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Conferences |
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Controversy Between Old and
New Therapeutics Under the patronage of His Excellency Prof.
Dr. Ismail Sallam, Minister of Health and Population
Scientific Program (Click on title for Abstract) Session I
Session II
Session III
Session IV
Session I Developments in Dermatologic Therapy Recent developments in Dermato-pharmacology and newly explored technologies have greatly extended and enriched the possibilities for dermato-venerologists in treating skin disease. In addition, experimental dermatology has expanded our horizons, new molecules are recognized and their pharmacologic mechanisms are better understood. In spite of the above mentioned fact alternative therapies have become a viable option worldwide. The use of Chinese herbs for Atopic Dermatitis has gained a lot of attention. The utilization of herbs and 'home remedies' for various disorders is on the increase but that raises several issues that have to be faced: How valuable are these? Do they have harmful side effects? How can use to benefit the patient? This presentation will focus on the most recent studies dealing with advances in the field of Dermatologic Therapy. Advances in Therapy Selected review of the recently introduced therapeutics for common skin diseases will be discussed. Pruritus / Itching The pathophysiologic Mechanism of pruritus will be discussed. The different theories forwarded to explain itching will be explained. The Mechanism of itching in diffirent skin disease and also among generalized medical conditions as ureamia chronic liver diseases will be illustrated and illuminated. Moreover the different general lines that should be taken into consideration during dealing with pruritus has to be visualized. Topical Corticosteroid Therapy: Strategy for Choice
of Increased Benefit / Risk Ratio Topical Corticosteroid (CS) revolutionized the treatment of
many skin conditions over the past five decades. The endogenous steroid hydrocortisone
(cortisol) is the parent compound of modern (synthetic) glucocorticoids including the
topical corticosteroids, which are generally 21-carbon steroids. Since the
anti-inflammatory properties of topical hydrocortisone were recognized in 1950s, chemical
modifications in many ways altered markedly the biological activity. Glucocorticoids have
anti-inflammatory, immunosuppressive and antimitotic activities; the anti-inflammatory and
the immunosuppressive activities are linked. Clinical potency (efficacy) is influenced by:
Session II Problems Diagnosis & Management Of Bullous
Dermatoses During the last 50 years many new blistering diseases have been recognized and defined. As an example is bullous pemphigoid, IgA pemphigus, linear IgA diseases, paraneoplastic pemphigus and others. The present communication diseases the limitations of the diagnostic procedures commonly used and the recommendations for arriving at the definitive diagnosis of a case presenting with bullae. Most of dermatologists still rely on and trust the clinical sense in diagnosis and management of bullous diseases. There are situations where clinical differentiation is not possible. Similarly, the use of conventional H& E pathology is limited value and offers only limited information. The use of direct immunofluorescence is a reliable tool but still there are situations where it cannot totally solve the problem. The salt split immunofluorescence has been introduced to help solve such problems. Immunochemical techniques such as immunoprecipitation and immunoblotting offer good and reliable methods of diagnosis and can help discovering newer disease. Acne Debate Now in year 2000 we have a lot about the Pathogenesis of Acne
Vulgaris, but still there are hot points, of these, two points will be discussed: Cutaneous depositions diseases No Abstract Available Treatment of Atopic Eczema from Tar to Gene The different treatment modalities will be briefly reviewed based on the different understanding of the basic mechanisms of Atopy through the years. Stress will be laid upon the practical point, which is essential to be clear in the mind of practitioners. Laser Assisted Hair Removal Hirsutism and / or hypertrichosis is one of the common distressing complaints of many female patients. Laser represents a good new option for long term to permanent removal of unwanted hair. Many types of laser are used for this goal e.g. ruby L., Alexandrite L. or Diode L., all share the character of having melanin as a target chromophore. The optimum goal is to destroy the hair follicle without damaging other skin structures. This is achieved through repeated laser sittings. Rational, techniques, results & side effects of the procedure are presented. Onycchomycosis More than Just a Cosmetic Problem Nails are specialized keratinous organs that beautify the appendages of the fingers and toe and play an important role in every day life activities. The clinical manifestations of onychomycosis are in the first place determined by the site which consume iceratin (Distal- Proximal- Total Dystrophy- Superficial leuconychia). Fungal infection of the nail present all the factors that make the diagnosis difficult that make matters worse, prognosis even after a correct diagnosis often disappointing. Terbinafine posses an unique clinical and tolerability; also it has specific pharmacokinetics in treating cases of mail fungi. Itraconazole is a masterpiece of pressure and antifungal like imidazole but with less hepatotoxicity and minimal androgenic effect, it achieves high and sustained levels in many tissues including skin & nails. Fluconazole is a good rival that possesses a satisfactory cure rate. Gresiofalvin still inspite of its long-term need, effective but its side effects need continuos follow up of liver and kidney functions and W.B.C. Tinea unguium is still widely incurable disease due to poor clinical response with oral antifungal (in some specific conditions)
Session III Phytotherapy of Skin Diseases The Old Became the New There is a green revolution in therapy. Most countries with advanced technology, seeks salvation from the plant kingdom. There is the healing flower the magic herbs, and the outstanding weed flora of Egypt. We are the ownerso of this heritage, and it is pity we are ignoring it. In my lecture, I shall give few examples. Also I will give a brief history of my love. The Houd El Marsoud. (If time permits) Diversity of Lichen Planus Where one sees histological damage to the lower epidermis and a grouped chronic inflammatory infiltrate in the papillary dermis that disturb the interface between the epidermis and dermis, then that dermatoses can be classified as lichenoid eruption. The protype of all lichenoid eruptions is lichen planus itself but a number of other diseases may develop a lichenoid tissue reaction. Our aim is to prove that the causative factor (S) in lichen planus or lichenoid eruption could be variable in its concentration from case to case in the same clinical type or even in the same case. Different lines of treatment of lichen planes are discussed. Hyperprolactinaemia As Trigger of Angioedema Angioedema and itching appeared in a 31-year- woman who was taking thioridazine (Melleril retard 200 mg daily) for the treatment of schizophrenic reaction. The onset of angioedema followed the inducation of amenorrhea and galactorrhea. Angioedema was occurring for the first time in her life and with no history of allergy. High prolactin level was revealed during this period. The subsequent decrease of the dose from 200 mg to 100 mg/ day thioridazine by the psychiatrist resulted in complete remission of angioedema, resumption of regular mensis, decrease of galactorrhea and normalization of prolactin level within few weeks. Another increase of the dose evoked angioedema after about two months and also with amenorrhea. This attack was rapidly controlled by bromocryptine with reduction of the dose of thioridazine to 100 mg/ day. Neuroleptic agents such as thioridazine (Phenothiazine group) have been established as a cause of galactorrhea and/ or amenorrhea (Wilson and Foster, 1992). The immune- stimulatory role acts by activating the proliferation and survival of T and B lymphocytes and macrophages (Pellegrini et al., 1992 ; Dardenne et al., 1994). Prolactin serves as a co- mitogen during lymphoid expansion (Clevenger et al., 1998). Association has been reported between prolactin levels and severity of systemic lupus erythematosus (Mc Murray et al., 1992; 1993). Bromocryptine appeared to have some efficacy in improving the course of the disease (Mc Murray et al., 1995). However, no documentation has been made of the association between disturbed prolactin level and angioedema or urticaria. Treatments in Leprosy between Truth and Myths "Care for the individual patient than for the special features of the disease" Sir William Osler The successful treatment of any disease involves more than prescribing of pills The pre-sulphone era. It took many centuries for the treatment of leprosy to pass from the horrific to the scientific. Before the present era, in China and in India, the oil expressed from the ripe seeds of Hydnocampus Wightiana was given as a treatment for leprosy. Chemotherapy. In 1940 Faget gave sulfonamide to leprosy patients in Carville. Promin, Diasone and Dapsone. Gerthard Henrik Armauer Hansen applied many regiments of treatment since the discovery of lepra bacilli 1873, the most common one is that of WHO regiments Since 1982 and this regimnets in turn passed through many modifications. Also Ethionamide, Prothionamide, Thiacetazone, Thiambutazone, Long-actingsulphonamides and Aminoglycosides have been tried in treating leprosy. Recently - few years ago - Ofloxacin, Minocycline, Clarithromycin and Erythromycin. Even a single dose therapy in some forms of leprosy was used. Antisense Elements and the Skin Nucleotides are the building units of nucleic acids (DNA & RNA). Antisense elements are synthetic nucleotide sequences, DNA Antisense, RNA Antisense or RNA molecule with enzymatic activity. When Antisense elements are introduced in a cell, they can pair with and functionally inhibit the expression of the targeted single stranded nucleic acid. (1) In this way, the genes that are DNA sequences can be altered and accordingly the expression of genetic information can be regulated. This process had been termed Antisense. (2) Antisense as a mechanism was found to be present throughout nature to regulate gene expression. (2) These elements were able to inhibit interferon gamma (IFN - GAMMA)- induced intercellular adhesion molecule -1 (ICAM-1) expression on human keratinocytes and thus can abort inflammatory reactions. (3) By using antisense elements, it was shown that retinoic acid receptor- beta- messenger RNA (RAR-B-mRNA) is expressed only in normal oral mucosa and lost in premalignant lesions and that isotretinoin treatment of such lesions restored these RAR-B-mRNA expression with associated parallel clinical response.(4) Also, it was found that the expression of insulin growth factor-1- messenger RNA (IGF-1-m RNA) was more in dysplastic than in common nevi, and in metastatic than primary melanoma.(5) Again, ribozymes effectively targeted HIV-1trancripts thus can be of help in HIV treatment.(6&7) Lastly malignancies characterized by enhances expression of protooncogenes can be treated by targeting their specific protooncogenes.(1) As such, antisense elements are attractive advance limb in gene therapy with selective targeting of gene defects that will be of much help in the coming years Case presentations by Al Haud Al Marsoud Hospital group Infandibulo folliculitis - Dr. Hala Amer Case No.1 A 25 years old dark male patient presented, with wide spread non-itchy skin eruption of several years' duration. Upon examination the eruption consisted of tiny follicular papules scattered on the trunk as well as the proximal extremities. Provisional Diagnosis: * Folliculosis pilaris as seen in atopic dermatitis. * Pityriasis versicolor. * Infundibulo folliculitis. Pathology: * Spongiosis within the infundibulum. * Lymphocytic infiltartes. Final diagnosis: * dissiminate and recurrent infundibulo folliculitis. Case No.2 A 32 years old male patient presented, 24 years ago, with follicular papular eruption on the right side of the forehead, nose and cheek accompanied by mild pain. Provisional Diagnosis: * Acne vulgaris. * Darier like epidermal nevus. * Follicular type of sebborheic dermatitis. * Localised darier. Pathology: Focal acantholytic dyskeratosis with supra basal clefts lying beneath columns of acantholytic and dyskeratotic cells, with prominent perinuclear vacuoles. Final diagnosis: Localized darier. Case No.3 A 36 years old male patient presented, tow years ago, with an erythematous, firm and slightly tender swelling on the left upper area of his back. Provisional Diagnosis: * Sarcoidosis. * Lymphoma. Pathology: * Abnormal lymphocytes with hyperchromatic in a follicular arrangement. * No epidermotropism. Final Diagnosis: * B-cell lymphoma. Case No.4 A 40 years old female patient presented, 15 years ago, with long standing pruritic skin lesions. Examination revealed multiple, well demarcated, dark, erythematous and violaceous infiltrated plaques, some of them show ulceration. Provisional Diagnosis: * Mycosis fungoides. Patology: * Dense lymphocytic infiltartion of the dermis showing epidermotropism. Final Diagnosis: * Mycosis fungoides. Case No.5 An 18 years old male presented with well circumscribed and fine wrinkling patches on his lower abdomen. On examination: The lesions are slightly pink and slightly raised. Provisional Diagnosis: 1. Connective tissue naevus. 2. Anetoderma. 3. Buschke Ollendorff syndrome. Pathology: Absent elastic fibres in the dermis. Final Diagnosis: Naevus anelasticus. Case No.6 A 29 years old male presented with non-itchy reddish brown papules located on the right leg, of about 6 years duration. The patient complains of poliomyelitis in the affected leg. Provisional Diagnosis: * Kapsi's sarocma * Pseudo Kaposi's sarcoma (acroangiodermatitis of Mali) * Angiosarcoma Pathology: * New blood vessels formation the dermis * Abcense of slit like vessels and of spindle cells * Abcense of atypical endothelial cells Final Diagnosis: Pseudo Kaposi's sarcoma (acroangiodermatitis of Mali) Case No.7 A 56 years old male presented with multiple symptomless nodules affecting the face, some are skin coloured others are reddish dating since 40 years. Provisional Diagnosis: 1. Multiple trichoepithelioma 2. Angiofibromata 3. Eccrine hydrocystoma 4. Naevoid basal cell carcinoma syndrome Pathology: * Lobules of small dark cells with a degree of peripheral palisading in the dermis * Fibrous stroma is seen around the cellular lobules Final Diagnosis: Multiple trichoepithelioma Case No.8 A 45 years old female patient presented, one years ago, with asymptomatic erythematous papules on the left cheek, upper lip and forehead. There is no extracutaneous physical findings and no laboratory abnormalities. Provisional Diagnosis: * Sarcoidosis * Chronic discoid lupus erythematosus * Lyphocytoma cutis Pathology: * Normal epidermis * Lymphocytic infiltartion of the dermis * The infiltrates is sepsrsted from the epidermis by a narrow grenz zone of uninvolved dermis. Final Diagnosis: Lymphocytoma cutis Case No.9 A 70 years old female patient presented, 2 years ago, with multiple asymptomatic erythematous papules and plaques on the forehead, nose and around the eyes, gradual in onset and progressive in course. There is no extracutaneous physical findings and no laboratory abnormalities. Provisional Diagnosis: * Polymorphous light eruption * Jessner's lymphocytic infiltrate of the skin * Chronic discoid lupus erythematosus tumid type Pathology: * Normal epidermis * Patchy dermal infiltartes mainly lyphocytes * The lyphocytic infiltartes tend to be arranged perivascularly Final Diagnosis: jessner's lymphocytic infiltrate of the skin Case No.10 A 22 years old female patient presented, 10 years ago, with an itchy hypertrophic linear zonal lesion involving the right side of the abdomen, chest and right thigh where it shows thick, withish, adherent scales, with few other plaques at the umbilicus. Provisional Diagnosis: * Linear verrucous epidermal nevus * Linear psoriasis Pathology: * Acanthosis * Parakeratosis * Club shaped elongated rete ridges * Loss of the granular layer Final diagnosis: * Linear psoriasis Case No.11 A 65 years old male patient presented, with wide spread skin eruption that comes in crops and heals with hyperpigmentated small macules. Upon examination the eruption consisted of small brownish papules distributed symmetrically over the trunk and proximal extremities. Mucous membranes were free. Provisional Diagnosis: * Pityriasis lichenoid chronica * Generalized eruptive histiocytoma Pathology: * Dense histiocytic infiltartes * Absence of giant cells and foam cells Final Diagnosis: Generalized eruptive histiocytoma
Session IV Androgen Therapy Uses and Abuses Testosterone is the natural androgen secreted by 700 million Leydig cells of the human testes. It is required for sexual differentiation of the internal sex organs during intrauterine life. Also it is essential for the second period of growth of sex organs and for acquiring male secondary sex characteristics at the time of purbety. In adulthood it is required for maintenance of spermatogenesis and sex derive. Androgens are the main anabolic hormone, it increases the proportion of protein laid down as tissue especially in the muscles and bone. The main indication for androgen therapy is testicular failure whether or secondary in either case replacement with androgen is often necessary. Although it is believed that testosterone is a male hormone, it plays an important role in female sexuality. Androgens are abused by adolescents playing body building to increase the bulk and the power of their muscles to proportions which cannot be attained by regular exercise only. Also it is abused by7 old men to restore their sex derive and to improve their potency. Rarely women may abuse androgens to improve their sexual desire. Abuse of androgens can cause many side effects as virilization, if used by women. Arrest of spermatogenesis, acne, seborrhea and early baldness if abused by adolescents. Salt and water retention, hypertension, hyperlipidaemia, Polycythaemia, increased blood viscosity, increased liability to stroke, coronary infarction and prostate carcinoma if abused by old men. So, androgen therapy should be given only under strict medical supervision. Diagnosis & Treatment of Erectile Dysfunction
(E.D.)
Era after Viagra Sildenafil (Viagra) took off faster than any drug before it when it debuted in April 1998, racking up 3 million prescriptions in the firs three-months. In 1999 the drug had worldwide sales of $ 1 billion. But sildenafil is vulnerable, and a slew of new rivals will challenge it in the next few years. It doesn't work for at least third of the men who try it. It can take an hour to kick in, even tow hours if taken after a meal (so much for romantic dinners). The side effects, though mild, can be a turn-off. Worst of all, Sildenafil can lead to death if taken by patients who are on nitrates or nitroglycerin, drugs used to treat some 3 million men with heart problems, many of whom also have erectile dysfunction. Even cardiac patients not on nitrate drugs can risk a heart attack on Viagra if they have sex and are badly out of shape. While the FDA says the numbers aren't alarming given Viagra's large patient base, such reports are enough to scare away some users. A huge market waits. Reports say 6 million men in the U.S. have tried Viagra, and perhaps 4 million are regular users. But up to 30 million men age 40 or older have some degree of erectile dysfunction, the National Institutes of Health says. That's more than half of men in that age group. Ten companies are preparing 10 new supposedly miraculous drugs for sexual dysfunction. These include TAP, Zonagen, ICOS and Lilly, Bayer, Bristol-Myers Squibb, MacroChem, NexMed, Nastesh, Pharmacia & Upjohn and a new drug by Phizer. A happy spin on the competitive outlook: "The winner is really the patient." Diagnosis & Management of E.D. in Clinical
Practice Erectile Dysfunction (ED), also called impotence, is common for many reasons, men are not approaching their caregivers about sexual health problems. Instead, they often hope and wait for their healthcare providers to uncover these problems and offer support and guidance. Although this responsibility may sound challenging, after sexual health discussions becomes a routine part of patients visits, it will become easier and the gratitude you will feel from the patients you help will reinforce your desire to help others with their sexual health problem. ED is related to many common health problems and lifestyle factors such as stress, obesity, alcohol abuse, or tobacco use. Additionally, depression and certain medications, such as antihypertensive medications,can cause ED. ED can often indicate the presence of a more serious illness such as heart discase, high blood pressure or cholesterol and diabetes. ED is treatable in most men. Empty Scrotum Syndrome (ESS) ESS includes undescended testes, retractile testes, ectopic testes and bilateral anorchia. Undescended testes occurin 21% of premature babies and 2.7% of full term infants, the testes often descend during the first year of life spotaneously and at the end of the first of age. Only 0.2% of testes remain A retractile testis is pulled up into the inguinal canal by astrong cremasteric muscle, it can be pulled down into the scrotum by gentle manipulation. An ectopic testis has descended beyond the external inguinal ring but lies outside the scrotum. An undescended testis may lie anywhere along the line of descent from the kidney to the scrotum. There is a 10-25% risk of malignancy in an intra-abdominal testis. Pathological changes start to occur in the undescended testis during the second year of life, so the optimal age for orchidopexy is about tow years of age. Role of Zinc in Delayed Puberty Purbety is a transition period between childhood and adulthood, which occurs in boys between ages of 10 and 14 years. Delayed sexual development is considered when there is failure of initiation of sexual development around the age of 14 years in boys, if not completed in 4.7 years after initiation or if stage 5 has not been reached at age of 17.1 years. Zinc in considered as important element for health. It is essential for the activity of many enzymes. In this study among 1106 school children examined 42 (3.8%) had signs of idiopathic delayed puberty, which passed through panel of investigations which were also done for 20 healthy control subjects. Sixteen of these 42 patients have received Zinc therapy for 6 months and re-examined at the end of therapeutic trial. After the course of Zinc therapy, the measured parameters improved within 6 months with significant elevation of serum Zinc, FSH, testosterone and testicular length compared to the pretreatment and the control values. Evaluation of Effect of Hypertension and
Antihypertensive Therapy On Male Sexual Function Hypertension is an important cause of impotence particularly in elderly males. In the present study, it was found to cause impotence in about 24% of cases due its effect on both the penile arterial and veno-occlusive systems Hypertension was also the most common cause of sexual dysfunction associated with atenolol and captopril therapy. The development of impotence depended primarily on the duration rather than the degree of hypertension. Psychic factors were the next common cause of sexual dysfunction both in treated and untreated hypertensive patients. So, most of the cases of impotence associated with atenolol and captopril therapy are not truly drug-induced. Captopril was better than atenolol as regards their effect on sexual function causing sexual dysfunction in only 5.5% of cases compared with 14.6% due to atenolol. The Great immitator: Syphilis Although, it is well known that the skin rash of 2nd syphilis is nonpruritic, accumulated data denote the reserve in a percentage of cases. Multiplicity of Chancre is not against the diagnosis, also the chancre may immitate any genital ulcer, although the classic hunterian chancre is the most common. If you are an expert in genital ulcers, a good percentage of your diagnosis is wrong!! All of us know that the syphilitic rash could immitate any other skin rash. Not only the classic form of rash (macular - papular papulosquamous and pustular). For the moment, variant has been described e.g.: lichenoid, follicular etc...
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