Dermatology in the Ancient Arab World
Oumeish Oumeish
Professeur Louis Dubertret
Institut de Recherche sur la Peau
Hopital Saint Louis - Paris
The psoriasis is at the origin of a revolution in the management of patient suffering from chronic diseases: the so called "patient based medicine». This revolution consists in considering the patient and not the disease as the center of the medical activity. This implies to take into account the evaluation by the patients of the consequences of the disease and of the treatments on his quality of life. The mechanisms of the disease and the positive and negative possibilities offered by each treatment must be explained and the patient must be involved in the therapeutic choice. This tailored approach make possible to define the best possible adjustment between the many therapeutic strategies available and a particular patient. This adjustment must take into consideration the psychological pain, the severity of the impairment of the quality of life, the effectiveness and the tolerance of the previous treatments, the co-morbidities, the age, the fertility, the clinical manifestations, the localizations, the time available for skin care, the relationships of the patient with the drugs and with the doctors, the opinions of the social environment. .A typical patient for each treatment and a typical treatment for each situation can be defined helping to better adjust the therapeutic negotiation. Conservative treatment of psoriasis in the
era of Biologicals
ABSTRACT UNAVAILABLE AT DATE OF PUBLICATION Acitretine, Methotrexate and Ciclosporine:
the good use

Louis Dubertret
Proffessor and Chairman
Saint Louis Hospital, Paris, France
Acitretine alone is efficient (PASI 90 : 40 %). In responders it is the best long term maintenance treatment (up to 29 years of continuous treatment). Their main side effet is their teratogenicity in ladies. It is necessary to begin retinoid treatment at low doses (10 mgr/day), increasing the doses step by step, looking for the maximum well tolerated dose, usually defined as a mild cheilitis. Doses highest than the highest well tolerated dose are frequently responsible In children retinoids are very efficient and nearly always well tolerated but it seems quite important never to give more than 0.5 mg/kg/day. Methotrexate is the best treatment of severe psoriasis. Given at low doses, once a week, it is a safe, cheap, convenient and efficient treatment if carefully monitored. The main problem is the possible long term liver toxicity of Methotrexate. The risk is very low in patients not at risk (No liver disease) In these cases liver biopsies are dangerous and useless. In the others cases the need for liver biopsy is very rare, decided only by the hepatologist, and must be replaced by Fibrotest + Fibroscan. The old American guidelines must not be followed and new guidelines are needed. Cyclosporine at low doses is an outstanding emergency treatment. It was first used as the last possible systemic treatment but long term continuous treatments are seldom possible due to alteration of the kidney functions. A careful follow up of the kidney functions with measurement of the glomerular filtration rate after each year of cumulative treatment is necessary. The Cyclosporine dose must be calculated according to the theoretical body weight in obese patients to avoid over dosage. Cyclosporine is mainly used now as a short time treatment, very efficient for young people in a difficult situation. Cyclosporine is not contra indicated during pregnancy. Raising the Bar on psoriasis treatment
Sarah Rogers
ABSTRACT UNAVAILABLE AT DATE OF PUBLICATION Topicals in the treatment of psoriasis - Daivobet.
Panagiotis Zografos
Medical Manager
LEO Pharma International

Psoriasis is a common disease involving more than 125 million patients worldwide of which 7 million patients in the United States alone. Psoriasis causes significant disability in many individuals, especially women and young patients. About 80% of patients with psoriasis report that the disease has a negative impact on their lives for a variety of reasons. These may include physical symptoms, embarrassing physical appearance (particularly because it begins at <30 years of age in 60% of cases), helplessness, frustration, anger, anxiety, depression, and increased use of alcohol. Patients with moderate to severe psoriasis have an increased prevalence of CAD and an increased risk for myocardial infarction. Patients with psoriasis have an increased prevalence of risk factors for CAD. Physicians and patients with psoriasis are generally unaware of the link between psoriasis and CAD. Dr Vincent E Friedewald (University of Notre Dame, IN) and colleagues—an expert panel of cardiologists, dermatologists, and scientists—have penned an editor's consensus in the December 15, 2008 issue of the American Journal of Cardiology (AJC).This consensus statement relates to the increased risk of coronary artery disease (CAD) observed in patients with psoriasis— particularly those with severe forms—and is stressing that patients must be informed of this link and have their cardiovascular risk factors regularly In this presentation, the newly issued guidelines on the management of psoriasis as presented by the American Academy of Dermatology will be discussed together with the clinical safety and efficacy record of Daivobet® The use of systemic drugs in pemphigus
Professor Alberto Giannetti
The traditional t r e a t m e n t s are r e p r e s e n t e d by high d o s e s of c o r t i c o s t e r o i d s , i m m u n o s u p p r e s s i v e d r u g s , a s a z a t h i o p r i n e , cyclophosphamide, Mycophenolate mofetil, cyclosporin . The mean treatment duration varies from 2-3 years to 10 years or even more. Main therapeutic problems are represented by recalcitrant types and relapses. Systemic corticosteroids represent the mainstay therapy and are used according to different regimens but they have several side effects. Azathioprine is normally added to CS in so called Lever regimen. Among the other immunosuppressive drugs fair or poor evidence support their Intravenous immunoglobulins allow CS dose and decrease the relapses. Immunoadsorption in pemphigus is probably efficacious in refractory Rituximab seems to be effective in recent acute recalcitrant pemphigus than in long-term evolving relapsing types. Strategies for early diagnosis of
Benvenuto Giannotti
Benvenuto Giannotti, MD. Dept. Dermatological Sciences, University of
Florence Medical School, Florence, ITALY
An important goal of the fight against melanoma is the improvement and refinement of criteria aimed at secondary prevention- including educational messages for professionals and adult population - in order to reduce the incidence of advanced forms. The knowledge of demographic and personal factors associated with early diagnosis of melanoma may be basically involved in the attempt to improve Future melanoma early diagnosis strategies should adequately stress the role of skin self examination among adult population and should induce dermatologists to perform total skin examination in order to identify suspect lesions also during consultations As regards the role of dermoscopy in pigmented skin lesion screening, according to a randomised study recently performed by our group, the use of dermoscopy was associated with a reduction of percentage of subjects referred for surgery aimed at diagnostic verification compared with conventional naked eye observation. What's New in Dermatologie therapy
Riad mashal MD.
The therapy, as always was the greatest concern of dermatologists, physicians and researchers. In this presentation I will review the new therapeutics in dermatology , and this will be based on accrediated scientific research , and the results published in the scientific and medical literature. The advances in the understanding of the immune Basis of the inflammatory skin diseases lead to development of the new therapies, especially the targeted drugs. The new innovations and therapeutic modalities include : New biologicals, Immunomodulators , new Vaccines in Dermatology, advances in vehicle formulations , new fields for application of photodynamic therapy. New options for the treatment of Hemangiomas. Skin deseases in mediterranean
Nejib Doss
Hisham Arda MD.
Prof, of Dermatology, Faculty of Medicine , AI Najah University This review will include data about bullous skin disease in Palestine seen in my clinic the last few years, between 40-45 cases of pemphigus and pemphigoid were seen ,of them 31 cases were complaining of pemphigus vulgaris and ten cases of pemphigoid ,and one case subcorneal pustular dermatosis and one case of herpes gestationis. All data and methods of treatment will be discussed Consanguinity, the hidden source of

in the Palestinian Society
Spiro Tarns MD.
Associate Prof, of Dermatology, Faculty of Medicine, Al-Quds university. Consanguinity , the hidden source of Genodermatoses in the Palestinian society Consanguinity is still considered in our society since hundreds of years as safe and normal, or even a privilege among cousins . It may have been a tribal invention to keep wealth and property within the family, or an easy and inexpensive way of marriage in a closed conservative mainly rural society. Unfortunately, consanguinity is neither safe, nor healthy, on the contrary it became a terrible burden, a curse, and a threat to our society for generations A presentation of some cases of rare genodermatoses may prove this opinion Food Allergy in Atopic Dermatitis
Proffessor Alberto Giannetti

The prevalence of food allergy varies from 25 to 65%. Itis more frequent in infants and children; there isnit specific clinical pattern. The clinical history is not suggestive and sensitivity of prick, RAST test is not high enough. The response to the diet is slow and difficult to evaluate. Repeated open food challenge with milk, egg or peanut carried out on 347 AD subjects resulted in 59 positive cases: 40 delayed, 12 combined and 7 immediate type. Essential are the amount of ingested food, repeated ingestion and a variety of symptoms can occur. Atopy patch test have been performed in 478 patients with different results and correlations with prick test, showing an higher sensitivity and the same specificity. Open challenge carried out in 369 patients was very useful in discriminating patients with food allergy, suggesting proper diets, which Atopic Dermatitis in Office Management
Anan Al-Faqih

Atopic dermatitis (AD), also called eczema, is a chronic inflammatory skin condition that is genetically transmitted and affects 10- 20% of the pediatric population and 1 - 3% of the adult population. 1 Less than 20% of adults with AD have the onset of disease after adolescence. 2 It is important for the primary care physician to understand how to and manage this condition as well as when to refer the patient for specialty consultation. Atopic dermatitis is pervasive, chronic and relapsing disease. An understand- ing of the disease epidemiology, and pathophysiology will aid in the rational approach to its treatment. Environmental controls for potential and pharma-cotherapy are first line treatments, trig-gers education is essential for suc-cessful disease Pa-tient Subspecialty referral is required for recalcitrant man-agement. Disease, requiring therapies with higher side effect and closer monitoring. If concerns regarding pro-files of diagnosis or specific allergic triggers or accu-racy dis ease processes affect a particular compli-cating patient, subspecialty referral is recommended. PYODERMA GANGRENOSUM: A NEW
Benvenuto Giannotti, MD. Dept.
Dermatological Sciences, University of Florence Medical School, Florence, ITALY Pyoderma gangrenosum (PG) is an uncommon ulcerative skin disease , first described in 1930. It is associated with systemic diseases (mainly chronic inflammatory intestinal diseases and arthritis) in at least 50% of patients. PG lesions may occur after skin trauma or injury to the skin in 30% of patients (so called pathergy). The main PG variants are the classic ulcerative form, usually observed on the legs, and the atypical forms. The etiology of PG is poorly understood. The disease has been regarded as a cutaneous vasculitis or a neutrophilic dermatosis; specifically altered neutrophil chemotaxis or circulating immunocomplexes are believed to be involved in its pathogenesis. The prognosis of PG is generally good. However, recurrences may occur and residual scarring is common. Therapy of PG is based on corticosteroids and other immunosuppressive agents. CHILDHOOD LUPUS ERYTHEMATOSUS: A REPORT OF 6
I. Mokhtar, R. Benmously, T. Badri, S. Fenniche
Dermatology department. Habib Thameur Hospital - Tunisia
Introduction: Discoid lupus erythematosus (DLE) is uncommon in childhood, especially during the first 2 years of life. Several authors suggested the presence of DLE in children as a marker of less severe disease, milder renal disease, and a more benign course. However, this notion is controversial and some authors have noted a high frequency of transition from DLE to SLE in children than in adults. Systemic lupus erythematosus (SLE) is not confined to adulthood and nearly 15% of cases present in children younger than 16. Recent reports have compared adult and paediatric-onset cases and have suggested that the presenting features are more severe in children than those of adult-onset SLE. The aim of this study is to analyse retrospectively the clinical and paraclinical features of both systemic and discoid childhood lupus erythematosus through a tunisian series over a-14-year period. Results: Six patients with a clinical and histopathologic diagnosis of lupus erythematosus were included in the study. The mean age of onset was 12,5 years (range 10 to 15 years) with all cases occurring after 10 years old. No family history of LE was noted, and 1 child had chronic anaemia and celiac disease. Among the six patients, 3 (2 girls and 1 boy) had DLE. Lesions were localized initially on the face in 3 patients and than disseminated to the neck and thorax in one case. Erythema, scaling, hyperpigmentation and atrophy were the predominant cutaneous lesions. No clinical or laboratory evidence of systemic disease was found during the short period of follow up. Sunscreens were routinely used by 3 patients. Three children with systemic lupus erythematosus were seen at the same period of study (2 boys and 1 girl). Arthritis and/or arthralgies, rash, and Raynaud's phenomenon were the commonest presenting symptoms. One patient developed haemolytic anaemia, lupus nephritis, fever, digital necrosis, pleurisy and pericarditis. All the patients had a raised erythrocyte sediment rate. Immunologic tests were performed. Antinuclear antibody (ANA) and antinative DNA were positive in two cases. Decreased complement level was observed in two cases. Positive anti-ENA was associated in one case. All 3 patients were referred to the médecine département. The evolution was considered satisfactory after 4 months of follow up. Conclusion: Lupus erythematosus is rarely observed in children than adults. However, we wish to emphasize that lupus erythematosus is not a static disease and progression from DLE to SLE is possible. The clinicians should be aware of the greater risk of systemic complications in children with systemic lupus erythematosus between 2 and 5 years of disease onset. Therefore, patient's with DLE and SLE should be continually followed up and therapy modified in response to the patient's clinical course and disease activity. Lymphocytic Cutaneous Infiltration
Reactive ? , Pseudo-lymphoma ?

Pre-lymphoma ? , Lymphoma ? .
Al-Sharabati Mohamed Barakat, MD, Rasheed Osaid, RN, CNS. Al-Ahli and Al-Makassed Hospital, Palestine In practice of general clinical dermatology the differential diagnosis between most of non-tumoral lesions are often not easy. In these cases the need of dermato-pathological opinion although not always clear cut, but it is of great benefit in many occasions. In this day we present two case reports. The first concerning a 62 yrs old female from Hebron area complaining of recurrent several round skin ulcers ranging from 1 - 2.5 cm in diameter involving the right lower extremity since 4-5 years. The clinical diagnosis proposed by different dermatologists ranged from nonspecific ulcer and insect bites, eczema to cutaneous Leishmaniasis (etc.O). The dermato-pathological examination was also variable. Finally our diagnosis was lymphatomatoid papulosis ( LP ) which is a chronic dermatosis characterized by the continual appearance of papulo- necrotic, nodular, and occasionally large plaque-like lesions showing histologic features suggesting malignant lymphoma. A l t h o u g h few patients have lesions that are clinically indistinguishable from pityrisis lichenoides et varioliformis acuta (PLVA). Even though individual lesions heal spontaneously in both diseases the duration of the disease is much longer in LP , exceeding 10 years in many instances. The most significant difference lies in the fact that 10-20% of patients with LP, lymphoma ultimately develops. The second case is a 35 yrs old pregnant lady with inguinal ulcerated mass since 12 months managed as cutaneous abscess treated with drainage and antibiotics. Finally the mass reached around 10 cm in diameter without any improvement, so an open biopsy was performed and the pathological diagnosis is cutaneous anaplastic large cell lymphoma ( A L C L ) ALK + (Alkoma ). It is important to separate these from cases of ALK Neg ALCL which have a poorer prognosis, and cases of primary cutaneous ALCL which have an excellent prognosis. Common Sexually Transmitted Diseases
Yousef Aldamen
ABSTRACT UNAVAILABLE AT DATE OF PUBLICATION HPVs have been at the focus of intense research during the last decade in medicine. They became more popular as their oncogenic potential and role were discovered. Recently, there is accumulating evidence in support of the existence of HPV in benign and malignant tumors as well as in psoriatic lesions, epidermal repair processes and trophoblasts. This presentation aims to update new and exciting clinical aspects of this pathogen. Bowenoid Papulosis
Bowenoid papulosis (BP) is an interesting pathology for its not well understood aethiology and variable clinical course: mainly benign, but sometimes associated with malignant invasive transformation (2.6%). BP may be considered to be a transitional state between a genital warts and Bowen disease. BP is manifested as papules that are induced virally by human papillomavirus (HPV) and demonstrates a distinctive histopathology (bowenoid dysplasia). Some sources argue that bowenoid papulosis, similar to condyloma acuminata, will resolve spontaneously, even after months or years. However, the behavior of HPV cannot be predicted histologically and local invasion seems to be more common in older adult patients and patients who are Combination of vitamins and hormons cream
for Skin health restoration
A u t h o r s : M. Tutino, A d a m Bodian University of Palermo, Department of ENT, Clinic of Plastic & Craniofacial Surgery Bodian Dermatology Center, New York, NY, USA Our group has developed a non invasive method, based on association of vitamin C 15% serum, a human hormone, the Melatonin, and the Resveratrol. Used together, determine a morphological and histological reduction of skin disorders. That has been tested on more 100 patients, with photoageing, wrinkles, melasma, solar keratosis and other signs of ageing. The results are very encouraging The method is based on the use of vitamin C ( serum of L-ascorbic acid at 15%), stabilized with vitis Vinifera melatonin and resveratrol. The passage of the active ingredients through the skin is facilitated by the low ph do to the high concentration of the L Ascorbic Acid. The study group had treatment specifically chosen personalized according to the skin problem. To achieve the best skin penetration of the active ingredients, we set up a basic protocol which causing the reduction of the skin ph would enhance the absorption of the preparations. The basic protocol included: 1) A skin purififying cleanser for acidification of the skin to ph 3.5 2) A purifying toner which clean in deap the skin reducing the ph to 3.2 3) A vitamin C 15% Laa serum where the Ascorbic acid is stabilized with Vitis Vinifera 4) A Restructurating cream where the Melatonin is at 0.5% concentration and is stabilized with Resveratrol, vitis vinifera and peptides in a multivitamin complex. The system has an application rate of 2 t/day of the creams. According to the skin condition, we may advice the patients to double the application of products in skin lesion in order to have a stronger action. In solar keratosis and hyperpigementation exfoliating cream together with Vit. A cream may be added in the basic kit. Results:
Has been noted the important biological function of that complexes ingredients
- they have an antioxidant action opposing to "oxygen free radicals»stimulated by the same cellular metabolism and by the smoke, by the ultraviolet light exposition and by other polluting attacks, and they oppose to the cellular ageing; - have an anti-inflammatory action due to a strengthening of the immune system; - reinforce the cellular response to the outer and intracellular nociceptive stimuli; - exert a noticeable action in the modulation of the immune response; -intervene with an important antioxidant action in the body zones where an alteration of the cellular growth having a tumour origin, a dysplastic alteration and/or a tissue atrophy is present. Conclusions:
The Ph Skin controlled system is promising in facilitating the skin health restoration and rejuvenation with high tolerance. Further clinical application are still under study Physiological Regulating Medicine in Wrinkles
Leonello Milani

I. Mokhtar, R. Benmously, T. Badri, M. Zghal, S. Fenniche
Department of Dermatology, Habib Thameur Hospital
Glucantime® is the firstline treatment for cutaneous leishmaniasis inTunisia. Adverse effects related to systemic administration of Glucantime® are frequent. The purpose of this retrospective study was to review the files of 53 patients who were treated for cutaneous leishmaniasis usingmeglumine antimoniate at a dose of 60mg/kg/day for 15 days during the period between 1998 and 2007. Adverse effects were observed in 5 men and 4 women with an average age of 40.8 years. Antimony intolerance occurred in 8 patients and stibio-intoxication occurred in 4.Glucantime® was considered as the most likely cause of adverse effects in 6 patients and as the plausible cause in 3 patients. Feverwas the most frequent complication of antimony intolerance followed by cough, myalgia, and cutaneous lesions. Hepatic cytolysis was the most frequent sign of stibio-intoxication.Asymptomatic elevation of amylase level to 108UI/lwas observed in one case. The most serious complication was acute toxic kidney failure on the 15th day of treatment. The incidence of adverse events to Glucantime® ranges from 16%to 59%. The most severe complication is acute renal failure on the 15th day of treatment, as observed in one patient in this series. Patient status must be monitored by performing laboratory tests at the beginning and end of the treatment. Since cutaneous leishmaniasis observed in Tunisia is a self-healing dermatosis that never results in sequels, treatment with Glucantime® should be discontinued in any patient who develops suspicious symptoms. The recent emergence of Leishmania tropica
in Jericho and its environs, a classical focus
of L. major
Dr. Suleiman Barqawi
Photodynamic therapy is a therapeutic method that is developing rapidly and increasingly applied in various medical specialties, including dermatology. Photodynamic therapy (PDT) employs a photosensitizer, light, and molecular oxygen to selectively destroy pathologic cells , while preserving the normal surrounding structures. The internationally expanding use of this novel therapeutic modality in dermatology has revealed its efficacy for the treatment of several dermatologie conditions including malignancies and selected benign skin disorders . PDT has been approved by the US Food and Drug Administration to treat actinic keratoses. In Europe, photodynamic therapy is currently being used in the treatment of actinic keratoses and superficial basal cell carcinoma. Other off-label uses of photodynamic therapy have included cutaneous lesions of Bowen's disease, psoriasis, cutaneous T-cell lymphoma and acne. Most recently, photodynamic therapy has been employed in photorejuvenation. The advantages of photodynamic therapy include the capacity for noninvasive targeted therapy via topical application of the drug and local irradiation of involved areas, as well as the ability to obtain excellent cosmetic results with minimal discomfort. PDT may prove advantageous where size, site or number of lesions limits the efficacy of conventional therapies, (e.g.penile, digital and facial involvement) This review summarizes the fundamentals of photodynamic therapy and its role in the treatment of several cutaneous disorders. How to treat Hyperpigmentation using
Melatonin, Alfa Arbutin , Resveratrol and

vitamin C 15% serum: a new skin care system
Dr.:Authors: Adam Bodian and Matteo Tutino
During recent years, diverse methods for achieving healthy skin and treating acne, melasma and aging have been presented worldwide, different active natural ingredients have been studied to achieve the best clinical results without major complication and with the highest compliance for the patients. It is known, that hydroquinone is a forbidden substance in Europe and Asia as it has been demonstrated, despite its efficacy in treating hyperpigmention, it is extremely toxic in that if it penetrates below the outer layer into the dermis it causes collagen fibres to thicken, leading to possibly irreversible damage to the connective tissue in skin cartilage and premature aging. Furthermore, recent literature demonstrates it possesses carcinogenic effects. Our group has developed a new, patented hydroquinone and paraben -free system based on the use of natural products, derived from vitis vinifera, melatonin, resveratrol and vitamin C Laa . The Yuvavitae system is not toxic, can be used for the treatment of post inflammatory hyperpigmentation and melasma. Moreover, the products used contain substances, which repair damaged DNA and stimulate collagen and elastin production giving the skin smoothness, tone, luminosity and even colour. Material and methods 50 patients have been treated from the period of January 2007 to the present. The system includes: an astringent, a 15% vitamin C serum (L-ascorbicacid), a colour balancing hydroquinone-free cream, an exfoliating cream and a cell renewal cream in conjunction with Melatonin cream. The patients, after having undergone a general medical and skin examination, were given the above cosmetic products and received clear instructions on their use according to the patient's skin type .The patients were not told to avoid sun exposure, however they were told to use a sun screen and vitamin C serum before and after the exposure. The initial treatment lasted 3 to 6 months. Once the desired results were achieved, the patients were put on a maintenance programme. Results: All patients said that they found the system to be efficacious and easy. We did not have any cases of post-inflammatory hyperpigmention, major complications, scars, nor product intolerance among our patients. Skin colour was even including the area surrounding the eye in 100% of the cases. In subjects affected by dermal melasma, the colour alterations by the end of the initial treatment was insignificant.
This new system for achieving skin health can be used in both medical and
invasive procedures. It is efficacious as an anti-aging programme and in the treatment of the different type of melasma, P. I. H., or paradox hyperpigmentation. It also has shown to enhance collagen production, reduce dilated pores and in inhibit oil production of the skin. FRAXEL LASER
Salah Safi MD.
The Fraxel laser penetrates deeply into the skin dermis with thousands of tiny microthermal treatment zones. New approach to skin rejuvenation treats wrinkles, acne scars, pigmentation of the skin with very little downtime. OCCUPATIONAL DERMATOSIS
Dr. Ghalib Barham
Dermatologist-private clinic Tulkarm Palestine Occupational dermatosis are any abnormal conditions of the skin caused or aggravated by substances or processes associated with the work environment. Occupational skin diseases (OSDs) are a major public health problem, because they are common, are often chronic, and have significant economic impact on society and on workers, among those are housewives. Housewife hand dermatitis is a distinctive inflammatory response of the skin secondary to number of exogenous factors. It is common, of all occupational diseases, 20% - 70% are dermatosis, among dermatosis are contact dermatitis, chronic pruritic disorder that perplexing and frustrating to patient and physician alike. It is most commonly a reaction to repeated contact with mild primary irritant such as soap and water, detergent, and solvents. Propylenglycol- uses in dermatology
Munir Abu Samen

Source: http://www.ojed.gazi.edu.tr/ojed/1-1-2009/PalestineAbstracts.pdf

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