospital records of patients with cicatricial alopecia were reviewed, and their demographic as well as clinical data were extracted and entered into prepared data gathering forms.

Results: One-hundred and ten patients (49.5%) had discoid lupus erythematosus, 71 patients (31.9%) had lichen planopilaris, 23 patients (10.4%) had pseudopelade of Brocq, 11 patients (4.9%) had keratosis pilaris spinulosa decalvans and 3 patients (1.3%) had central centrifugal cicatricial alopecia. Each of alopecia mucinosa and dissecting cellulitis/folliculitis were observed in 2 patients (0.9%). The correlation between of illness, extent of disease, gender, location, occupation, and clinical features of the disease were studied.

Conclusion: Cicatricial alopecia usually results in irreversible hair loss, but early diagnosis and treatment can prevent the progression of the lesions and its complications. The diagnosis of this disease is possible with a clinicopathologic study.