Saturday, 28 December 2013

Friday Meetings: Friday 10/1/2014

Friday 10/1/14 1:30 pm Cairo Time Google Plus Hangout

One-topic meeting:

An update on the management of psoriasis

Free talks via Google Hangout on Fridays have been arranged. These Friday Meetings have been audiovisual online meetings where we have typed, talked and screen shared. The Handouts, when available, can be emailed on request unless they become out-of-date.  

Similarly, Thursday Meetings have been developed to discuss Rook's Textbook of Dermatology on Google Hangout. 

Saturday, 16 November 2013

Friday, 1 November 2013

Wednesday, 23 October 2013

Sperm vitality tests

The percentage of live spermatozoa is assessed by identifying those with an intact cell membrane, by dye exclusion test or by hypo-osmotic swelling testThe lower reference limit for vitality (membrane-intact spermatozoa) is 58%.


When the percentage of sperm motility is low or absent, vitality tests are used in order to determine whether spermatozoa have lost their flagellation because of metabolic dysfunction and/or axonemal defects, or are simply dead (necrozoospermia). When ART is considered, viable sperms are picked out for use. Vitality results should be assessed in conjunction with motility results from the same semen sample. Necrozoospermia may indicate epididymal pathology. Vitality tests are routinely performed on all samples by some. They also provide a check on the motility evaluation, since the percentage of dead cells should not exceed the percentage of immotile spermatozoa. Vitality should be assessed as soon as possible after liquefaction of the semen sample, preferably at 30 minutes, but in any case within 1 hour of ejaculation, to prevent observation of deleterious effects of dehydration or of changes in temperature on vitality.


Suitability for ART
Dye exclusion test (eosin*-nigrosin test)
Dead sperms allow eosin to penetrate and thus stain the cell as damaged membranes in dead sperms, allow entry of eosin. Live sperms exclude eosin.
Nigrosin is used to increase the contrast between the background and the sperm heads, which makes them easier to discern. It also permits slides to be stored for re-evaluation and quality-control purposes.  Spermatozoa with red /dark pink heads are considered dead, whereas spermatozoa with white/light pink heads are considered alive. If the stain is limited to only a part of the neck region, and the rest of the head area is unstained, this is considered a “leaky neck membrane”, not a sign of cell death and the sperm is considered alive. If eosin is used alone, it might be difficult to discern the pale pink stained heads, in such circumstances nigrosin is used to increase the contrast of the background.
Sperms are killed in the vital staining process and cannot be used subsequently for ART.
Hypo-osmotic swelling (HOS) test
It is test of the integrity of the semi-permeable plasma membrane of the viable sperm tail. If live sperms are placed in hypotonic solution, water will enter the cell and cause the cell to increase in volume; this becomes evident in   the tail region where swelling of the sperm tail can be easily seen.
Semen is diluted with a hypotonic solution so that water enters sperm tail osmotically. Intact spermatozoa are revealed by swelling-related changes enforcing a coiling of the tail. In contrast, dead cells have damaged membranes that provide no osmotic gradient for swelling of the sperm tail to occur.
Sperms are not killed during the test and the test can be used in a therapeutic manner for ART including testicular sperm extraction (when only non-motile sperms are present, the test allows the technician to pick out viable non-motile sperm). It should be noted that the time and preparing the reagents differ between diagnostic use and therapeutic use. 

 *Eosin (Greek, Eos goddess of dawn) is a red dye resulting from the action of bromine on fluorescein. Structures that stain readily with eosin are termed eosinophilic. There are closely related interchangeable compounds commonly referred to as eosin. These are the one usually used eosin Y (with very faint yellowish cast), and eosin B (with very faint bluish cast).

What else to be considered?

1 1) The possibility of the semen specimen being exposed to contaminants within the container or to extremes of temperature, or prolonged abstinence periods. Also, consider the possibilities of genital tract infections and varicocele2) Defective transport through the genital system. 3) Antisperm antibody assay. It is preferable to use direct assays since these determine the presence of sperm-bound antisperm antibodies, as compared with indirect assays that determine the presence of antisperm antibodies in serum. 4) Electron microscopy studies for ultra-structural defects (commonest is immotile cilia syndrome).

 This page was last updated in November 2013

Tuesday, 17 September 2013

Truncal eruptive vellus hair cysts

Eruptive vellus hair cysts (occlusion and cystic dilatation of vellus hair follicles) commonly present as asymptomatic (but itching has been reported) small red, yellow, bluish-grey or brown, papules (occasionally scaly) on the chest, abdomen (A), and axillae (B) (but can be unilateral or generalised) in the second decade of life. They were first reported in 1977. The diagnosis is often made clinically, because of typical age of onset (before puberty), the site of the lesions, and their appearance. The differential diagnosis may include other cysts, different types of folliculitis, keratosis pilaris and keratosis follicularis. Dermoscopy may be useful in reaching a diagnosis, as lesions display an erythematous maroon halo with occasional irregular radiating capillaries at the periphery and the vellus hairs can be identified opening onto the epidermis. Histopathologic examination reveals a cystic structure located in the middle or upper dermis. It is lined by a stratified squamous epithelium with focal features of outer root sheath differentiation at the level of the follicular isthmus and trichilemmal cornification. The lumen contains keratin and numerous transversely and obliquely sectioned vellus hair shafts. Some cysts may show a connecting pore at the skin surface, the likely mechanism of the spontaneous regression. Also, incision or puncture of the cyst and examination of the contents in potassium hydroxide, under a microscope will reveal the vellus hairs. Eruptive vellus hair cysts can overlap clinically and pathologically with steatocystoma multiplex (hybrid cysts). The so-called steatocystoma multiplex suppurativa mimics acne conglobata. Twenty-five percent of eruptive vellus hair cysts cases spontaneously regress through transepidermal elimination. Various methods have been used to treat the lesions but beware of scarring. The lesions may clear after application of topical retinoids. Erbium: YAG laser has been successful in treating the lesions*. 



*Kageyama N, Tope WD. Treatment of multiple eruptive hair cysts with erbium : YAG laser. Dermatol Surg 1999; 25: 819–22.

This page was last updated in April 2014

Friday, 13 September 2013

Oral antiretroviral pre-sexual exposure HIV prophylaxis, causes for concern

Sexual contact is the most common route of HIV transmission* whose rate of infection after a sexual contact varies according to the nature of the contact and whether it is protected or not and the HIV subtype. The search for potential vaccines has yielded little result. Oral antiretrovirals, life saving drugs for HIV-infected patients, have a role to play among other means in the prevention of sexually transmitted HIV infection in at-risk HIV negative populations. In this context, they are used for pre-sexual exposure prophylaxis (PrSEP), post-sexual exposure prophylaxis and early treatment of the HIV-infected partners. Other means include topical antiretrovirals, male circumcision and male/female condoms. Certainly abstinence is the definitive way for prevention of any sexually transmitted infection. Pre-exposure prophylaxis that is shown to be effective in reducing HIV transmission in one population may not necessarily work in other at-risk populations, hence the conduction of trials in different population groups representing different routes of HIV transmission, including heterosexuals, MSM, and injecting drug abusers.

The concept of providing pre-exposure prophylaxis is not new. Apart from vaccines, a famous example is the pre-exposure prophylaxis against malaria for travellers to endemic areas. Theoretically, if HIV replication is inhibited from the moment the virus enters the body, it may not be able to establish a permanent infectionPrSEP has been shown to reduce the risk of HIV infection among adult men and women at high risk for HIV infection through sex.  The FDA has approved the combination medication tenofovir disoproxil fumarate plus emtricitabine for use as PrSEP among sexually active adults at risk for HIV infection. At-risk populations such as MSM are not necessarily aware of the presence of PrSEP. However, knowledge about this role of oral antiretrovirals may have effect on willingness to accept it. Serodiscordant couples have been advised of early treatment for the infected partner, PrSEP for the uninfected partner, or a combination of the two. PrSEP might be an effective prevention method for women who are unable, for whatever reason, to negotiate condom use. PrSEP might also be used as a risk reduction strategy for HIV negative women who request to conceive naturally from HIV positive men via timed unprotected sex, PrSEP for conception (PrSEP-C). 

It should be noted however that PrSEP can give a false sense of security that might lead to easier transmission of other sexually transmitted infections.  Moreover, continued use of a PrSEP regimen in the presence of undiagnosed HIV infection is analogous to the HIV monotherapy or dual therapy strategies used in the early stages of the HIV epidemic. Such regimens are known to carry an unacceptably high risk of HIV drug resistance, with important clinical implications for the patient and public health implications for the sexual partners. Extensive studies are needed to address the safety concerns associated with use of daily oral PrSEP in HIV negative people, whether in long or short term courses, and to address cost concerns of PrSEP and feasibility to deliver it.

*National statistics show injection drug use is the principal mode of HIV transmission in Iran.

This page was last updated in October 2013.

Monday, 9 September 2013

Papillon–Léfèvre syndrome

Papillon-Léfèvre syndrome is a very rare syndrome of autosomal recessive inheritance (the prevalence has been estimated as 1–4 in 1 million) characterised by palmoplantar keratoderma (A), and periodontitis (C). The lesions may extend to the dorsal hands and feet and may also be present on the elbowsknees (B), and Achilles tendon areas. The condition usually has an early age of onset. The severity of the periodontal disease does not correlate with the severity of the skin lesions. Periodontitis leads to the loss of deciduous teeth by the age of 5 years unless treated; permanent teeth may be lost in the same way. Associated hyperhidrosis causes an unpleasant odour. The hair is usually normal. Other associated features have been reported such as pyogenic infections of the skin and internal organs and pseudoainhum of the thumb.

This condition is caused by a mutation in the lysosomal protease cathepsin C gene located at chromosome 11q14.1–q14.3This explains the predisposition to pyogenic infection, but the mechanism of keratoderma is not established.   The phenotypically related Haim–Munk syndrome (it combines the features of Papillon–Léfèvre syndrome with onychogryphosis, arachnodactyly and acro-osteolysis) is an allelic mutation. There may be mild phenotypic expression of the disease with late onset and mild skin or periodontal disease. In some late-onset patients, no mutations in the cathepsin C gene were found, suggesting the possibility of another genetic cause. Periodontitis is also present in the ‘HOPP’ syndrome (hypotrichosis, acro-osteolysis, palmoplantar keratoderma, and periodontitis) but there is no mutation in the cathepsin C gene.

Histopathological changes are non-specific. Treatment with oral acitretin has been effective in controlling the disease. 

This child has presented with hyperkeratosis of the palms and soles that has first developed during the first few months of life. The lesions spread on the elbows and knees over the following years. On examination, loss of dentition has also been noted. It has started since the eruption of deciduous teeth. A diagnosis of Papillon-Léfèvre syndrome was made. Treatment with acitretin has been discussed with the mother and it was decided to postpone it in view of the possible side-effect of premature epiphyseal closure. The patient is currently being treated with topical preparations for symptomatic relief.

This page was last updated in September 2013.

Saturday, 29 June 2013

Tuesday, 11 June 2013

Leprosy, an overview

Leprosy, an overview. 1:30 pm - 3:00 pm (including discussion) - Friday 21/6/2013, Egyptian Medical Syndicate (Dar Al Hekma), Qasr Al Aini Street, Cairo

Registration: Egyptian Medical Syndicate

المحاضرة مجانية و لن تحصل رسوم ادارية للنقابة

Saturday, 25 May 2013

How to become a dermatologist in Egypt, the third lecture

How to become a dermatologist in Egypt, the third lecture. 1:30 - 3:00 pm (including discussion) - Friday 7/6/2013, Egyptian Medical Syndicate (Dar Al Hekma), Qasr Al Aini Street, Cairo

Registration: Egyptian Medical Syndicate

EMS Event Page

المحاضرة مجانية و تحصل رسوم ادارية للنقابة

Friday, 26 April 2013

Racial longitudinal melanonychia

Melanonychia is a brown to black colour of the nail. It is due to the presence of melanin in the nail plate. It is caused by activation or benign/malignant proliferation of nail matrix melanocytes.

When the pigmentation involves the whole nail it is called total melanonychia. When it is banded it is either transverse or longitudinal. Longitudinal melanonychia is the commonest form. The commonest cause of longitudinal melanonychia in adults is racial variation (see photo), trauma has been implicated in their development. The commonest cause in children is benign melanocytic hyperplasia.

Longitudinal melanonychia of a single nail deserves biopsy in adults as a high degree of suspicion is required if subungual melanoma (or another pigmented malignancy) is not to be missed.  In children it is usually benign in nature and can be followed

Racial longitudinal melanonychia

This page was last updated in April 2013

Thursday, 14 March 2013

Role of topical calcineurin inhibitors in the treatment of urticaria pigmentosa

Pimecrolimus inhibits the release of both preformed and de novo synthesized mediators from activated mast cells and inhibits accumulation of mast cells by inducing apoptosis. Thus pimecrolimus and tacrolimus are now considered as a potential therapeutic approach for mast cell-associated diseases such as mastocytosis.

This child skin showed multiple, generalized tan to brown macules/papules with classic features. Pigmentation and all evidence of the disease commonly disappear within a few years, generally before puberty. The eruption, however, may uncommonly persist into adult life. Although systemic involvement is possible, malignant systemic disease is extremely rare.

Such lesions are often confused with insect bites at first, but they persist and gradually increase in number for several months or years. Many children and adults have few, if any, symptoms. Childhood urticaria pigmentosa usually develops in the first year of life. Adult urticaria pigmentosa usually develops between 20 and 40 years. The lesions appear anywhere on the body but classically sparing the central face, scalp, palms and soles. Stroking a lesion with the blunt end of a pen induces a weal of the entire lesion that is usually confined to the stroked site (Darier's sign). The weal may take up to 10 minutes to appear. Stroking may also produce wealing in clinically unaffected skin. Darier’s sign is more pronounced in children due to a higher density of mast cells and the rubbed area may even blister.  This test is highly characteristic and is usually seen as reliable as a biopsy for establishing the diagnosis.  Having said so, Darier’s sign is not always demonstrable and is not 100% specific for mastocytosis, since it has also been described rarely in juvenile xanthogranuloma and acute lymphoblastic leukaemia of neonates. Interestingly, juvenile xanthogranuloma has been reported in association with urticaria pigmentosa*.

A skin biopsy is desirable to confirm a clinical diagnosis in many patients, although observation alone is appropriate in very young children. A full blood count should be performed at presentation and at yearly intervals when systemic disease is suspected. Other investigations should be guided by the clinical presentation. Juvenile xanthogranuloma is generally a self-healing tumour and lesions generally resolve in 1–5 years. Having said so, disseminated neonatal juvenile xanthogranuloma may be more aggressive and fatalities in this group have been reported. The major difficulty in clinical diagnosis of juvenile xanthogranuloma is with the nodular forms of Langerhans’ cell histiocytosis. Histopathology and immunocytochemistry will easily differentiate the two disorders. Some believe that benign cephalic histiocytosis represents a clinical variant of juvenile xanthogranuloma but the clinical features of the disease are distinct enough to maintain a separate nomenclature.

*DeVillez RL, Limmer BL. Juvenile xanthogranuloma and urticaria pigmentosa. Arch Dermatol 1975; 111: 365–6.

This page was last updated in November 2015. 

Friday, 22 February 2013

Friday Meetings: Friday 1/3/2013

Friday 1/3/13 1:30 pm Cairo Time Google Plus Hangout


1-Hereditary angioedema update
2-AESOP  syndrome1
3-Treatment of plane warts
4-Condoms lubricants
5-Hormone disrupting chemicals
6-Phenytoin and recessive dystrophic epidermolysis bullosa
7-Aciclovir and erythema multiforme
8-Treating ED in patients at cardiovascular risk
9-New British Guidelines (pelvic inflammatory disease - ART for HIV-1 infected adults)
10-Royal College Associate Category

Free talks via Google Hangout on Fridays have been arranged. These Friday Meetings have been audiovisual online meetings where we have typed, talked and screen shared. The Handouts, when available, can be emailed on request unless they become out-of-date. 

Similarly, Thursday Meetings have been developed to discuss Rook's Textbook of Dermatology on Google Hangout. 

Tuesday, 19 February 2013

Friday Meetings: Friday 22/2/2013

Friday 22/2/13 1:30 pm Cairo Time Google Plus Hangout


1-Sexually transmitted diphtheria

2-Unmasking IRIS
3-Ulerythema ophryogenes
4-Degos disease
5-Specific dermatoses of pregnancy
6-Use of linezolid

7-Treatment of pityriasis rosea
8-New British Guidelines (alopecia areata - bullous pemphigoid - bacterial vaginosis)

Free talks via Google Hangout on Fridays have been arranged. These Friday Meetings have been audiovisual online meetings where we have typed, talked and screen shared. The Handouts, when available, can be emailed on request unless they become out-of-date. 

Similarly, Thursday Meetings have been developed to discuss Rook's Textbook of Dermatology on Google Hangout. 

Friday, 1 February 2013

Friday Meetings: Friday 15/2/2013

Friday 15/2/13 1:30 pm Cairo Time Google Plus Hangout


1-Clear cell acanthoma of Degos
2-Acanthosis nigricans (obesity related) 
3-Chlamydial urethritis
4-Ross’s syndrome

Free talks via Google Hangout on Fridays have been arranged. These Friday Meetings have been audiovisual online meetings where we have typed, talked and screen shared. The Handouts, when available, can be emailed on request unless they become out-of-date.

Similarly, Thursday Meetings have been developed to discuss Rook's Textbook of Dermatology on Google Hangout. 

Thursday, 24 January 2013

Friday Meetings: Friday 25/1/2013

Friday 25/1/13 1:30 pm Cairo Time Google Plus Hangout


1-Secondary hyperkeratosis of the nipple and/or areola
2-Hypopigmented parapsoriasis
3-Update on ART

Free talks via Google Hangout on Fridays have been arranged. These Friday Meetings have been audiovisual online meetings where we have typed, talked and screen shared. The Handouts, when available, can be emailed on request unless they become out-of-date.

Similarly, Thursday Meetings have been developed to discuss Rook's Textbook of Dermatology on Google Hangout. 

Friday, 11 January 2013

Update on Antiretroviral Therapy (ART) for Treatment-Naive HIV-1 Adult Patients

Annual ESDV Conference 2013
Marriott Hotel, Zamalek, Cairo, Egypt

Update on Antiretroviral Therapy (ART) for Treatment-Naive HIV-1 Adult Patients

Thursday 17/1 at 10:50 am

Abstract: There is no cure for HIV infection but treatment is aimed at reducing the plasma viral load as much as possible and for as long as possible. The most recent British HIV Association (BHIVA) treatment guidelines published in 2012 will be discussed in relation to treatment-naive adult patients. How to get ART in Egypt will be discussed too.

ESDV Competition Regulations:

1- You must be a trainee in Dermatology/Venereology in Egypt (i.e. below Consultant level); a scanned statement issued by the Hospital Department is required.

2- The statement and the answers are sent to AND TO from 16/12/12 to 31/12/12. Answers without the statement are not accepted.

3- First ten highest scorers will win the full Conference

4- Whenever the statement and answers are received, you should receive the following "Answers and the statement have been received. Thanks."

5- Those who win the competition will be named on 1/1/13.

6- All those who get full marks will be named even if they do not win the competition (not among the first ten highest scorers).

7- All those who pass the test will be named  even if they do not win the competition (not among the first ten highest scorers).

8- A mark of 60% is required to pass the test.


This page was last updated in January 2013

Main Works of Reference List (The first eight are my top favourites)

  • British National Formulary
  • British National Formulary for Children
  • Guidelines (BAD - BASHH - BHIVA - Uroweb)
  • Oxford Handbook of Genitourinary Medicine, HIV, and Sexual Health
  • Oxford Handbook of Medical Dermatology
  • Rook's Textbook of Dermatology
  • Simple Skin Surgery
  • Weedon's Skin Pathology
  • A Concise Atlas of Dermatopathology (P Mckee)
  • Andrews' Diseases of the Skin
  • Andrology (Nieschlag E FRCP, Behre M and Nieschlag S)
  • Bailey and Love's Short Practice of Surgery
  • Davidson's Essentials of Medicine
  • Davidson's Principles and Practice of Medicine
  • Fitzpatrick's Colour Atlas and Synopsis of Clinical Dermatology (Klaus Wolff FRCP and Richard Allen Johnson)
  • Fitzpatrick’s Dermatology in General Medicine
  • Ganong's Review of Medical Physiology
  • Gray's Anatomy
  • Hamilton Bailey's Demonstrations of Physical Signs in Clinical Surgery
  • Hutchison's Clinical Methods
  • Lever's Histopathology of the Skin
  • Lever's Histopathology of the Skin (Atlas and Synopsis)
  • Macleod's Clinical Examination
  • Martindale: The Complete Drug Reference
  • Oxford Handbook of Clinical Examination and Practical Skills
  • Oxford Textbook of Medicine
  • Practical Dermatopathology (R Rapini)
  • Sexually Transmitted Diseases (Holmes K et al)
  • Statistics in Clinical Practice (D Coggon FRCP)
  • Stockley's Drug Interactions
  • Treatment of Skin Disease: Comprehensive Therapeutic Strategies
  • Yen & Jaffe's Reproductive Endocrinology