Inflammatory dermatoses are a spectrum of diseases in dermatology in which the core pathogenesis of the disease revolves around the pathological inflammation of the skin, it’s manifestations and treatment. It encompasses acne, contact dermatitis, atopic dermatitis, psoriasis, keratosis pilaris, seborrheic dermatitis, urticaria and urticaria pigmentosa.
I work in a tertiary care university-based hospital with a total of 4000 beds. It’s the second largest hospital in Pakistan and the second largest dermatology department in Pakistan. In our hospital patients are referred from across Pakistan ranging from complex tinea corporis all the way to complicated uncontrolled erythroderma. The most common diseases that present to us consist of acne, contact dermatitis, atopic dermatitis, psoriasis, seborrheic dermatitis and urticaria. Chemistry labs are done at subsidized cost to patients including CBC, liver function, kidney function, Hep B/C screen, fasting lipid profile, RA factor, tissue biopsy (H&E), tissue culture. We are unable to do specific antibodies for psoriatic arthritis, GeneXpert TB, TB dot, HIV, Hba1c, deep fungal stains, mycobacterial stains and immunofluorescence.
In Pakistan, most of the prescription medicines are available over the counter and anyone can buy them ranging from simple aspirin to IV propofol. Anyone can go to a pharmacy without a prescription and buy the drugs. That puts at patient’s and quack’s hands a lot of drugs to experiment with on the patient without proper monitoring or screening before starting them on it. Another example is clobetasol which is regulated in UK but available OTC in Pakistan. A lot of our patients have already tried it on their skin for years before coming to us as a last resort. In Pakistan patients cannot sue the doctors and if they do they are settled outside the courts as implementation of tort laws in Pakistan is negligible and access to justice is expensive for general public.
Most of the psoriasis patients come in the beginning of their disease from within a 300 miles radius. We don’t do PASI or DLQI in our hospital because of resource limitation. If the patient’s BSA is less than 10% we start them on triple combination topical therapy (clobetasol + salicylic acid + coal tar) on skin and if there is scalp involvement a shampoo is given in addition with same ingredients. We also screen them for metabolic syndrome, nail and joint involvement. If anyone of them is suspected on labs or history, we refer them to endocrinology and rheumatology.
Involvement of more than 10% BSA crosses the line where we are more inclined towards giving oral therapy and not in favor of topical therapy. In Pakistan, we usually start with methotrexate or acitretin based on their HCV/HBV status. These two medications are very cheap in Pakistan and most patients can afford them. Methotrexate 15 mg weekly dose costs 18 UK pence and acitretin 10 mg OD cost UK 19 pence. I never saw any patient being given a biologic, phototherapy cyclosporine, or mycophenolate in our practice setting. Most of such patients either drop out and stop coming or opt for private practice setting. Biopsy is rarely needed as it is mostly a clinical diagnosis.
Acne patients usually presents to us in three major groups; mild and severe acne, nodulocystic acne, steroid induced acne. Mild, severe and steroid induced acne we give the same treatment regimen in addition to counseling for stopping the usage of steroids. Our regimen includes oral doxycycline 100 mg BD + topical clindamycin in morning and topical benzoyl peroxide at night. A four week follow up is scheduled and if patient responds to treatment doxycycline is tapered on 8th week to OD dose. Later on the patient is maintained on topical erythromycin + isotretinoin. Females are counseled by us in our setup but rarely done by private practitioners. If the patient has nodulocycstic acne we start them on oral isotretinoin 20mg OD initially increasing to 40 mg OD after calculation of cumulative dose and monitoring lab work. However, in private practice I have seen doctors putting patients on isotretinoin without any screening or lab work. Being over the counter, this drug is also popular among teens as the go to drug for self-medication for acne. Most patients drop out before completing 6 months follow up. Out of our 20,000 annual dermatology patients we only have less than 10 acne patients who are with us for continued treatment. Rest of them we don’t know what the outcome was or what happened to them.
Treatment of contact dermatitis revolves around diagnosing the exact agent which is causing the allergy or irritancy. In Pakistan, patch testing is expensive and whenever patients are referred for it they never follow up or just drop out. We usually give them a second generation H1 blocker along with topical clobetasol in adults and topical methylprednisolone in kids. A follow up at 2 weeks is scheduled and 80% patients improve. If no improvement is seen, we admit the patients and start steroids under occlusion. Almost all the patients have been cured.
As Pakistan doesn’t have pediatric dermatology as an established specialty, neither do we have a board of it. Most of the atopic patients are managed by pediatricians. They only present to us when they are complicated, extensive or unstable. Again, the patients are unable to afford serum IgE levels and they are rarely done. Presenting to us the patient has already exhausted the options of emollients and topical steroids. We usually start them with clobetasol on body calculating not to exceed max dose and topical tacrolimus on body. Tacrolimus 15 g tube lasting less than a week is around 5.55 GBP so a lot of people are unable to afford it. I have never given any oral medication to such a patient neither have seen anyone giving in my hospital.
Seborrheic dermatitis is a clinical diagnosis. Most patient have already tried non-medicated shampoos. We start them on topical ketoconazole + coal tar + salicylic acid. The intention is to target all four pathogenesis of seborrheic dermatitis in this situation. Almost all the patients get better and stay in remission. Most patients coming to us are young adults. We rarely get any old patients in this disease spectrum.
Urticarial diagnosis is based on history and physical exam. We start patient with oral H1 and H2 blockers in OD dose and gradually increase the dose until disease is controlled. Patients are unable to afford H. pylori testing, serum IgE testing and patch testing. Patients with urticaria change their physicians almost every other visit as they are unwilling to do patch testing and unwilling to know the exact cause as its expensive. But they keep on trying new doctors and medicines as it is a cheaper way of satisfying their mental conscience.
A lot needs to be improved in terms of patient care in Pakistan. Pharmacies needs to get regulated the sale of all prescription medicines needs to be banned without prescription. Most importantly the quality of life of general public has to be elevated so they can afford better diagnostic studies and better treatments.
Rossi, A. (2018). Seborrheic dermatitis in children and adults [online] Available at: http://www.dynamed.com/topics/dmp~AN~T116636/Seborrheic-dermatitis-in-children-and-adults#Diagnosis [Accessed 1 Apr. 2018].
Burris, K, Psoriasis. (2018). Available at: http://www.dynamed.com/topics/dmp~AN~T116742/Psoriasis [Accessed 1 Apr. 2018].
Asero, R (2018). Urticaria. Available at: https://www.uptodate.com/contents/new-onset-urticaria?search=urticaria&source=search_result&selectedTitle=1~150&usage_type=default&display_rank =1 [Accessed 1 Apr. 2018].