Monday, 23 March 2015

Annular lichen planus

It is evident that specific immunologic mechanisms control the development of lichen planus (LP). It has been proposed that CD8+ cytotoxic T cells recognize an antigen (currently unknown) associated with the major histocompatibility complex (MHC) class I on lesional keratinocytes and lyse them. Direct immunofluorescence examination of LP shows colloid bodies in the papillary dermis, staining for complement and immunoglobulins, particularly IgM. An irregular band of fibrin is present along the basal layer in most cases. Often there is irregular extension of the fibrin into the underlying papillary dermis.

Annular lesions occur in about 10% of LP cases. Men represent 90% of patients with annular LP.  Patients usually have fewer than 10 lesions. Most patients with annular LP are asymptomatic. When itching exists, most patients react to the itching by rubbing rather than scratching. Arcuate groupings of individual papules develop rings. Clustered papules with peripheral extension and central clearing leads to annular lesions too. Male genitalia are involved in 25% of LP cases (partly explained by the Koebner phenomenon) and it may be the only manifestation of the disease. Chronic erosive gingival and genital lesions (genito-gingival syndrome) has been described. Chronic mucosal erosive LP is associated with a risk of squamous cell carcinoma (SCC). Most reports linking the two concern oral LP though. SCC has occurred in the context of hypertrophic LP of the glans penis.  

Annular LP is most commonly found on the penis as shown in this patient. Lesions usually have a very narrow rim of activity and a depressed, slightly atrophic, centre hence term annular atrophic lichen planus. Much less often, the margin is wide, and the central area is quite small.  Polycyclic figures may be formed. The differential diagnosis includes granuloma annulare. Central hyperpigmentation may be the dominant feature as shown on the glans penis of this patient.  LP can cause phimosis. Bullous penile LP has been reported. Actinic lichen planus is frequently annular in shape too.

Histopathology of LP shows a lichenoid reaction pattern characterised by the combination of degeneration of the basal layer of the epidermis and a band like lymphocytic infiltrate obscuring the dermoepidermal junction. A distinct entity termed annular lichenoid dermatitis of youth has been described, and is characterized by persistent asymptomatic erythematous macules and round annular patches with a red-brownish border and central hypopigmentation, mostly distributed on the groin and flanks, in children and adolescents. Histopathology reveals lichenoid reaction pattern with necrosis/apoptosis of the keratinocytes limited to the tips of rete ridges. It can affect adult patients too; therefore, the name “annular lichenoid dermatitis” has been proposed. 

Although LP is self-limiting, some patients experience relapses and remissions. Potent or very potent topical steroid creams and ointments usually produce remission and remain the treatment of choice for lichen planus in patients with classic and localized disease. Patients should be warned about postinflammatory hyperpigmentation. It can persist for months to years. Circumcision is seriously considered if there is phimosis. 

Potent or very potent topical steroid creams and ointments usually produce remission as shown here and remain the treatment of choice for lichen planus in patients with classic and localized disease.

This page was last updated in September 2015

Saturday, 21 March 2015

Role of oral terbinafine in the treatment of tinea capitis

Tinea capitis, an infection of scalp hair follicles and the surrounding skin, is predominantly an infection of children, although adult cases are occasionally seen.

Whereas all three genera attack the skin, Microsporum does not infect nails and Epidermophyton does not infect hair. Tinea capitis is caused by dermatophyte fungi, species in the genera Microsporum and Trichophyton. Single fungus can produce more than one clinical type of tinea capitis. Hair shaft infection is preceded by invasion of the stratum corneum of the scalp.  Because of the cuticle, the fungi cannot cross over from the perifollicular stratum corneum into the hair but must go deep into the hair follicle to circumvent the cuticle. This helps explain why topical antifungals fail to treat tinea capitis. The fungus grows down through stratum corneum layer into the hair follicle and gains entry into the hair in the lower intrafollicular zone, just below the point where the cuticle of the hair shaft is formed. Thus, infection originates inside the hair shaft in all patterns of hair invasion. The growth of hyphae occurs within the hair above the zone of keratinization of the hair shaft (Adamson “fringe”) and keeps pace with the growth of hair. Distal to this zone of active growth, spores are formed within or on the surface of the hair, depending on the species of dermatophytes. Hyphae grow inside and fragment into short segments called spores. Endothrix infections have spores remaining within the hair shaft and the affected hair shaft breaks at the surface of the scalp being severely weakened but in favus endothrix pattern, the fungus does not fragment into spores thus the infected hair commonly grows to normal lengths. Ectothrix infections have spores dislodging outside the hair shaft, the cuticle is eventually destroyed and the hair shaft tends to fracture a few millimetres above the surface.

Factors to be considered when managing a case of tinea capitis are the anatomic structure of the hair follicle, the dormant sebum-production before onset of puberty, the organism isolated, and the antifungal to be chosen (see table). 

Terbinafine is an allylamine that acts on the cell membrane and is fungicidal. It shows activity against all dermatophytes, but has much higher efficacy against Trichophyton species than Microsporum. For M. canis infection, the minimum inhibitory concentration for terbinafine can exceed the maximum concentration reported in hair, which might lead to treatment failure.

Terbinafine hydrochloride is well absorbed from the gastrointestinal tract. It is distributed into the stratum corneum of the skin (by sebum and by direct diffusion from the vascular system), sebum, the nail plate, and hair where it reaches concentrations considerably higher than those found in plasma. It is not found in sweat. It appears in breast milk.  Terbinafine will not be built on the hair shaft because it is not found in sweat but it is integrated via the hair papilla in the newly formed keratin of the growing hair where it can eliminate the infection. Accordingly, it will not reach paediatric ectothrix hair infection via sweat, as mentioned above or via sebum because of the dormant sebum-production before onset of puberty and this might explain its lower efficacy in such circumstances. However, it has been said that Microsporum infections (ectothrix) just require higher doses and longer courses of therapy with terbinafine. The current British guidelines state that at higher doses, terbinafine is more effective against M. canis but prolonging treatment does not improve efficacy.

Prepubescent children have functioning sweat glands, and therefore griseofulvin, fluconazole, and itraconazole can reach the outside of the hair in this fashion.

There is a positive effect for terbinafine against Trichophyton spp. in paediatric tinea capitis. In patients who have not yet reached puberty, only the portion of terbinafine that is integrated in the keratin through the hair root is effective. It has been shown that 4 weeks of terbinafine is at least as effective as 8 weeks of griseofulvin in T. tonsurans infections and thus terbinafine is now considered the optimal choice, when cost-efficiency and compliance are taken into account in treating such infections.

Oral terbinafine is not recommended for patients with chronic or active liver disease. Any pre-existing liver disease should be assessed. Periodic monitoring of liver function test is recommended.

The terbinafine dose in tinea capitis is as follows, over 1 year, body-weight 10–19 kg, 62.5 mg (one-quarter of a 250 mg tablet) once daily; body-weight 20–39 kg, 125 (half of a 250 mg tablet) mg once daily; body-weight 40 kg and above , 250 mg once daily  usually for 4 weeks. The tablet may be split accordingly and hidden in food. Overall, terbinafine appears well tolerated in children. A granule formulation of terbinafine to be sprinkled on food has been licensed for use in children > 4 years of age in the USA. 

If itraconazole is selected as first-line therapy (because it has activity against both Trichophyton and Microsporum species), terbinafine is considered second line for Trichophyton infections and griseofulvin is considered second line treatment for Microsporum species, at standard dosing regimens. Ketoconazole shampoo left on the scalp for 5 minutes three times a week can be used as adjunctive therapy to oral antifungal agents to reduce the shedding of fungal spores. Fluconazole has been used in the treatment of tinea capitis but its use has been relatively limited.

Tinea capitis caused by Trichophyton species.

This page was last updated in December 2015

Friday, 20 March 2015

Egyptian Health Service

The British National Health Service (NHS), the top model of a nationalised health system in the world, has recently been suffering a lot because higher costs have to be covered and now the private sector is apparently essential to maintain the NHS. It helps with the workload, brings new skills, and contributes to competition. The term charities or third sector refers to organisations that are not for profit and non-governmental. This is where I currently practise in Egypt. It has been suggested that charities should get longer and more stable contracts than the private sector. It has also been stressed that the NHS will not achieve sustainability on its own; only by working in close partnership with charities will it succeed in adapting to the demands of 21st century healthcare. The original UK GP fundholding concept has been replaced by presence of clinical commissioning groups (partly run by the GPs) but new integrated care systems are being developed.

If Egypt follows the British model, Egyptians are expected to be registered at general practitioners (GPs) units. I dare to say that GPs and consultants should not be allowed to have governmental and private practices together. Moreover, trainees should be in the governmental practices only. GPs decide who can be managed at their units and who to see the consultants. Exemptions can occur such as in emergencies and when seeking sexual health service where patients can directly seek the consultants help. The patient should be able to change the GP, whether governmental or in the third and private sectors, as long as the patient is in the catchment area. The have-nots should be offered GPs services gratis.

In my opinion, the Ministry of Health role in Egypt should be limited to the following:
1) General Public Health measures e.g. water and food safety, vaccination programmes and pricing drugs.
2) Governmental GPs units: GPs who are employed by the Ministry of Health should be given the necessary funds to cover management and referrals of patients. I do think that they are the suitable personnel at the Ministry of Health to choose what is best for their patients using the funds to cover the expenses of diverse spectrum of providers including the third and private sectors. Governmental GPs (fund-holders) should normally pay the consultants fees and treatment expenses whether in the governmental or the third and private sectors but if the funds cannot cover such expenses, the GP should choose the consultants who can see and manage the have-nots gratis or with sliding fees (if compatible with the taxes system). A list of these consultants should be available to all GPs, nationwide, and to the public. It should be kept up to date.  

Where appropriate, Ministry of Health hospitals can be turned into university hospitals (nearest Faculty of Medicine) and all university hospitals can follow the British NHS model. The rest of the Ministry of Health hospitals can remain as such where appropriate but become independent of the Department of Health (hospital trusts following the English NHS model in particular) or be sold to the private sector if they fail to function satisfactorily. Teaching, research and trainees salaries should be separate from consultations/treatment fees (including fees in the form of a salary).

It is very interesting to note that Canadian healthcare services (Canada is still a constitutional monarchy where the British monarch is the head of state and a federal parliamentary democracy) are largely delivered privately, but funded publicly - typically a fee per consultant service not a salary (though new entrants might prefer to change the system from fees for service with no pensions to classic salaries - pensions system)Costs are paid through funding from income taxes. Health Act does NOT generally cover prescription drugs, home care or long-term care, prescription glasses or dental care, which means most Canadians pay out-of-pocket for these services or rely on private insurance. Cosmetic surgery is generally NOT covered. The government does NOT participate in day-to-day care or collect any information about an individual's health, which remains confidential between a person and the physician/surgeon/family doctor. Administrative simplicity dominates the process where in each province, each doctor handles the insurance claim against the provincial insurer. 

Actually, I do think that the current Canadian system not covering certain aspects in healthcare is a reasonable one that better suits Egypt (but with the classic salaries - pensions system)
Primary care is the foundation of the Canadian healthcare system but patients can have direct access to consultants without needing a GP referral. The College of General Practice of Canada was founded in 1954 but in 1967 changed its name to College of "Family Physicians" of Canada.

Egyptian College(s) should be established as soon as possible (there is only one Royal College in Canada for Physicians and Surgeons). There is a need for major law changes in order to replace the current MSc exam with a national membership exam. I envisage, in the future, membership of the Egyptian Colleges will be considered a mark of excellence replacing the old variable standards in Egypt. A national certificate of completion of training (CCT) should also be introduced and continuing professional development (CPD) credits awarded. The Egyptian Medical Syndicate headquarters should be renamed the Egyptian Medical Council or that the Council should be established independently. Likewise, there is a need for an independent medical protection society to provide the best possible protection and peace of mind for medical professionals throughout their careers. This role is currently partially played by the Egyptian Medical Syndicate.


سؤال متكرر: اين عيادتك الخاصة في مصر الان؟ لا توجد. اعمل بعيادات للعمل الطبى الخيرى كلما سمح وقتى ولا اتقاضى راتب او اتعاب منها. يسمى هذا القطاع بالقطاع الثالث لانه ليس حكوميا ولا خاصا يهدف الي الربح. لماذا اخترته؟ اخترته بعد رحلتى في كل من القطاع الحكومى ثم القطاع الخاص ومن التجارب المستفادة. سؤال اخر: هل هذا هو الاختيار الامثل لك؟ الحقيقة لا لانى افضل دائما انا اعمل داخل نظام قومى يعتد به مدعم بالقطاعين الثاني والثالث كما هو الحال في بريطانيا مثلا رغم ما تعانيه من مشاكل شرحتها فى المقال اعلاه. لكن هو الاختيار الانسب لى في مصر بعد الخبرات المكتسبة. لم اسجل لممارسة الطب الا في بلدين بلدى الحبيبة مصر وفي ام الطب بريطانيا

خواطر من الماضي

لم افتح عيادة خاصة في مصر إلا بعد استقالتي من الحكومة. تحيرت كثيرا في تحديد قيمة الاتعاب ولم اتحير ابدا في القاعدة العامة "مجانا لغير القادرين" وكذلك قاعدة "مجانا لاهل المهنة ومن يعولونهم". منطقيا تزداد قيمة الاتعاب وفقا لازدياد التضخم ولكني وجدت ان مفهوم ال
 sliding fee 
هو الانسب بمعنى ان قيمة الاتعاب تقل وفقا لميزانيتك

عن نفسي طبقت ما تنادي به حاليا نقابة اطباء مصر (دار الحكمة) ولكني طبقته سابقا طوال فترة عملي الحكومي في التسعينات حتي الاستقالة لاني رأيت ان هذا حق المريض في اماكن عملي الحكومية. يقصد بالعلاج المجاني العلاج باجر رمزي جدا (تذكرة الكشف تتراوح من 1 الي 3 ج حاليا). بدا يومي مبكرا وانتهي متأخرا مرورا بما يسمى العلاج الاقتصادي ثم ما يسمي العلاج المتطور بنفس التذكرة (تذكرة ما يسمى بالعلاج المجاني) طوال اليوم فضلا عن عملي في الاقسام الداخلية. هناك من اعتاد سؤال المريض من تنتظر بهذه التذكرة والاجابة انه ينتظرني ولي الشرف فاذا رغب المريض في صرف ادوية من المستشفي تصرف فقط بتذكرة الاقتصادي او المتطور قام بذلك اختياريا ونفس المنوال في الاختبارات وكنت سعيدا بتبرع امريكا حينذاك بمعمل مجاني تماما لكشف الامراض المنقولة جنسيا مما ساعدني على عمل رسالة بحثية كما يجب ان تكون. هل واجهت مشاكل؟ نعم بالطبع انتهت بالاستقالة ثم العودة الي بريطانيا. سقط والدي الراحل مريضا عندما كنت في بريطانيا وبعد وفاته، واجهت مشاكل في الميراث لسنوات عديدة، وكنت غير متأكد أين أفضل الاماكن لمواصلة حياتي المهنية ولكن في النهاية قررت البقاء في مصر محاولا المساعدة في اعادة بنائها رغم أني أفهم تماما أنه من غير المحتمل أن ارى التغييرات المنشودة في حياتي. هل ندمت على الاستقالة؟ لا اطلاقا بل تحررت واخدم بلدى وفقا لمعايير ارتضيها ومجانا لغير القادر (حينما كنت في القطاع الخاص). البركة فى حضراتكم ايها الجيل الصاعد لترون مصر افضل ان شاء الله. قد تسمون ذلك هروبا ربما ولكن التناقض احساس صعب جدا

اعادة بناء مصر طبيا

This page was last updated in February 2019.

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